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Quitting Psychotropic Drugs: How, When and Who?


For many people worldwide, psychotropic drugs, which are medications used to treat mental health conditions, are beneficial in improving mental health and overall well-being. Nevertheless, at some point during or after the recovery process, the desire to quit may become stronger than the wish to continue.


The decision to quit (or 'discontinue') can be challenging, raising important questions. Is this the right time to quit my medication? How quickly should I discontinue? What are the chances of relapse? Will discontinuation affect my work or social life?


Recently, we have seen increasing interest in the topic of discontinuation, both in science and in the general media. As a PhD student and clinician myself, learning about the effects of psychotropic drugs, the working mechanisms, and the side effects, is an important part of my clinical training. Yet, I have noticed that I often struggle to answer a common clinical question: ‘How long should I keep taking this drug?’


I have felt that the topic of discontinuation is equally important to making informed prescribing decisions (both for patients and clinicians), but that for most drugs, we lack sufficient knowledge.


In a paper published this year in the scientific journal Molecular Psychiatry, we summarised the evidence on discontinuation of psychotropic medications grouped into six different classes: antidepressants, antipsychotics, benzodiazepines (a type of sedative medication), opioids (usually prescribed for persistent or severe pain.), mood stabilisers, and stimulants (medications which enhance brain activity). For each class, we went over three essential questions: Who can discontinue, when can they discontinue, and how can they discontinue? We also discussed similarities and differences between classes and concluded with several recommendations for further research.  

 

So, what is the evidence, and how should we move forward to ensure we have proper guidance for both clinicians and patients?

 

Let’s look at some of the key results.

 

Before we go any further, it is important to answer one question:


Why do people discontinue their medication?

The pros and cons may differ from person to person. For some, the side effects may have become too bothersome, especially after their mental health symptoms have improved. For others, it may be that they wish to live a life without medication. Another reason could be that the circumstances in someone’s life have improved so using medication feels no longer necessary to them. Fear of dependence or societal stigma are other commonly reported reasons.


On the other hand, people may have doubts or face barriers that prevent them from discontinuing their medication. Common is the fear of experiencing relapse, the reappearance of mental health symptoms after improvement, or discontinuation symptoms, especially if previous discontinuation attempts were unsuccessful. Clinicians may also be reluctant about discontinuation, for example, they might be afraid that their patient may relapse or have prior negative experiences with discontinuation. A lack of guidelines or knowledge may also prevent clinicians from initiating a discontinuation attempt. That being said: discontinuation is not a goal in itself, there may be many valid reasons to continue medication, and the individual’s well-being should remain the ultimate clinical ambition.

 

Now that we have looked at some of the considerations for discontinuation, we can cover the evidence we presented.

 

Discontinuation symptoms

Discontinuation symptoms are a common and challenging clinical occurrence while using psychotropic medications.


In the case of selective serotonin reuptake inhibitors (SSRIs), the most commonly prescribed type of antidepressant, symptoms are sometimes abbreviated with the acronym FINISH: Flu-like symptoms, Insomnia (when you aren't sleeping as you should), Nausea, Imbalance (the loss of balance or unsteadiness), Sensory disturbances (such as brain zaps), Hyperarousal (that is when the fight-or-flight response is constantly engaged in a state of increased responsiveness to stimuli).


We know that quick (for instance, <2 weeks) or abrupt cessation (ending suddenly) increases the risk of experiencing discontinuation symptoms, as well as using rapid-acting drugs, meaning that they are quickly excreted from the body.


While for most patients discontinuation symptoms are mild, in some cases, they can be very debilitating. It is therefore important that we understand who is at risk of developing these symptoms.  Although no clear risk factors have been identified yet, previous failed discontinuation attempts and long-term use of the drug are often mentioned in scientific literature for antidepressants, for example.


Another common problem, both in practice and in research, is that it can be difficult to distinguish if someone experiences discontinuation symptoms or a relapse of the mental health condition the medication was prescribed for in the first place. This is important as both problems require different approaches and treatments. Discontinuation symptoms are often temporary and disappear after increasing the dose again, while a relapse might require longer treatment.


Slower discontinuation is (usually) more effective

For many psychotropic drugs, it is not advisable to go ‘cold turkey’ (stop abruptly), as it increases the risk of relapse or experiencing discontinuation symptoms. Gradually reducing the dose is generally recommended. Some rapid-acting psychotropic drugs (benzodiazepines, opioids) can be switched to long-acting agents of similar classes, so the drug is more gradually excreted from the body.


While, as mentioned, a longer discontinuation approach is usually more effective, it may not always be feasible for everyone. It is therefore important that we investigate the pace at which patients can safely discontinue, while at the same time identifying those who may benefit more from slower, tapering approaches. For scientific research, this means conducting studies that compare different discontinuation strategies to find optimal dosing strategies.


Many people can successfully discontinue

Another finding is that most medication classes are effective in preventing relapse, so continuing them after remission is still a valid option. For example, continuing antidepressants decreases the risk of relapse by 50% compared to placebo (a treatment without active properties, e.g., a dummy pill), and for antipsychotics, this percentage is even higher.


Nevertheless, many people are still able to successfully discontinue without experiencing a relapse. While relapse rates can be used to make an informed decision, often other more personal considerations are discussed between the patient and the clinician (such as previous discontinuation attempts, their personal circumstances, etc.).


Ideally, the decision should be shared with the patients, who should have their values centralised, and feel properly equipped to choose a personalised trajectory with their clinician. Family members and other support systems may also be involved in the decision-making process. A personalised treatment plan could be helpful in identifying early signs of relapse or discontinuation symptoms.


So, how should science move forward to guide both patients and clinicians?

Here are some of the recommendations we presented:


First, future research should provide insight into effective discontinuation strategies as well as learn from individual patient’s experiences. While relapse is an important outcome measure, we should equally focus on other patient-relevant outcomes, such as social functioning and overall well-being, and gather more relevant clinical patient data, such as previous discontinuation attempts and medical history.


Another recommendation is to investigate the outcomes of dose reduction strategies compared to full discontinuation and not limit clinical trials (research projects aiming to investigate the efficacy of treatments) to only patients with a specific diagnosis.  


Overall, the amount of evidence on discontinuation is still quite limited compared to the vast amount of research that has been conducted on the effectiveness of psychotropic drugs.


However, it is becoming increasingly clear that discontinuation is an important topic that merits serious consideration. Ideally, both the patient and clinician should feel well-equipped to create a personalised discontinuation plan through shared decision-making. To ensure that this is the case, it is necessary to have not only sufficient clinical evidence, but also effective interventions that can be readily applied in clinical practice.


While current evidence provides a general direction, much more work needs to be done to ensure not only evidence-based prescription but also the discontinuation of drugs in psychiatry.

 


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