Dr. Rakesh Jain on the Art and Science of Deprescribing

In this video, Psych Congress Steering Committee member Rakesh Jain, MD, MPH, discusses deprescribing, the process of tapering or stopping medication being taken by a patient.

"Classically, we have said go ahead and stop the medication. But as data over the last few years has told us, that is fraught with danger," he says. "Patients can suffer a recurrence or relapse of their underlying psychiatric difficulty, or they might suffer from the consequences of withdrawal."

Dr. Jain presented a session on the topic, "I Bid You a Fond Adieu - Deprescribing for the Thoughtful Clinician" at the 2020 Psych Congress Elevate virtual conference.

Read the transcript:

Deprescribing. That's not a phrase we hear very often in our training. We do get trained considerably on how to prescribe medications, how to increase the dose, how to manage side effects. All of those are crucially important. What about the art and science of deprescribing? Not every medication should be present continuously in a patient's treatment program.

How do we talk to our patients about deprescribing? Classically, we have said, "Go ahead and stop the medication." But as data over the last few years has told us, that is fraught with danger. Patients can suffer a much more rapid recurrence or relapse of their underlying psychiatric difficulty or they might suffer from the consequences of withdrawal, perhaps insomnia, perhaps even worse. They might have seizures. We have seen that with too abrupt a taper of certain medications.

The issue of deprescribing has been underemphasized in our training. Here at Psych Congress, we chose to bravely take on that topic. There is a great deal of science behind it. There is a great deal of art behind it. The upshot is the following.

Deprescribing ought to never be conducted in isolation. We should communicate with our patients, create a treatment program of prescribing and deprescribing that is conducted in a communicative fashion as a collaborative effort. Psychoeducation is very important in order to have a successful deprescribing course.

Then, finally, patients do need appropriate directions with appropriate guardrails placed in action, too. Let's cover a few of the important issues here. First of all, as I've said before, a collaborative approach is necessary. Two, knowing the pharmacokinetics of the medication you are considering deprescribing is crucial. What is the half-life? When does C_max arrive? When does t_max arrive?

Then, of course, the pharmacodynamics. Which receptors does this medication work on? If I was to pull it away too abruptly, will it be difficult or problematic? When we put all this information together, then suggesting to a patient an appropriate treatment course is not all that difficult. Patients are very grateful for a proactive conversation on deprescribing.

Patients also are very grateful not to be on medications that they may no longer need but the act of leaving the medication is conducted with grace, and calmness, and with scientific vigor. Now, there are some medications that are particularly problematic in terms of deprescribing. Let's talk about that for a second.

In psychiatry, the use of benzodiazepines has both significant pluses and significant minuses. If a patient does need ongoing treatment, that's perfectly OK. Should we wish to taper them off it, a deprescribing program should at the very least include psychoeducation, a slow taper that can be modified if a patient's needs change.

By the way, the same is true with anticholinergics. The same is true with antidepressants. Some of the antidepressants have very long half-life so I can taper off rather rapidly, but that is not the case with every one of them. Needless suffering occurs when we the clinicians don't think out the issue of deprescribing appropriately.

In conclusion, what I would share with you is congratulations on being very well-trained on the art of prescribing medications. It is, however, very important to buff up our skills, our knowledge base about deprescribing.

To do so, one requires a desire to know more about the science of the medications involved but also the art, the communication with the patient, the reassurances we offer them. Of course, we are with them every step of the way so that the deprescribing process goes through with smoothness and with success. Thank you.