Best Practices for Deprescribing in Schizophrenia

“We're really good at starting medications, but we're really lousy at ending them,” observes Andrew Penn, PMHNP-BC, NP, CNS, MS, RN, clinical professor, University of California, San Franscisco.

In this video, Penn offers some key clinical takeaways from his session on deprescribing presented at the 2024 Psych Congress in Boston, Massachusetts. He introduces the concept of deprescribing, why it’s important, and how it has a place even when treating patients living with serious mental illness like schizophrenia.

For more expert insights on schizophrenia treatment and management, visit the Schizophrenia Learning Library here on the Psych Congress NP Institute Online Learning Hub.

Read the Transcript      

Andrew Penn, PMHNP-BC, NP, CNS, MS, RN: Hi I’m Andrew Penn. I'm a psychiatric nurse practitioner and a clinical professor at the University of California San Francisco School of Nursing. I'm also a member of the Psych Congress steering committee.

Psych Congress Network: Could you explain the primary considerations when deciding whether to begin a deprescribing process with a patient?

Andrew Penn: One of the things that we talked about in our session at Psych Congress 2024 is that we're really good at starting medications, but we're really lousy at ending them. So, one of the first things we have to decide when we're thinking about this with a patient is, what are we treating? Are we treating something that's chronic or are we treating something that's episodic? If we're treating something that's episodic, is there a reason to be taking medication to prevent the next episode? Where this gets a little bit tricky is deciding in mood disorders that are not bipolar disorders such as major depression. So for some people that have had an episode of major depression, they may be well for many months and then the question will arise because we bring it up as clinicians or because the patient brings it up, do I need to stay on this medication? That's something that we need to have a plan as to how we're going to stop a medication when it's appropriate to stop a medication and how we do that safely.

Psych Congress Network: Are all psychiatric medications suitable for deprescribing? Which patients might not be the best candidates?

Andrew Penn: We're dealing with different illnesses obviously in our clinical practice, and some conditions may be less suitable for deprescribing. For example, many people with schizophrenia are likely to be on some form of medication, probably chronically. Now they may have an acute exacerbation of that illness and they may be put on additional medications, which perhaps after the acuity of the crisis has ended they don't need, and we need to think about how to discontinue those. So it's really going to depend on the patient, the presentation that that patient is bringing, and what medications they're currently on. I certainly see plenty of people who may have a diagnosis of schizophrenia who are on multiple redundant medications. In a situation like that, I might be looking for an opportunity to consolidate medication so that there's less of a pill burden, there's fewer side effects, fewer trips to the pharmacy, et cetera. We know that when a medication regimen is simplified, it's more likely to be adhered to. Whereas if somebody is having to take medications 4 times a day or something like that, adherence tends to drop pretty precipitously.

Psych Congress Network: Could you walk us through what deprescribing might look like when treating a patient with schizophrenia?

Andrew Penn: An example of that might be that a patient with schizophrenia comes out of a hospitalization and they're on, say, a benzodiazepine in addition to, or maybe even more antipsychotic medications. That benzodiazepine might've made a lot of sense when that patient was really agitated and perhaps not sleeping, but now that they're doing better, whatever other medication changes were made during the hospitalization, they might not need that hypnotic medication for sleep and so we might think about how to taper that medication off.

One of the big take home messages from yesterday's talk was really thinking about taking our time with medication discontinuation. A lot of times what ends up happening is we go too fast, particularly we go too fast towards the end. So there's the concept known as hyperbolic tapering, which means that at the beginning when we're on a full dose of medication, often a significant reduction, like a 25% reduction only results in a very small reduction of the percentage of occupancy of that receptor site. What ends up happening, and we see this clinically, is that oftentimes the first part of a taper is fairly uneventful. If somebody is on say, 225 milligrams of venlafaxine, we go down to 150, no big deal. Maybe we even go down to 75, no big deal. And that's because we're reducing the occupancy at those serotonin and norepinephrine transporters by only a small percentage, even though we're going down perhaps 50% on the total number of milligrams. But when we get down to that last stretch, that's when things tend to get clinically challenging. And this is when we tend to hear from patients who are complaining of say, paresthesia across their scalp, what are sometimes referred to as brain zaps, or they're feeling like they're coming down with the flu. And it's at that point, we really have to slow down the process.

One of the challenges sort of practically for de-prescribing is oftentimes the increments of medication that are commercially available they're too big of a step. So even to go from, say, using the venlafaxine example, to go to 150 to 75, now down to 37.5, which those would be the sort of pill size increments. Well, what do you do when you want to go from 37.5 to lower than that? It doesn't come in at least an extended release version smaller than that. So this is one of the things where we talked about how to use some liquid medications, sometimes as a means of slowly tapering medication. There is now a telehealth company that will work with patients and a compounding pharmacy to slowly reduce their dose of medication. You can also do things like introduce a longer-acting medication like fluoxetine at the same time that you're tapering the venlafaxine because venlafaxine has a short half-life, fluoxetine has a long half-life. Once you stop that fluoxetine, the fluoxetine is very slowly fades out of the patient's system, which makes that transition off of a serotonergic medication easier.

Andrew Penn, MS, PMHNP, is a clinical Professor in the University of California, San Francisco, School of Nursing where his teaching has received the UCSF Academic Senate Distinction in Teaching Award, among other recognitions. He has practiced as a psychiatric/mental health nurse practitioner, treating veterans and training residents at the San Francisco Veterans Administration Hospital. As a researcher, he collaborates on psychedelics studies of psilocybin and MDMA in the Translational Psychedelics Research (TrPR) lab at UCSF, serving as Co-PI on a phase 2 study of psilocybin for depression and is currently working on a study using psilocybin to treat depression in patients with Parkinson’s disease. A leading voice in nursing, he is a co-founder of the Organization of Psychedelic and Entheogenic Nurses (OPENurses.org), advocating for the perspective of nurses in psychedelic therapy, he has published on psychedelics in the American Journal of Nursing, Frontiers in Psychiatry, and The Journal of Humanistic Psychotherapy.