Top Strategies for Deprescribing in MDD Care

Determining when to take a patient off of a medication and honoring their wish to discontinue medication, all while ensuring their well-being, can be a tough balancing act. Especially when treating chronic conditions such as depression, clinicians may be unsure about exactly when to deprescribe. 

In part 1 of this Q&A, Andrew Penn, MS, PMHNP, a clinical professor at the University of California, San Francisco, and Saundra Jain, MA, PsyD, LPC, an adjunct clinical affiliate at the University of Texas at Austin, discuss the importance of deprescribing in various disease states, shedding light on the nuances of managing medications for conditions like depression and schizophrenia. Penn also shares valuable strategies, emphasizing the significance of gradual tapering and careful monitoring.

Stay tuned for part 2

Answers have been lightly edited for clarity.

Saundra Jain, PsyD: When thinking about deprescribing, we have many different disease states we care for, and many of those require medications. Are there any that you'd speak to that you would want our audience to home in on and listen to?

Andrew Penn, PMHNP: When we think about the diseases that we treat, we've got episodic diseases like depression, and then some diseases are more chronic and enduring, such as schizophrenia and chronic depression. Those 2 different disease states call for other strategies. Of course, we've all heard patients ask if they're going to have to take an antidepressant for the rest of their life when starting a new medication, and the good news is, for many people, the answer is no. However, the tricky question is when we should take people off. The conventional wisdom that I was trained on says you don't want to do it too early due to the risk of relapse, but you also want to honor people's wish not to be on a medication for a long time.

Now, usually this is safest with people that have not had many episodes of depression, but let's say somebody has an episode of depression, and they go on a medication. They've been on it for 6 to 12 months, and they remit and they say want to stop taking it. This is where doing a gradual taper really makes a lot of sense, watching both for physiologic withdrawal symptoms and the return of a depressive episode. Sometimes what we find out when we take somebody off an antidepressant is that depression was kind of waiting in the wings to come back in. So the person will go off the medication and they'll find the depression coming back, and other times people go off of it and the depression doesn't come back. Then we just maintain surveillance to make sure that they're not falling back into depression as time goes on.

Jain: We've previously discussed the need to have a complete medication list; a patient's full history, context, how they're presenting currently with symptoms, but like you've said previously, you don't want to have more medicines on board than you need. How do you navigate that in order to have the fewest number of medicines for our patients?

Penn: Whenever we can consolidate and make things more simple, then that's ideal. One thing that I find is that a lot of people have more than one provider. So for example, I work in the VA, and a lot of our veterans may have health insurance from other providers because they're employed and have insurance there. They're seeing outside providers, and then I find out later that they're taking medicine from that provider that I didn't even know about—not because they're trying to hide anything, but because they didn't think it was worth mentioning. One of the things that I like to do is suggest they bring all of their medications in to an office visit, then we'll lay them out on the desk and I'll have the patient tell me what it is, why they need it, and how often they take it. Then we can ensure they're not doing anything dangerous.

Jain: It's a great way to do it.

Saundra Jain, MA, PsyD, LPC, is an adjunct clinical affiliate, School of Nursing, at The University of Texas at Austin, and a psychotherapist in private practice. Dr. Jain is a co-creator of the WILD 5 Wellness Program and co-author of a well-received workbook written for those interested in improving their mental wellness - KickStart30: A Proven 30-Day Mental Wellness Program. She is co-creator of the Psychedelics and Wellness Survey (PAWS) exploring the intersect between psychedelics and wellness. She serves as a member of the Psych Congress Steering Committee providing direction regarding educational gaps/needs for mental health practitioners, and Sana Symposium providing psychedelics education for mental health and addiction professionals.

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 cofounder of the Organization of Psychedelic and Entheogenic Nurses (OPENurses.org).