Deprescribing in Depression Treatment

Understanding 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 like schizophrenia and depression, clinicians may be unsure about when exactly to deprescribe. 

Join 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, as they discuss the importance of deprescribing in various disease states, shedding light on the nuances of managing medications for conditions like depression and schizophrenia. Nurse Penn also shares valuable strategies, emphasizing the significance of gradual tapering and careful monitoring.

Watch Part 2 of this interview: Top Strategies for Deprescribing in Depression Care

Read the Transcript: 

Dr Saundra Jain: Andrew. I'm wondering, with deprescribing, we have lots of different disease states we take care of.

Andrew Penn: Sure.

Dr Jain: Many of those require medications. So I'm guessing deprescribing is important in some form or fashion, that conversation to be had with patients. But are there any that you'd really speak to that you would want our audience to really home in on and listen to?

Nurse Penn: Yeah. Well, when we think about the diseases that we treat, we've got episodic diseases like depression, hopefully for some people. There are obviously people with chronic depression, and then there are diseases that are more chronic and enduring, such as schizophrenia. And those two different disease states call for different strategies. So of course, we've all heard that question when people start on an antidepressant, "Am I going to have to take this for the rest of my life?" And the good news is, for many people, the answer is no. But then the tricky question is, well, when do we do this? When do we take people off? And conventional wisdom that I was often trained as, you don't want to do it too early because the risk of relapse is there, but you also want to honor people's wish not to be on a medication for a long period of 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, they go on a medication, they've been on it for 6 to 12 months, and they remit and they say, "I think I'd like to stop taking this. How do we approach that?" And this is where doing a gradual taper really makes a lot of sense, watching both for physiologic withdrawal symptoms of that drug, but also the return of a depressive episode. Because 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, and the person will go off the medication and they'll find, "Oh, darn, the depression is right there again." And other times people go off of it and the depression doesn't come back. And that's great. And then we just maintain surveillance to make sure that they're, they're not falling back into depression as time goes on.

Now, with schizophrenia, it's a little more challenging because schizophrenia tends to be more of a chronic and enduring illness. There can be waxing and waning of symptoms, for sure, but usually it doesn't remit entirely, especially once the illness is established. However, we often have to change antipsychotics, either because the antipsychotic wasn't working very well, or the side effects they were having were problematic. And so when we do that, we have to cross taper. So what that means is we keep one medication going while we bring the new medication on board. And it's only when we get the new medication up to a reasonable level do we start to reduce the first medication.

And this can be a little bit tricky. Sometimes, you see patients who are quizzically on two antipsychotics, which are fairly similar in their mechanism of action, both at moderate doses. And what that often shows me is that somebody got stalled out in the middle of that transition. And so we don't want to have people on more medicine than they need to be. And so the idea of finishing that taper is really important. But generally, we don't wait to stop. We don't stop a first antipsychotic entirely before we start a new one because we create this gap in which relapse is more probable. And so that's a little trickier.

Dr Jain: That last example you walked us through reminds me of what you and I talked about yesterday, the need to have a complete medication list. The full history, the context, how they're presenting currently with symptoms, but like you said, maybe two medicines that are doing the same thing, and you don't want to have more medicines on board than you need, but to really have that list and spend some time looking at it and trying to determine, is it time to discontinue one to have the fewest number of medicines for our patients?

Nurse Penn: That's right. Whenever we can consolidate and make things more simple, then that's ideal, really. And another 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 they have insurance there. And so 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. And not because they're trying to hide anything, but they didn't think it was worth mentioning. And so, one of the things that I like to do is just say, "Bring in all your medications into your office visit. Let's lay them all out on the desk, and you tell me what this is and why you take it and how often you take it. And then we can make sure that you're not doing anything that is inadvertently dangerous."

Dr 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).

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