Deprescribing Can You Stop Meds?

A man in his early fifties visited my practice a couple of years ago, struggling with a major depressive episode fueled by a difficult period in his marriage. He displayed the hallmark symptoms: a heavy sadness that clung to him, lost interest in his usual pastimes, shifting sleep and eating patterns, and a constant feeling of hopelessness. I started a course of Zoloft and offered regular talk therapy alongside the medication. Within six months, his depression had eased considerably, though challenges in his marriage remained. 

Then he raised a question that highlights a common misconception: "Doc, am I going to have to stay on this Zoloft indefinitely?" While feeling more like himself again, he was understandably concerned about the medication's impact on his libido. 

His situation sheds light on the widespread, but false, belief that psychiatric medication always equals a life-long commitment. This notion, unfortunately, persists both in the general public and even among some healthcare professionals. 

In this particular instance, his history indicated a safe route for gradually tapering and then stopping the Zoloft, followed by close monitoring. The only other time he had struggled with depression was many years prior, during his twenties, and had recovered at that time without medication. 

Like other doctors, psychiatrists are primarily trained to diagnose and actively treat health concerns. We are adept at pinpointing the right medication to provide relief; the concept of "de-prescribing" sometimes gets less emphasis. 

Let's explore what "de-prescribing" means. 

Deprescribing is a thoughtful process where a doctor determines that a medication, or other treatment, has served its intended purpose and a plan is made for safely discontinuing it. It's less common than it should be, partly due to the tendency to associate chronic illnesses, like depression, with lifelong treatment. 

However, even chronic conditions such as depression ebb and flow in severity and can impact people quite differently. If you've recently emerged from your first major depressive episode, there is a moderate risk of another within the first year of ending medication – roughly a 33-50% chance. Yet, this also means that more than half of those who recover continue to thrive without ongoing medication. The overall lifetime risk of recurrence following a single episode remains around 60%, but that doesn't mean a relapse is guaranteed to happen soon. 

Because of this, if someone has experienced a single depressive episode, it's often wise to explore ending medication after a solid recovery period (usually at least six months to a year). 

Of course, there are always exceptions. If someone struggled with a particularly severe first episode, especially one involving thoughts of self-harm or a major disruption to their life, continuing long-term treatment might be recommended to manage risks. Those with a history of multiple depressive episodes are also more likely to need long-term medication; after five episodes, the chance of experiencing another rises to roughly 80%. 

Finally, there are specific chronic illnesses such as bipolar disorder and schizophrenia where lifetime medication is generally essential to prevent severe setbacks. 

Deprescribing popular anti-anxiety medications 

De-prescribing isn't just relevant to depression; there are other situations where careful consideration of ending treatment is crucial. One such area involves the use of popular anti-anxiety medications called benzodiazepines, which include well-known names like Klonopin, Ativan, Xanax, and Valium. 

These medications are fast-acting and highly effective at managing various types of anxiety, but their potential for dependence and significant long-term side effects is a serious concern. 

Benzodiazepines are generally safe and helpful when used on a short-term basis. Unfortunately, what often happens is that doctors prescribe these medications during times of intense stress or life events and then inadvertently continue the treatment long after the initial crisis has passed. 

A common scenario is using benzodiazepines like Ativan to manage the anxiety and insomnia frequently associated with depression while waiting for an antidepressant to take full effect (which can take several weeks). Ideally, once the depression lifts, the benzodiazepine should be discontinued, but it's incredibly common for these medications to be prescribed indefinitely out of habit or at the patient's insistence. 

Failing to de-prescribe benzodiazepines like Klonopin or Ativan can have consequences. These medications have the potential to cause reversible, but nonetheless concerning, cognitive side effects such as impaired memory and decreased focus. They can also slow down reflexes and reaction time, increasing the risk of falls, particularly in older individuals. 

Understanding the issue of "polypharmacy" 

Perhaps no clinical situation calls for more thoughtful de-prescribing than "polypharmacy," which refers to the use of multiple medications at the same time. 

Let's imagine a patient who began taking Lexapro for depression but wasn't seeing the desired results. Wellbutrin, another antidepressant, was then added, but this too failed to bring significant relief. Next, Zyprexa, an antipsychotic medication sometimes used to enhance the effect of antidepressants, was layered into the mix. The patient feels better but complains of feeling overly sedated, so a low dose of the stimulant Adderall was added to combat the fatigue. Now, the patient is on a total of four medications, feels better overall, but is also grappling with a range of side effects. 

It's important to be clear – there is strong evidence supporting the use of multiple medications in what's known as "augmentation treatment" for various psychiatric conditions. However, there's also a lot of unnecessary polypharmacy caused by failing to carefully evaluate the effectiveness of each medication before adding another. 

Without this evaluation, you end up with a complex mix of psychotropic drugs, making it impossible to determine which medications are actually helping and which are contributing to unwanted side effects. Gradually de-prescribing medications, one at a time, can bring clarity back to a treatment plan. 

Depending on your specific condition, if you've experienced significant improvement and no longer have any symptoms, it's well worth discussing with your doctor whether carefully ending your medication could be the right next step. Naturally, never abruptly stop a psychiatric medication without your doctor's guidance. 

Additionally, if you're currently taking a combination of psychiatric medications, it may be worthwhile to talk to your doctor about whether strategic de-prescribing might simplify your treatment plan without sacrificing any benefits. 

The result could be a welcome improvement in your overall well-being. 

The risks of long-term benzodiazepine use 

The concerns surrounding the long-term use of benzodiazepines like Valium or Xanax warrant further attention. While highly effective in the short term, these medications carry several risks when used over extended periods: 

• Tolerance: The body can build up a tolerance to benzodiazepines, meaning that over time, you need higher and higher doses to achieve the same level of relief. This can increase the risk of dependence and addiction. 
• Dependence and addiction: It's surprisingly easy to become physically dependent on benzodiazepines, even when taking them as prescribed. This dependence can develop within weeks, sometimes even sooner. Addiction, which involves compulsive drug-seeking behavior, is a less common but very serious potential risk associated with long-term use. 
• Withdrawal: If someone who is dependent on a benzodiazepine abruptly stops taking it, they may experience severe withdrawal symptoms. These can include increased anxiety, insomnia, tremors, seizures, and even delirium in some cases. Careful tapering under medical supervision is essential to minimize withdrawal risks. 
• Cognitive decline: Studies suggest that long-term benzodiazepine use can be associated with an increased risk of cognitive decline and dementia, particularly in older adults. While there is still debate about the cause-and-effect relationship, it's definitely a concern worth noting. 
• Accidental overdose: Mixing benzodiazepines with alcohol or other sedative medications like painkillers can be deadly. This risk is heightened when medications are not carefully prescribed and monitored. 

Safely tapering down: A collaborative approach 

If you've been taking benzodiazepines for a while and are considering stopping, it's crucial to never attempt this alone. Your doctor will guide you through a tapering process to gradually reduce your dosage over time. This minimizes withdrawal symptoms and makes for a smoother transition off the medication. 

The length of the taper will vary based on several factors, including the type of benzodiazepine, the dosage you've been taking, and how long you've been on it. Sometimes the transition involves switching to a longer-acting benzodiazepine with less intense withdrawal effects as an initial step. 

Along with the physical taper, it's equally important to address the underlying reasons why you started taking benzodiazepines in the first place. If you suffer from an anxiety disorder, therapy such as cognitive-behavioral therapy (CBT) can be incredibly helpful in learning coping skills and managing anxiety without relying on medication. 

De-prescribing: A patient-driven conversation 

The concept of de-prescribing is one that doctors and patients should embrace more wholeheartedly. If you're taking medication, it's always reasonable to have periodic discussions with your doctor about whether it's still the best course of treatment. Taking charge of your health in this way is vital. After all, your doctor can only make the best decisions based on the information you share with them. 

Empowering yourself with knowledge and open communication are key to ensuring you receive the best care. Don't be afraid to ask questions like: 

• Is this medication still necessary? 
• What are the potential risks of continuing this medication for a long duration? 
• If I decided to stop this medication, what would that process look like? 

De-prescribing other types of medications 

The benefits of thoughtful de-prescribing aren't limited to psychiatric medications. There are various situations where stopping or reducing medication makes sense: 

• Proton pump inhibitors (PPIs)

 These medications, such as Prilosec and Nexium, are frequently prescribed for acid reflux and heartburn. While helpful in the short term, overuse is surprisingly common. Long-term use of PPIs has been linked to several potential health risks, including an increased risk of bone fractures, gut infections, and vitamin and mineral deficiencies. If your initial symptoms have been resolved for some time, it's definitely worth discussing with your doctor whether you can discontinue or reduce your PPI medication. 

• Long-term sleeping pills

 Like benzodiazepines, sleep aids such as Ambien and Lunesta become less effective over time and carry risks of dependence, cognitive issues, and daytime drowsiness. If you've been relying on these medications for a long period, a better long-term solution might be a treatment called Cognitive Behavioral Therapy for Insomnia (CBT-I). This form of therapy focuses on developing healthy sleep habits and thought patterns that promote natural sleep without the need for medication. 

• Cholesterol-lowering medications (statins)

 Statins are widely prescribed and effective at reducing the risk of heart attack and stroke in those at high risk. However, they can also cause side effects, most commonly muscle aches and pain. If you have been taking a statin and your risk factors for cardiovascular disease have improved (such as losing weight, lowering your blood pressure, and quitting smoking), it might be possible to discuss reducing or stopping your statin with your doctor. 

• Blood pressure medications

 If lifestyle changes, such as getting regular exercise, improving your diet, and managing stress, have lowered your blood pressure, you might be able to safely reduce or eliminate blood pressure medications. Of course, this must always be done under a doctor's guidance. 

Important note: Never stop taking any medication without consulting your doctor first. Abruptly stopping certain medications can have serious side effects or lead to the return of your original symptoms. 

The role of non-medication strategies 

It's essential to remember that medication isn't the only solution to health problems. Often, lifestyle changes and non-medication therapies can be equally or even more effective long-term options: 

• Therapy for mental health conditions: If you live with a condition like anxiety or depression, there are several excellent evidence-based therapies (like Cognitive Behavioral Therapy) that can equip you with the skills and tools to manage your condition for years to come. 
• Exercise for physical and mental well-being: Regular exercise offers a wide range of benefits for both physical and mental health. Not only can it improve cardiovascular health, weight management, and bone density, but it can also act as a powerful antidepressant and reduce anxiety. 
• Healthy eating for a stronger body: Diet plays a critical role in our overall health, and what we eat can directly impact various medical conditions. Switching to a balanced, nutrient-rich diet can be a transformative step for many. 
• Stress management techniques: Chronic stress takes a serious toll on both mind and body. Learning healthy coping mechanisms through mindfulness, meditation, or stress-reduction techniques can make a big difference in your well-being over time. 

Key takeaways and empowering patients 

The central themes we've explored about de-prescribing can be distilled into several important points: 

• Medication can be a lifesaver, but not always a lifelong necessity: Medications play a vital role in treating various health problems, but it's important to remember that treatment needs can shift over time. Many conditions, even chronic ones, might not necessitate lifelong medication. 
• De-prescribing is collaborative: Ending a course of medication should always be a thoughtful decision made in partnership with your doctor. Having open conversations and weighing risks versus benefits is crucial. 
• There are often effective alternatives to medication: Lifestyle changes, behavioral therapies, and other non-medication approaches offer powerful alternatives and long-term solutions for many conditions. When coupled with periodic reassessment, it's sometimes possible to safely reduce or eliminate certain medications. 
• Be your own health advocate: Don't hesitate to ask questions and initiate conversations with your doctor about your treatment plan. If you are on medication and feeling well, it's perfectly reasonable to ask, "Is it possible to consider tapering down or stopping this medication?" 

Potential barriers to de-prescribing 

While de-prescribing is a valuable practice, there are some real-world challenges worth acknowledging: 

• The inertia of the status quo: Clinicians are often overworked and pressed for time. It can sometimes be easier to maintain a patient's current medication regimen rather than initiating the careful process of de-prescribing. 
• Patient anxiety: Some patients feel anxious about the idea of stopping a medication that has helped them, even if they no longer experience symptoms. Open communication and a thoughtful tapering process are vital in overcoming these concerns. 
• Lack of awareness: Many doctors and patients might not be fully aware of the concept of de-prescribing and the benefits it can offer, both in terms of well-being and reducing potential medication side effects. 

A call for change 

We need to incorporate de-prescribing more deliberately into standard medical practices. This could involve: 

• More education and training for doctors: Greater emphasis on de-prescribing during medical training would arm physicians with the skills and knowledge to apply it confidently. 
• Patient-friendly resources: Easy-to-understand, reliable information about de-prescribing can empower patients to engage in informed conversations with their healthcare providers. 
• Reimbursement models that reward proactive care: The current system often focuses on treating acute problems. Creating financial incentives for doctors who take the time to evaluate long-term medications and de-prescribe when appropriate could accelerate change. 

Final thoughts 

Medication has the potential to be transformative, offering effective treatment for countless conditions. Yet, it's vital to view medication as one tool within a broader and evolving approach to health and wellness. 

Embracing de-prescribing is a path toward optimizing care, minimizing unnecessary risks and empowering patients to play an active role in their health journey.