Clinical Focus
Deprescribing
When less medication is better medicine: systematic, evidence-based medication simplification.
What is it?
Deprescribing is the systematic process of reducing or discontinuing medications that are unnecessary, ineffective, or potentially harmful. It is not simply stopping medications. It is a deliberate, evidence-based clinical process that involves reviewing the rationale for each medication, evaluating ongoing benefit versus risk, tapering gradually, and monitoring for withdrawal or symptom recurrence.
Psychiatric polypharmacy has increased dramatically over the past two decades. Many patients arrive at our practice taking three, four, or five psychiatric medications prescribed sequentially by different providers, often without a unifying diagnostic formulation. Each medication was added to address a new symptom or a side effect of a previous medication, creating regimens that are complex, expensive, and burdened by cumulative side effects.
Clinical Presentation
Deprescribing is appropriate when a medication was prescribed for a condition that has since resolved, when it was prescribed based on an inaccurate diagnosis, when the side effect burden outweighs the benefit, when medications interact adversely, or when a patient's clinical picture has changed.
Common scenarios: patients prescribed both an SSRI and a benzodiazepine when the SSRI alone would suffice at adequate doses; patients on multiple medications for depression when the underlying condition is actually ADHD or bipolar disorder; patients on antipsychotics originally prescribed for insomnia that are no longer needed; and regimens that accumulated over years of brief appointments where adding was easier than subtracting.
Our Approach
Accurate diagnosis is the prerequisite for rational deprescribing. A patient cannot be safely tapered off an antidepressant until we are confident the antidepressant is treating the right condition. If the underlying diagnosis is wrong, removing the medication may unmask the true condition.
Polypharmacy creates its own diagnostic confusion. Medication side effects can mimic psychiatric symptoms: fatigue from one medication is treated with a stimulant; insomnia from the stimulant is treated with a sedative; weight gain from the sedative triggers another prescription. Each addition made sense in isolation; the combination makes no clinical sense.
Cognitive side effects of polypharmacy are a particular concern. Anticholinergic burden, sedation, and drug interactions can produce concentration difficulties, memory complaints, and processing slowdowns that mimic ADHD or early cognitive decline. We have seen patients referred for dementia evaluation whose cognitive complaints resolved after medication simplification.
Treatment Approach
We begin with a comprehensive medication review during the initial 60 to 90 minute evaluation. For each medication, we assess the original prescribing indication, current clinical benefit, side effect burden, and whether the underlying diagnosis is accurate. We then develop a staged plan in collaboration with the patient.
Medications are tapered one at a time with adequate monitoring between each change. Some medications, particularly benzodiazepines and certain antidepressants, require particularly slow tapers. We set clear expectations: deprescribing takes months, not weeks. The goal is not minimal medication for its own sake. The goal is the simplest regimen that effectively manages the accurately diagnosed condition.
Why This Is Different at Our Practice
Deprescribing requires enough time to take a comprehensive medication history and the diagnostic expertise to determine whether each medication is treating the right condition. A 15-minute medication check is not sufficient to evaluate a five-drug regimen. Our 60 to 90 minute evaluations exist precisely for this kind of clinical complexity.
Dr. Lodhi and Dr. Patel both completed neuropsychiatry fellowships at Stanford. When we tell a patient that a medication is unnecessary, that assessment comes from physicians trained to understand the neurobiological effects of every drug in the regimen. Patients who come to us on five medications often leave on two.
Psychiatrist: Dr. Lodhi, Dr. Patel, and Dr. Staley
Frequently Asked Questions
Is deprescribing safe?+
Yes, when done systematically under medical supervision. Deprescribing involves gradual tapering of one medication at a time with close monitoring. Abruptly stopping medications is not deprescribing and can be dangerous.
Will I need to stop all my medications?+
Not necessarily. The goal is the simplest regimen that effectively treats your accurately diagnosed conditions. Some patients reduce from five medications to two. Others find their medications are appropriate but need dose adjustments.
How do you decide which medications to taper first?+
We prioritize medications prescribed for an incorrect diagnosis, medications causing the most side effects, medications with the weakest evidence, and medications with adverse interactions.
Can deprescribing make me feel worse before better?+
Some patients experience temporary withdrawal symptoms during tapering, particularly with benzodiazepines, venlafaxine, and paroxetine. We taper slowly and adjust the pace based on your tolerability.