One of the best psychiatrists I know ran a large
antipsychotic long-acting injectable (LAI) clinic and the largest clozapine clinic
in the state. There was not a side effect he had not seen or addressed related
to medications. He also happened to be one of the most well-liked clinicians I have
ever known. Years after he left our clinic
his former patients would approach me in the hallways and ask me if I knew how
he was doing.
Since I was in acute care, I would occasionally see one of
his patients on my inpatient service and call him about that. One day we had a
conversation about polypharmacy and all of the guidelines at the time. Quality assurance guidelines said that monotherapy
in any general class of antipsychotics, anxiolytics or mood stabilizers was
preferred at the lowest effective dose. We both recalled many patients where
that was not true and even slight changes in their medications resulted in
significant destabilization. In some
cases the destabilization was so severe it resulted in long term care in a
state hospital.
Both of us had the privilege of practicing in a time when
the only atypical antipsychotics were clozapine and later risperidone and
olanzapine. But we also saw a lot of people who had been stabilized on first generation
antipsychotics that were used for treatment for bipolar disorder, psychotic depression,
and schizophrenia. In those days it was
very appealing to consider starting lithium and stopping the antipsychotic,
stopping the antipsychotic due to a movement disorder (tardive syndrome or
akathisia), stopping the antipsychotic trying to get to antidepressant
monotherapy, stopping the antipsychotic to get to antipsychotic monotherapy,
stopping the antipsychotic due to more typical side effects, or stopping the
antipsychotic just on the general thought that they were bad medicines
that should be taken only in desperate situations.
We reviewed a number of clinical scenarios involving polypharmacy. He told me that some of his patients were
taking an embarrassing list of medication. He used the term because the medication list
flew in the face of conventional wisdom at the time about how
medications should be prescribed. He had
tried to alter the medications to approach those idealized guidelines but the
patients did not do well and he invariably had to go back to the original combination.
Most of these patients had come out of
state hospitals where they were observed for months or in some cases years on
this medication. He followed everyone closely,
knew their family and social situations, and whether he would admit it or not
did supportive psychotherapy. He saw people on a weekly basis during these
medication changes.
I shared my same experience with him. I had been trained by the authors of The Lithium
Encyclopedia. They also ran the Lithium
Information Center at the time. My training was that people with bipolar
disorder should be treated with lithium. I was seeing people with clear cut
bipolar disorder who were stabilized on chlorpromazine – the oldest
antipsychotic medication. I knew how to start lithium and gradually taper
chlorpromazine so why not do it? The person
I am thinking of had dry mouth as the most significant side effect of
chlorpromazine. When the lithium level
was therapeutic for a few weeks, I started the slowly taper of what was considered
a low dose of chlorpromazine. When the
uneventful taper was over it took just 2 weeks for the patient to experience a
manic episode that required hospitalization and restabilization on
chlorpromazine.
And so, the stories went.
Apparently successful transitions with weeks to months off of a particular
medication, nothing that would be considered a discontinuation or withdrawal
effect, and then relapse to the primary disorder. My personal experience was meager compared
with what I witnessed as an inpatient doc.
I saw the worst possible outcomes of these medication discontinuations including suicide attempts, homicides, high speed chases and other confrontations with the police including
shoot outs, inadequate self care including stopping life saving medications
like insulin, and destabilization of living situations and homelessness. I even
had to put up with blowback from people I had stabilized. I was criticized by
one of my bosses for an aggressive patient on the inpatient unit who was there
because an outpatient provider decided to change the medication I had just stabilized
the patient on because of concerns about weight gain.
To be clear, there are many reasons to stop medications or
change them. I am an expert at
that. There is also no assurance that a
specific dose of medication will continue to work well forever. Environmental changes like sleep deprivation
can trigger relapse in people who are on effective maintenance medications. All of the usual lifestyle factors need to be
addressed. But it is a clear mistake to think that lifestyle factors or
psychological interventions alone are enough to keep people stable in those who
need them. Risk stratification is also important. I have a review that I co-wrote with Ron Pies, MD coming out next month. One of the studies we reviewed looked at all of the antidepressant prescriptions in the country. Only 3% of that population was ever hospitalized. It is a good idea to include that risk in any risk/benefit decision on either side of the prescribing equation.
Political approaches to complex medical problems never
work. The idea that a government official
with no knowledge of the field can start a massive deprescribing program or
proclaim that he knows the cause of autism is hopefully the absurd conclusion that
medications rather than mental illness is the main problem. At a more subtle level, deprescribing
is has infiltrated the popular culture as a magical solution. It is widely promoted but has no more legitimacy
than the old term that I have used for decades – discontinuation. Deprescribing carries with it the implicit
notion that medications, especially psychiatric medications are overprescribed and either harmful
at best or lethal at worst. None of that is consistent with the literature or
the experience of clinical psychiatrists.
As I have written many times before - nobody that I ever met inherently
wants to take a medication every day.
That includes myself. That decision requires a careful risk/benefit
decision. Rational thinking would lead to a decision to keep taking a
medication with a favorable risk/benefit/analysis. That decision is complicated by personal
values, personal preferences, cognitive ability, and medication tolerance and efficacy. It is further complicated
by placebo effects, nocebo effects, and habituation to side effects. As an experienced clinical psychiatrist, I can
say unequivocally that it is rare to find a person who needs a medication and
cannot tolerate all of the medications in that class. Notice I said rare, because I am sure those
people exist.
Whether you are a psychiatrist or a patient considering the current
deprescribing hype either in social media or the professional literature keep
this in mind. These statements are made
with a degree of certainty that does not exist.
Carefully consider the circumstances and err on the side of caution. I
don’t anticipate that people advocating deprescribing at a global level will be
measuring any outcomes. I hope that some of the experts in observational
studies will be able to design outcome studies. The harms of medication discontinuation
and deprescribing need to be documented before anyone can truly give informed
consent.
George Dawson, MD, DFAPA
Supplementary 1:
Galbraith’s concept of conventional wisdom includes the
following:
Acceptability over Truth: People associate truth with
what is convenient or reassuring. Ideas become "conventional wisdom"
because they fit comfortably with existing preferences, self-interest, and
social norms. Creates obvious inertia
against any identified out-groups and easily reinforced by rhetoric rather than
reality.
Resistance to Change: Because people invest prestige
and stability in these accepted ideas, conventional wisdom resists updates even
as real-world circumstances shift underneath it. Antipsychiatry rhetoric is making ideas like
the need for deprescribing conventional wisdom and accepted without any critical
challenge even though it does not match reality.
Breakdown via Events, Not Arguments: Galbraith argued
that conventional wisdom is rarely overturned by debate or logical argument.
Instead, it only breaks down when hit by the unyielding force of events—when
real-world circumstances change so drastically that the old ideas can no longer
explain reality. All of the rhetoric
against psychiatry has not been able to destroy psychiatry precisely because
all of the rhetoric of overprescribing, conflict of interest, social control,
etc does not match the reality of the providers of last resort who are actually
interested in severe mental problems.
The conventional wisdom mentioned in the above post were quality assurance guidelines about medication usage that were not empirically derived.
Note that the third feature of conventional wisdom (if accurate) is why the Trump?MAGA ideology may be unravelling as the events and obvious failures accumulate.
Ref:
Galbraith JK. The
concept of the conventional wisdom.
In: Galbraith JK. The Essential Galbraith. Houghton Mifflin,
Boston, 2001: 18-30.
