Continuing Medical Education about discontinuation from Psychiatric Times

[Altostrata]

The author of this Continuing Medical Education was a top recipient of payments from pharmaceutical companies and is still on many pharma speaker's bureaus.  

About the author: "John J. Miller, MD, was on the Speakers Bureau for Pfizer Inc, until April 26, 2012. He is currently on the Speakers Bureau for AstraZeneca, Sunovion, and Forest; is a consultant for AstraZeneca and Sunovion; and holds Pfizer stock in the amount of $3552."  

http://www.medscape.com/viewarticle/780835

Psychiatrists Top List of Big Pharma Payments Again Deborah Brauser Mar 14, 2013

"The list's number 3 position is occupied by John J. Miller, MD, medical director of Brain Health in Exeter, New Hampshire, and a staff psychiatrist at Seacoast Mental Center. The report notes that he received $669,935 since 2009 from AstraZeneca, Forest, and Pfizer."

  http://www.psychiatrictimes.com/cme/discontinuing-medications-when-why-and-how/
Discontinuing Medications: When, Why, and How-to
CME | July 19, 2013 |  By John J. Miller, MD

Most often, psychiatric medications are discontinued unilaterally by the patient, without the psychiatrist’s input or consent. This creates a burden on the mental health system when discontinuation of medication results in decompensation into a psychotic, manic, or severely depressed state that leads to an emergency psychiatry visit or hospitalization.  

As clinicians, our best preventive strategy is educating patients and their caregivers about why the medication is being prescribed, what the adverse effects are, how to manage the adverse effects, and the risk of relapse with abrupt medication discontinuation. Setting the stage early with a discussion about medication discontinuation is time well spent. Pregnancy, medical comorbidities, extended travel abroad, relocating geographically, change in insurance/financial status, and converting to a medication-aversive religion are just a few of the occurrences that create an immediate need to discuss the risks and benefits of medication adherence.

If discontinuation of a medication is inevitable, a planned discontinuation will optimize outcomes. Table 1 lists many common scenarios in which a planned discontinuation occurs. The psychiatrist’s role is to act as a consultant to maximize the likelihood of a successful taper and discontinuation, and minimize collateral morbidities or withdrawal complications.

....
Once a patient has made a clear decision for a medication-free trial, it is important to collaborate with him during this process. Ideally, this includes regular follow-up visits to monitor the patient for early signs of relapse and withdrawal or discontinuation symptoms. Assure the patient that you will remain active in his treatment, despite your disagreement with the decision to stop the medication, and that you will restart the medication at any time as needed.

In rare cases, when medication discontinuation creates a risk of danger to the patient or others, legal intervention may be required, including the possibility of requesting a court-appointed guardian to make the final decision. One example of this is a patient with recurrent MDD, currently symptom-free and receiving medication, who has a history of high suicide lethality when depressed. Another example is a patient with schizophrenia, currently with remission of positive symptoms, who experiences auditory hallucinations and delusions when decompensated and places others in serious danger. ....

Edited March 7, 2014 by Altostrata
fixed text

[Altostrata]

Current evidence-based guidelines
The American Psychiatric Association has developed guidelines to aid in the treatment of many major mental illnesses....

Major depressive disorder. .... A higher degree of confidence for discontinuing pharmacotherapy for MDD occurs when the patient completes a course of adequate cognitive-behavioral therapy or interpersonal psychotherapy. The antidepressant medication should be slowly tapered over several weeks at a minimum.

Bipolar disorder. .... The guidelines are outdated and in dire need of an update. It is common practice to treat bipolar I disorder with lifelong maintenance pharmacotherapy, but the published literature is limited on this topic. There is consensus that maintenance pharmacotherapy should follow a single manic episode.
 
Schizophrenia. .... This guideline states that antipsychotics for maintenance treatment “substantially reduce the risk of relapse in the stable phase of illness and are strongly recommended. . . . Indefinite maintenance antipsychotic medication is recommended for patients who have had multiple prior episodes or 2 episodes within 5 years.”
 
Obsessive-compulsive disorder..... The guidelines state: “Successful medication treatment should be continued for 1 to 2 years before considering a gradual taper by decrements of 10% to 25% every 1 to 2 months while observing for symptom return or exacerbation. ....”

Panic disorder. .... The guidelines recommend continuing pharmacotherapy for 1 or more years after acute symptom response to allow further symptom improvement and to minimize risk of relapse. The recommendation when using SSRIs, SNRIs, and TCAs is to lower the dosage slowly every month or two and monitor for early symptoms of relapse. The recommendation for benzodiazepines is a decrease in dosage no faster than 10% weekly.....

Strategies and considerations during discontinuation
When meeting with a patient who is requesting medication discontinuation, the first step is to engage in a conversation aimed at having the patient reconsider his decision. Exploring all of the reasons that contributed to the patient’s decision for medication discontinuation provides insight that can help address his concerns. Detailed documentation in the patient’s medical record of this conversation is important. In some cases, it may be prudent to have the patient or guardian acknowledge competent understanding of the risks involved with discontinuation and sign an informed consent.
....
Occasionally, there may be serious adverse effects with the continued use of a medication. Neuroleptic malignant syndrome can occur with any dopamine-2 receptor antagonist, and leukopenia can be a consequence of clozapine treatment. Serotonergic agents can cause serotonin syndrome, which is as serious and life-threatening as neuroleptic malignant syndrome. The risk of a benign rash with use of lamotrigine for bipolar disorder and other mood disorders is as high as 10%; the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis in adults is 0.08% (higher in children).

Unplanned pregnancies present an especially difficult challenge, because the risk of relapse of the primary psychiatric disorder may cause greater harm to the developing fetus than continuing the medication. Mania, severe depression, severe anxiety, and psychosis can significantly affect fetal development. With some medications, such as lithium, divalproex, carbamazepine, and the benzodiazepines, the first trimester presents the greatest risk of teratogenesis. Exposure in the third trimester is of greater concern with other agents, including the serotonin reuptake inhibitors.
....
When an immediate medication discontinuation is not required and the patient is agreeable to a planned taper, there are many pharmacokinetic and pharmacodynamic factors to consider that will maximize a successful discontinuation (Table 2). In general, the longer the patient has been receiving the medication and the higher the maintenance dosage, the slower the taper. This is especially true for SSRIs, SNRIs, antipsychotics, lithium, and benzodiazepines.


 
Abrupt discontinuation of an SSRI or SNRI, with the exception of fluoxetine (because of its long half-life), can result in serotonin discontinuation syndrome. Although not dangerous, serotonin discontinuation syndrome can cause significant distress for a patient, not uncommonly resulting in a trip to the emergency department because of the patient’s fear that some serious brain insult has occurred. Often, the acute distress from serotonin discontinuation syndrome is misinterpreted by the patient as relapse of symptoms, and the patient can become fearful of tapering and discontinuing the medication.

Many antipsychotics have complex receptor binding profiles, and abrupt discontinuation of these agents can produce a wide range of withdrawal symptoms (Table 3). For more potent dopamine-2 antagonists, withdrawal dyskinesia can be quite unsettling, although it is rapidly reversed by restarting the antipsychotic at its previous dosage and then proceeding with a much slower taper. Other abrupt withdrawal effects include psychosis, cholinergic rebound, histaminergic rebound, and α-adrenergic rebound.

 

It is generally accepted that rapid discontinuation of lithium increases relapse risk compared with gradual discontinuation for a patient with bipolar disorder. Although controversial, some findings suggest that after lithium discontinuation and subsequent symptom relapse, a person is less responsive to lithium when it is restarted.9 Acute benzodiazepine discontinuation can be life-threatening, putting the individual at risk for hypertension, cardiac complications, and seizures.

Conclusion
The decision to discontinue a psychiatric medication involves weighing the risks versus the benefits. Abrupt discontinuation, although occasionally necessary, results in a higher incidence of withdrawal symptoms, relapse, and other complications. Once the decision has been made by a competent patient to discontinue medication, even if you disagree with the patient’s decision, a thoughtful and gradual tapering strategy should be designed based on the pharmacodynamic, pharmacokinetic, and disorder-specific factors that exist.

[Barbarannamated]

"The guidelines state.." makes me go twitchy.

[Rhiannon]

yeah, gotta love it. Instructions for how to quit drugs, from a guy hired by drug dealers. What could possibly go wrong?