Hello and welcome. I'm Dr. Rob Cotez, Director of the Clinical Research Program for Psychosis at Grady Health System and Associate Professor at Emory University School of Medicine. I'm so pleased that you are joining us for today's SMI Advisor webinar, A Delicate Dance, The Principles and Practice of Deprescribing Antipsychotic Medications. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you to get the answers you need to care for your patients. Next slide. Today's webinar has been designated for 1.0 AMAPRA Category 1 Credit for Physicians and 1 Nursing Continuing Professional Development Psychopharmacology Hour. Credit for participating in today's webinar will be available until May 16, 2022. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Please click the link to download the PDF. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Now I'd like to introduce you to the faculty for today's webinar, Dr. Swapnil Gupta. Dr. Gupta is an Associate Professor and Medical Director of the Ambulatory Psychiatry at Mount Sinai Morningside Hospital. Dr. Gupta was trained as a psychiatrist in both India as well as the United States, working specifically on phenomenological, psychodynamic, and neurobiological approaches towards distressing psychological experiences. Dr. Gupta's current work focuses on developing educational materials on deprescribing psychotropics and eliciting knowledge and attitudes about deprescribing among psychiatrists. Dr. Gupta, thank you so much for leading today's webinar. Thank you so much, Dr. Curtis. I'm so happy to be here and discuss this very important topic for everyone involved in mental health care, not just clinical practice. So I'm really, like I said, I'm really excited. I do not have any relationships or conflicts of interest related to the subject matter of this presentation. My hope is that at the end of this activity, all our attendees and participants would be able to incorporate some of the principles of deprescribing antipsychotics in specific patients and situations where this practice might be applicable. Our attendees would be able to develop more flexibility and adaptability in decision-making around antipsychotics. And finally, they will be able to list some of the key steps of deprescribing antipsychotic medications. Here is an overview of what I will be discussing today. I think the most important part here is what is the need for deprescribing antipsychotics? Why do we really need to develop such an intervention and what is its importance in psychiatry? Next, we'll move on to what some of the proposed definitions are and a little bit on the history of deprescribing, where it comes from in general medicine. Some of the major principles of deprescribing in psychiatry, which will include principles of recovery-oriented care, some basic pharmacology of antipsychotic medications, some basic principles of good prescribing, such as evaluation of risk-benefit ratios, and a consideration of the psychosocial context of medications. Next, we'll move on to the key steps of deprescribing and what is the importance of each of these steps? What are some of the major barriers and pitfalls you might encounter? And finally, references, some additional resources, and most importantly, some acknowledgements from my side. So let's jump into what is the need for deprescribing antipsychotics. So antipsychotic tapering or even antipsychotic cessation may be needed in a variety of situations. To me, the most obvious situation where you might need it is when antipsychotic polypharmacy is being used and we don't know for how long it is needed. A very classic situation where a patient might end up on more than one antipsychotic is when patients change psychiatrists. This was a case that I encountered several years ago where Joe was being tapered off haloperidol and was being placed on clozapine. The psychiatrist was changed when Joe was taking haloperidol 2mg and clozapine 300mg. As Joe looked better, he did not have any psychotic symptoms. He ended up taking the combination for several months. So this is one of the classic situations where patients land up on antipsychotic polypharmacy. Another situation where tapering may be needed is when antipsychotic medications are used as augmenting agents. We know that antipsychotics are used to augment antidepressants in a variety of conditions such as major depressive disorder or obsessive-compulsive disorder. Adipiprazole is one common medication used to augment SSRIs, although nowadays it's even used as monotherapy for treatment of depression. The unfortunate sort of side effect of this is that patients may end up taking combinations for long periods of time and the clinician or neither the clinician nor the patient have any indication of when they could actually taper off the antipsychotic. A third situation is where antipsychotics are used for off-label indications and the commonest offender in this category is cataepine when it's used for insomnia. Adverse effects might pop up and skew the risk-benefit ratio significantly towards deprescribing. For instance, if a patient has taken haloperidol or another first-generation antipsychotic for a long period of time, has had no positive symptoms whatsoever, and has been recently diagnosed with idiopathic Parkinson's disease. If a patient explicitly states that they don't want to take antipsychotics. This was another patient that I encountered several years ago who said that if not taking antipsychotics meant that he would just have to go to the hospital for a couple of weeks in a year, he would very much prefer to do that. So, what exactly is deprescribing? This particular definition has been taken from Scott's paper in 2015, which comes out of the geriatric medicine literature, and it says that deprescribing is a systematic process of identifying and reducing or discontinuing drugs. Please note that it's not just discontinuing. It can just also be just a reduction of the dose in instances where existing or potential harms outweigh the existing or potential benefits. And very importantly for psychiatry, this happens taking into account the patient's general medical status. Do they have diabetes, hypertension, other medical conditions? What is their level of functioning? Are they attending college, going to school? Do they have a part-time job, a full-time job? And patients' values and preferences that are extremely important. So, like I mentioned initially, deprescribing was initially designed in geriatric and palliative care medicine, mainly with the goal of minimizing adverse effect and drug interaction burden. However, as time has passed, other fields of medicine, such as primary care, neurology, cardiology, have also started questioning the continued use of combinations of drugs or even monotherapy. An important point to remember is that deprescribing focuses on parsimonious or careful use of medications rather than complete cessation of a given medication. Now, here are some references for how deprescribing has been mobilized in other fields of medicine. For instance, in neurology, in seizure disorder or epilepsy, the discontinuation of anti-epileptic medications has been considered after a patient has been seizure-free for X number of years. Of course, they take into consideration many different factors, such as what type of seizure the patient had, what is the age of the patient, etc. In cardiology, there was this wonderful paper written by Rosello in 2016, where they are actually questioning the long-term use of ACE inhibitors, statins, beta-blockers, aspirin, in post-myocardial infarction patients. Now, their rationale for questioning this was that we do have data for patients receiving beta-blockers, ACE inhibitors, for up to a year after MMI, but what happens after that? We just don't know for sure. Even in primary care, the continued use of proton pump inhibitors in patients who have GERD, for example, has been questioned. So, moving on to some of the key principles of deprescribing. I've divided them into four blocks here. First is principles of recovery-oriented care, basic pharmacology of antipsychotic medications, using the existing evidence base, and using good prescribing practices, including considering risk-benefit ratio, the psychosocial context of pharmacology, and good, healthy dose of clinical pragmatism. So, recovery-oriented principles, or recovery-oriented prescribing, in this case, because we are talking about medications, is basically conceptualized as a way of thinking about medication as only one of the very many possible recovery tools that a person can use to support their well-being. And it's reimagining medication as just one tool in a whole toolbox. It also includes a range of practices which professionals can use to support people in being more active in taking part in different decisions related to medications. Now, what does this actually mean when we translate it into practice? It means that if a medicine is not supporting but hindering recovery, then the prescriber is going to offer a change in the medications, whether it's tapering, changing, stopping an antipsychotic, and at the same time, constantly offering shared decision-making and supporting the patient's decision to the extent that it's possible safely. So, this is a slide taken from one of the papers written by my colleagues, John Cahill, Rebecca Miller, and me, where we have deployed some of the principles of recovery-oriented care and showed how it's applicable to deprescribing. So, the four main pillars of recovery-oriented care are shared decision-making, person-centered care, and fostering hope and empowerment. And if we look closely at the third column in this table, we see that deprescribing, in fact, aligns very well with all these principles because it is founded in shared decision-making. The treatment or the medication treatment is constantly being individualized to suit the person's needs, their recovery, and their functioning. So, it's very person-centered in that care, in that sense. And we are empowering the patient to take a very active stance in their own medication treatment. And we are definitely fostering hope by emphasizing that what's important here is the patient's recovery, their goals, and their preferences. So, moving on to the next section, this is a little bit dense, but I've simplified it as much as possible. I think these are very, very important principles that we need to remember anytime that we are tapering antipsychotics. We all know that the therapeutic effect of antipsychotics is known to be mediated by D2 or dopaminergic D2 receptor antagonism. So, that's key fact number one. Building on that, the second important fact here is that the relationship between the dose on the serum level of the antipsychotic and the D2 receptor occupancy is hyperbolic. Remember, it's not a straight line, it's hyperbolic, as we see in this curve here. So, what happens when we suddenly stop antipsychotics? There is unopposed dopaminergic action because D2 receptors have become super sensitive and have upregulated due to chronic dopamine blockade. So, this is called dopamine supersensitivity. Now, if we want to reduce the D2 receptor occupancy in a slow and careful way, the reduction of the dose has to be in a hyperbolic fashion. What happens if we reduce the dose in a linear fashion? Let's say if a person is starting off with five milligrams of Haldol and we reduce it by five to four to three, two and one milligram and so on. Because the dose is dropping in a linear fashion, the D2 receptor occupancy will drop as a hyperbolic function of the dose. Going back to remember the last slide where the relationship between the D2 receptor occupancy and the dose of the serum level is hyperbolic. So, if the dose reduction is linear, the D2 receptor occupancy becomes hyperbolic. And that is a problem. When there is a sudden drop in D2 receptor occupancy, a person can develop symptoms of dopamine supersensitivity that can manifest in a variety of ways. I covered that in a little more detail in the section on steps of deprescribing and managing withdrawal symptoms. Now, in addition to D2 blockade, antipsychotics also have many other antagonistic effects, such as antagonism of muscarinic, histamine, serotonin receptors, as well as other types of dopamine receptors. They also have agonistic effects of GABA, glutamate, some subtypes of serotonin and other dopamine receptors. So, accordingly, abrupt cessation of antipsychotic can cause an antipsychotic withdrawal syndrome, which produces cholinergic and histaminic rebound symptoms as well. So, a patient could present with, for instance, severe diarrhea, and there are even documented cases of serotonin syndrome, as well as catatonia, especially in the case of clostridium. There are at least five case reports of catatonia in abrupt cessation of clostridium. All right, moving on. Another important consideration when reducing medication, reducing antipsychotics, is the pharmacokinetics. So, medications with shorter half-life and rapid dissociation from D2 receptors, such as catiopine and clostridium, have a propensity to cause withdrawal symptoms towards the evening, if given as a single lifetime dose, which is, again, a very interesting finding and supports this whole idea of a supersensitivity syndrome or antipsychotic withdrawal syndrome. And it has been seen that some cases of treatment-resistant schizophrenia may actually respond to long-acting injectables instead of oral medications, because LAIs produce less peaks and drops and produce a more stable blood level of antipsychotics. And this reduces the chance of a supersensitivity psychosis, or like a breakthrough psychosis, popping up whenever the blood levels of the medicine drop. Okay, moving on to evidence from, you know, guidelines and evidence from randomized control trials and antipsychotic discontinuation. We know most guidelines recommend that, if a person has been diagnosed with schizophrenia, the antipsychotic medicine should be continued indefinitely. And this recommendation is grounded well in a very robust evidence base that says that there are increased relapse rates in persons who have psychosis once they discontinue the antipsychotic. However, there's a little caveat here. We need to remember that most of these studies discontinued antipsychotics relatively abruptly or over a shortish period of time, often three months or less, which does not really align well with the hyperbolic curve that we saw earlier in this presentation. There was really no individualization of the taper, like the group of people were put on a standard taper schedule, and no psychosocial interventions were offered. So I think these are important things to keep in mind while, you know, while accepting these recommendations mentioned in the national guidelines. Moving on to the risk-benefit ratio. As with good prescribing, we as prescribers want to weigh the risks against the benefits, keeping in mind that we want to weigh the current risks against current benefits as well as potential risks against potential benefits. Now, one of the problems with this kind of an equation is that we don't have, you know, we don't have evidence to answer to fill up all the, to fill the equations with actual numbers. So some of, most of the variables end up just remaining variables. I remember drawing a little table on my whiteboard here to discuss it with my patient, and I ended up filling most of the blocks with, we're not really sure. Another important factor in considering risks versus benefits is they must factor in patient preference and a decision of how much risk is acceptable. Some additional considerations are concepts such as dignity of risk and therapeutic risk. Dignity of risk has been very elegantly defined by Abraham and Davis in 2013 as the principle of, the principle of allowing an individual the dignity afforded by risk-taking, which may, which may subsequently enhance personal growth and quality of life. And the therapeutic risk, the therapeutic risk, which is a related concept, but not quite the same. It says that potential, therapeutic risk is the potentially positive and, potential positive in health and well-being outcomes that can arise from risk-taking, which is somewhat counterintuitive because we assume that risk-taking is always counter-therapeutic. So again, these are two useful concepts to consider while thinking of risk-benefit ratio. The next concept, the next sort of questions to consider are, how is benefit actually defined? Are we defining it in terms of symptoms, that the patient doesn't hear voices anymore, or are we defining it in terms of quality of life, that I reduce the dose of Haldol and the patient is able to sit through class without having to get up and is thereby performing better in their semester exams? Is the mode of achievement of benefit aligned with the patient's values? If the patient says that I prefer to take a small dose of medication and go to group therapy and CBT for psychosis rather than taking a high dose of medication. And the third and important question for all of us as psychiatrists is who is benefiting? Often we are torn between our obligations to consider the safety of the community in addition to considering the safety of the patient. Some of the most powerful effects of medications are from their psychosocial context. We always have to remember that the acts of prescribing as well as swallowing a pill and their subsequent effects are all embedded in this matrix of the patient's psychology, the patient's immediate social surroundings, as well as the larger culture. There is a wonderful paper titled Medication as Object, which says that the medication can function as an object in the psychodynamic sense, and their effects can actually extend way beyond their pharmacodynamics or their effects on the dopamine receptor in this case. And finally, we have to remember that both prescribing and deprescribing from the prescriber's side can sometimes derive their motivation from countertransference. I think this is particularly important in the case of individuals who have serious personality disorders, and that's the idea we have mobilized in this paper by Dr. Feinberg and me, which we wrote in 2019, where we're talking about how patients with personality disorders may actually create very big feelings of the prescribers, and sometimes our prescribing behavior gets motivated by that. Moving on to the next slide, this is just a summary. So it's important to consider the psychological mechanisms at work. The patient might experience deprescribing as a disruption of oral gratification, an activation of a fear of relapse. What are the relationships that are likely to get affected by deprescribing? Especially intimate relationships that may be contingent on ongoing medication of the patient. I've had more than one situation where the spouse threatening to leave a patient if they reduced their antipsychotic. What is the social role that is getting, that the patient has developed because they are on medications? There is an identity as a sick person. Sometimes there are allotment of disability benefits contingent on taking medications. I've heard more than one concern about the possibility of disability benefits getting declined because the patient was not taking enough number of medications. Moving on to the steps of deprescribing. As prescribers, as clinicians, all of us know that choosing the right time is of utmost importance. Careful medication reconciliation. Discussing things, discussing issues with the patient and anyone else that the patient wants to include in this discussion. Preparing and strengthening psychosocial interventions. Making a decision around which medication to taper. Initiating a taper. And then monitoring and adjusting the taper. So there are times during treatment and the patient's life that might be less conducive to reducing medicines. These might be times of increased psychological stress such as bereavement, housing or employment instability, a big change in the care team that would include either the psychiatrist, therapist, or other people in the care team that the patient might be really attached to. But over the years, practicing and deprescribing have come to realize that sometimes there's really no good time and we just have to maybe reframe it as picking the least disruptive time to change medications. So the next step is medication reconciliation. And in my experience, this has been one of the hardest steps. Finding a list of all medications prescribed by all specialties, getting their dose, duration, benefits and adverse effects from the patient is relatively easy. But tracking down the original indication often becomes quite complicated because of poor continuity of care or insufficient records or simply inability to obtain benefits. And it's also very important to solicit what these particular medications mean to a particular patient and what are their attitudes towards the medication. You might also realize during med reconciliation that a patient is in fact not taking a particular medication when the assumption has been all along that they have been taking it. So one particularly striking example of the meanings attached to medication is often patients see that as a connection to the original, see a medication as the connection to the psychiatrist who originally prescribed that medicine and may want to continue taking it just to feel connected to that particular psychiatrist. Here is a sample worksheet where you can review and document all the medications that the patient is taking. The first big column says what medication is the patient taking, what is the dose, what is the form, is it a syrup, pill, how do you actually take it, what were the directions given to you and how do you actually take it, what was the original indication or at least what is the patient's understanding of the original indication and what are some of the pros and cons of continuing to take it, both current and future. I think the last column is again very important because I don't think the first few columns adequately capture all the feelings and attitudes that patients might have towards a particular drug. So in summary, the idea of, when you actually propose this idea of tapering or even stopping a medication, it is going to produce a big emotional reaction and it's important for us to be prepared for it. Often patients can manifest a lot of confusion because their whole lives they have been advised that to stay well, they have to take their pills and if they don't take their pills, they are going to fall sick. So being ready for an emotional reaction is very, very important. The next important step is discussing with the patient what would be the most useful way of providing some education. Would they prefer handouts? Would they prefer to watch videos online together or just talk about it? Many people prefer a handout so they can take them home, read them and come back to discuss. The next step, which again becomes a little difficult and often involves saying, I don't know quite a bit, is conveying the uncertainty about the risks and benefits of tapering and making sure that this is being conveyed in a sensitive way and an understandable way. For instance, there are people who might not be able to understand the concepts of audit issue or relative risk and you might want to put it a little more simply while conveying the uncertainty. One intervention that patients have found very useful is being very clear and saying that I'm not sure about what the risks of tapering the medicine might be. What I can be sure of is that we will do everything to minimize the risks and should you run into a problem, your team is going to be here to look after you. It's really important to create some space for the patient to express their concerns, values, preferences, fears, questions. Lots of questions come up and whenever appropriate, it's a good idea to involve other people in the patient's life, the patient's therapist, maybe even other physicians, if appropriate, a pharmacist. They can only provide more useful information. So what are some of the psychosocial interventions that might be helpful? At this point, I want to emphasize that I'm not proposing that any of these interventions can replace medications. They can support pre-prescribing. So it's a very important thing to remember here. Some things that I found very, very useful are developing a list of early signs of relapse and these may range from insomnia to getting a little more chatty to not wanting to take showers and developing a solid plan of what to do when the patient manifests these symptoms. These would be a part of a WRAP plan, which is a Wellness Recovery Action Plan that I'm sure most of you are familiar with. Providing peer support has been found to be very, very important and it's been seen that peer support during the process of pre-prescribing is very highly valued by the patient. Mobilizing this idea of personalized medicine, and which is proposed by Pat Deegan that is available on her wonderful website, which many of my patients use, and providing, maybe supporting pre-prescribing through active psychoeducation, both about the medications, about illness management, and family therapies. So what are some of the steps in the decision-making around which medication to take? This can be tricky. Now, if a patient comes in on risperidone, a benzodiazepine, Depakote, and Benadryl, as prescribers, we may tend to prioritize drugs which have potential for abuse. In this instance, a benzodiazepine, we might tend to prioritize that medication for pre-prescribing. However, keeping an open mind and conveying some flexibility is really important and that is really supported by this framework of shared decision-making. Again, it's important to solicit preferences for education, provide more information about the meds that the patient is taking, make sure, again, you convey the uncertainty about the risks and benefits in a understandable way, share information, exchange information, openly receive information, and solicit all fears, anxieties, hopes around tapering. And very importantly, convey to the patient that you're flexible, that this may be a trial-and-error approach, and that you will individualize the taper depending on how the patient is doing after the first step. So this is one decision-making worksheet or a grid that I sometimes use with patients where this is a decision-making grid for continuing haloperidol versus pre-prescribing haloperidol. And, of course, taking into account the patient's values, preferences, what the plan is going to be. In this case, it was to pre-prescribe haloperidol and what some of the interventions are before actually launching into adjustment of the medication. Psychoeducation about withdrawal symptoms, as well as interventions for monitoring any recurrence of old symptoms. So this is another worksheet which helps us decide which medication might be useful for pre-prescribing. So documenting which factors are most important to the patient. Lots of patients don't want to take Depakon because they end up having to take sometimes up to four or five pills, and the pills are really large. That might be important to them. Specific side effects that they find especially disturbing. For instance, severe tremors because of haloperidol and a sort of interruption in their social life because of that. For some patients, preventing a hospital admission might be the most important thing. Along with soliciting their anxieties and fears, it's also really important to get a good idea of what are they hoping to get out of this. So fostering some hope is also important. And who should be involved in this decision? Families, supports, providers. And then this is a list of the potential medications for pre-prescribing and then documenting the risks and benefits of pre-prescribing. Each of them digesting all this information. And finally, in the last row, noting down which medicine you have finally zeroed in on. So initiating a taper. Now we'll go back to that hyperbolic tapering curve. So when we want to taper medications based on a hyperbolic T2 receptor occupancy curve, this Mark Horowitz has proposed this 10% taper method based on this curve. And this paper was published in Schizophrenia Bulletin March 2021, I believe. And it is a wonderful paper that I would recommend everyone thinking about tapering an antipsychotic rate. So if you keep tapering a medicine by 10% every few months, even that is not decided, whether it's two months, three months, or six months. But realistically, theoretically, the taper would just go on for years and years. But realistically, in practice, the duration actually depends on the smallest doses one can get. And for instance, if we were to try and taper olanzapine 20 milligrams by 10%, we might be able to go down to 17.5%. Sorry, 17.5 milligrams from 20 milligrams. As a next step, we might be able to go down to 15. We might be able to cut down from 15 by 1.25 milligrams. But, and slowly, we might be able to get down to 1.25 milligrams because the smallest dosage of olanzapine is a 2.5 milligram tablet. But going down below that is going to be hard. Some people, including patients themselves, buy solvents for many of these drugs and create solutions for themselves. Some pharmacies can compound custom solutions, but typically insurance companies will not pay for this. So it's not an option for patients who really cannot pay out of pocket. And this is an important diagram which lists all the potential symptoms that can pop up during antipsychotic tapering. And this has been divided by neurotransmitters, so you can have cholinergic withdrawal symptoms with medications that have a high anticholinergic potential, dopaminergic withdrawal symptoms like we discussed earlier, some serotonin withdrawal symptoms, adrenergic, other types of dopaminergic withdrawal symptoms based on the anatomic location, as well as histamine withdrawal symptoms. How do we manage these? The single most, you know, the single best way of handling withdrawal symptoms is to avoid them by actually tapering very slowly and carefully. But if they do show up, then we may need to go back to the previous step in the taper, not back to the original dose that you started off with, but just the previous step in the taper. These are some references for different types of symptoms, case reports that document different types of symptoms that have popped up. For instance, withdrawal catatonia associated with clostridol. It's of note that clostridol is very similar in structure to benzodiazepines and has a, you know, has a dominant effect at GABAergic receptors. So withdrawal catatonia is understandable in that way. A variety of movement disorders, such as adeskinesiasis, tremors, even NMS, cortical movements. And the last point that has been proposed in this paper by Guy Chouinard et al in 2017 was that one way to prevent dopamine supersensitivity is by keeping beta antagonism at a minimum in the first place. So don't give people more hard out than they need. The final step in deep prescribing is monitoring and repeatedly adjusting the taper. So you want to monitor for withdrawal symptoms, make sure patient is not relapsing. If needed, holding the taper for a longer period of time or just going back up to a higher dose if a relapse is suspected. Making sure that the clinician is available to the patient either by phone or in person. Being flexible in terms of adjusting the medicine and adapting quickly. Also, it's really important to maintain a biopsychosocial perspective on relapse and recurrence just as we maintain a biopsychosocial perspective in the initial diagnosis. There is this wonderful concept of the therapeutic illusion which is proposed by Casseret in 1978 in general medicine which says that as prescribers we tend to assume that the biggest effect on a patient's illness is coming from the most controllable factor in which in our case for us is medication. That's the factor that we are able to control best. And we assume that that's what's affecting the patient's illness the most. And this might just not be true. So it's important to try and combat the therapeutic illusion by exploring all possible component causes of a clinical presentation. If a person is presenting with a relapse and you had dropped the dose of Haldol a few days, a few months ago, is it just the medication drop that's causing the relapse? Or is it the fact that the patient lost a beloved pet a few weeks ago? A small little section on the ethics of deprescribing. Understandably, prescribers, psychiatrists may be concerned about documentation, how they should document this intervention and litigation. But when you look at the four principles of medical ethics, autonomy, beneficence, non-beneficence, and justice, deprescribing can emerge as an ethically sound practice because it's predicated on patient autonomy and shared decision-making. It aims to minimize adverse effects of the medicines and maximize the potential benefits of the medicines. Finally, it is undeniable that we need to talk more about deprescribing because it is needed. It must be carried out in the context of recovery-oriented care, using sound pharmacological principles to determine the rate of taper and incorporating good prescribing practices, such as considering risk-benefit ratio, as well as considering the psychosocial-cultural milieu of the medication. And finally, I think deprescribing demands a lot from the prescriber, which includes transparency, flexibility, and a healthy dose of tolerance of uncertainty. Here are some of the key references that I've used throughout the paper. If you had to read just one, I would suggest reading Dr. Horowitz's paper from Schizophrenia Bulletin because it probably has elements from all the different citations that I have here, except for the literature on recovery-oriented prescribing. So it is available for free online as are Schizophrenia Bulletin's papers in general. Finally, I just want to acknowledge a few people. First of all, all my patients who have trusted me enough to let me walk with them on this journey. I don't think I would have learned even a quarter of what I have without them. A number of colleagues and mentors who have collaborated with me, guided me, and supported this work. Dr. John Cahill, who works in early psychosis at Yale. Dr. Rebecca Muller, who is Director of Peer Support, also at Yale. Dr. Horowitz, who I've mentioned several times. He is also a psychiatrist in the UK leading the RADAR study. And Dr. Sandy Steingard, certainly last but not the least, who has been a wonderful mentor and supporter of this work. She is currently the Editor-in-Chief of the Community Mental Health Journal. We can move on to the questions and answers at this point. All right. Thank you so much, Dr. Gupta, for that wonderful presentation. Before we shift into the Q&A, I just want to take a moment to let everybody know that SMI Advisor is available from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. Download the app at smiadvisor.org. All right. And now we'll go to the Q&A. We've got a number of questions in the chat. So the first question, Dr. Gupta, is, do you have any practical recommendations about how to discontinue a long-acting injectable antipsychotic medication when a patient requests to do so, taking into account the dopamine receptor occupancy? That's a fantastic question because the last paper that I read in preparation for the seminar actually suggested that it might be easier to be prescribed long-acting injectables as opposed to oral medications because the variation in blood level is lesser. In practice, what I've typically done depends upon the starting dose of the Halodol or whichever injectable it is. I've reduced only Haloperidol dex so far, but there are no standard recommendations. What I've typically done is reduced by the smallest dose possible every month. Got it. Thank you. And just sort of a follow-up question. I think that one thing that logistically happens with some long-acting injectables, especially that need a prior authorization, because oftentimes when you order a long-acting injectable, you may only get that authorized for a particular dose. When doing dose reductions, have you encountered any logistical difficulties in reducing the long-acting injectable based on sort of insurance coverages? I have not encountered that so far, but again, it's an interesting question that you're bringing up because that's right. We do get authorizations for specific doses, but I spent a lot of time trying to figure out that if I reconstitute the drug in my office, can I just reduce the amount, reduce the volume that I'm injecting, and would that be okay, and how do I get around the documentation related to that? Because what I'm ordering is still 300 milligrams of Fevelify, let's say, so I'm still trying to figure out a workaround around that. All right. Thank you. Another question that's related. In planning a medication reduction with attention to the hyperbolic curve, what does this look like practically? Do you go down more slowly during the middle portion of the taper? So, typically, I go down relatively faster at the start of the taper and slowest at the end of the taper. For instance, if we are starting with a dose of, let's say, 20 milligrams of olanzapine, I might even feel more comfortable dropping the dose from 20 to 15 milligrams because at that point, there is a very little difference between the B2 receptor occupancy at 15 and at 20 milligrams. So, dropping from 20 to 15, you can go a little faster at that. Even from 15 to 20, I mean, sorry, 15 to 10, you might be able to go a little faster, but following that, you want to go down way slower than the first two steps. Sounds good. And a follow-up to that question, do you ever use plasma antipsychotic levels to help guide the dose reduction? I haven't done that so far, but that's an excellent thought, actually. All right. Sounds good. Next question. I was wondering if there were efforts underway to incorporate training and deprescribing in residency training programs? There have been efforts. Dr. Cahill and I taught a class at the Yale residency training program. The class consisted of three sessions where we offered some clinical case examples, solicited clinical situations from residents, and we're trying to expand the curriculum a little bit into eight sessions. Hopefully, we should have it ready by the end of the year. That's outstanding. And one resource to keep in mind is the idea of a model curriculum via Adpert. Those can be publicly available and could benefit potentially a lot of people. All right. One question that I had is a lot of times it seems like in this era of community mental health, there's a lot of turnover. People are seeing new patients often. People are working with new patients from another prescriber. People are already on a big list of medications. I'm curious, do you have any practical tips about how to do deprescribing in a busy outpatient clinic? I think making the patient the carrier of that decision is one step to address this staff turnover issue, at least, that when patients get transferred from one prescriber to another. Are you asking about that or are you asking about having too many patients? Yes, more of the latter. I think with just volume and time pressures and things like that, how do you incorporate those sorts of things? That's a really good question again. So time, there are many different ways to address the issue of time. I have a set of videos that I send to patients and I just ask them that, is it okay if I send you this video? Can you watch it at home and bring me your questions? So we don't have to watch it together, give people handouts or reading material to go over together. There are things that that the patient can do in advance before coming in. And I think just creating this idea that a medication may be reduced right from the start. So when I see a patient for the first time, I always ask the question that how long do you see yourself on this medication? Where do you see the medication treatment going? So the idea that we are going to be talking about this all the time is I think a good start, at least some groundwork. And the other part, other piece of it is if you work at a clinic with other disciplines such as therapists, social workers, it's useful to create that culture within the clinic where everyone is talking about it and everyone is open to the idea. So if I pick up the phone and I say, hey, I'm going to reduce, you know, Dan's olanzapine today from 20 to 17 and a half, they're on board right away. They know what I'm talking about and the patient knows that they can talk about it with their therapist as well. So just creating that broader culture within the clinic is useful. Yeah, I think that's an excellent point. I wanted to ask you a little bit more about, you know, how do you create that culture in an outpatient clinic and sort of along with that, how can you say a little bit more about how the non-prescribers can support the prescribers in the deprescribing process? Oh, that's great. I think the non-prescribers, the therapists and case managers are really, really important. So I've had a lot of patients who have relied on visiting nurse services, you know, before COVID times at least, and they proved to be so important in this intervention. Most patients would consent to me discussing, you know, discussing their med changes directly with them and receiving phone calls directly from them. And they were a huge support because they see the patient multiple times a week in their home and were so much more sensitive to any changes in the patient's status and were able to even discuss that with the patient or encourage them to call me. So that's for the visiting nurse. As far as they met at the therapists within the clinic, again, like often the therapists discuss different issues, sometimes have an even closer relationship with the patient than the psychiatrist, and they might be in a better position to elicit some of the fears and anxieties around it. And sometimes even the hopes and goals, you know, goals and hopes for their life. So in that way, therapists can definitely support the intervention. One intervention that I've been hoping to set up and I haven't done yet is actually groups for people who are sort of feeling ambivalent about the medicines they take right now or want to take their medicines. I think people can really support each other through that process. As far as creating a culture within the clinic goes, discussing, you know, offering some little bits of education, 10-15 minutes in a staff meeting, that's something that I've done often. Discussing the topic with trainees, just asking therapists, hey, what do you think? Is the clothespin making Jessica too sleepy in class? Do you think it might help to reduce it a little bit? And doing this over a period of time consistently, it ends up changing the culture little by little. I just have one more thing to add. There are some, you know, systemic interventions as well. Like if you have a good, if you're able to generate good prescribing reports from your EHR, I think develop, like getting individual prescribing patterns through your EHR, offering individualized feedback at times to different prescribers in the clinic, that might be another way to do it. You just have to make sure that it doesn't come across as punitive in any way. Or, you know, it doesn't end up feeding stigma about taking medicines in any way. That's an excellent point. I was wondering, one of the comments from the chat is, I think peer support specialists can be invaluable in helping patients think through these decisions about medications. And I was wondering if you could say a little bit more about the role of peer support. Absolutely. So there are, and you know, this comment is well-supported by, I shouldn't say well-supported, there are two papers. One is by Alicia Ostro, who's in California, and the other by Miriam Larson-Barr, where they showed that individuals who were trying to taper their psychotropics found that talking to other people who were tapering was really very helpful. I think the mobilizing peer staff is extremely important. One of the sort of founders of this idea of prescribing in psychiatry was Rebecca Miller, who is the, you know, who's the director of peer support at one of the community health centers at Yale. So, and it came from her, a lot of the ideas came from her personal experience with different types of medications. And here again, within my clinic, I'm able to refer to our peer staff who are quite open about what medicines they have taken, what has been their experience, both during tapering and sometimes during resuming medication, what's the experience been like, because sometimes a lot of affect emerges when patients taper off, both antipsychotics or antidepressants. So, I see that as a key intervention, actually. If I had to name one most important intervention during prescribing, it would be peer support groups, both by, you know, peer counselors or people who are employed as peer counselors, as well as by support from other people who are tapering medications. And a lot of people end up seeking support in online forums. Excellent points. One question I wanted to ask you is, you know, being very close to this literature, what do you see as some of the biggest gaps in the literature regarding deprescribing? And what do you think could be some of the highest yield studies that could be done in order for us to be able to, you know, have question marks less in some of these boxes? I think studies can be done at so many levels. If you want to talk about more sort of mechanistic bench research studies, simple studies of, you know, just imaging D2 receptors, for instance, after a person has taken haloperidol or any other D2 blocker and seeing what the rate of taper is, sorry, what the rate of reduction in the occupancy is and correlating it with clinical symptoms, that would be one piece of it. Focusing a little more on the randomized clinical trials taking place for antipsychotics and building in a component of how to taper off the antipsychotic for these patients, because I presume that is being done when a patient is, when a research subject is started on a particular antipsychotic. Building in, you know, a component of trying to find some biomarkers of who may need long-term antipsychotic treatment and who does not, because in many of these discontinuation studies, the conclusion has sort of invariably been that there is a percentage of patients with schizophrenia that does not need antipsychotics for the rest of their life. So, I think there are just so many avenues for research, both clinical bench research and even at the systematic, sorry, systemic level, more pharmaco-epidemiological data or even like pharmacoeconomic data from the point of view of the payers. Well, Dr. Gupta, thank you so much for this wonderful presentation and for your pioneering work in this area. Unfortunately, we are at the end of the hour, and I wanted to go ahead and wrap things up. Thanks so much to the audience for your great questions. Thank you for having me. Absolutely, absolutely. And if you do have, you know, if anybody does have follow-up questions about this or any topic related to evidence-based care for SMI, our clinical experts are now available for online consultations. Any mental health clinician can submit a question and receive a response from one of our SMI experts. Consultations are free and confidential. So, on behalf of SMI Advisor, I'd like to invite you to learn more about the APH 2022 annual meeting. The in-person conference takes place May 21 through May 25 in New Orleans, and the virtual meeting takes place June 7 through June 10. During the live conference, clinical experts from SMI Advisor are leading a variety of sessions on how to improve care for individuals who have SMI. Topics for these sessions include the basics on how to use Clozapine, digital navigators, and making technology work, and how to improve physical health in individuals who have SMI and more. I encourage you to take a moment right now and browse the agenda at psychiatry.org slash annual meeting. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. You'll then be able to select next to advance and complete the program evaluation before claiming your credit. Please join us next week on Monday, March 21, 2022, as Anita Brinkley, Tony Sanchez, Justin Volpe, and Dr. Deb Pinals present Overcoming Barriers and Recognizing the Unique Value of Including Peer Support Specialists with Prior Justice Involvement in Recovery. Again, this free webinar will be March 21, 2022, from noon to 1 p.m. Eastern Standard Time. Please do note that this webinar is on Monday rather than the usual Thursday or Friday time slots. In conclusion, thank you so much to everybody for joining. Until next time, take care. you

deprescribing antipsychotic medications

recovery-oriented care

shared decision-making

pharmacology

risk-benefit ratios

medication reconciliation

psychosocial interventions

tapering

monitoring

individualization