Half (48%) of the UK population take at least one prescribed medicine, while a quarter (24%) take three or more prescribed medicines (Neave, 2017). In the UK, 17% of the population (7.3 million people) are prescribed an antidepressant, while 5% (2.9 million) are prescribed either a benzodiazepine or a z-drug (Public Health England, 2019).
Although prescribing rates are increasing, with the volume of prescription items dispensed in the last decade being 47% higher than the previous decade (Public Health England, 2019), rates of non-adherence remains high. In patients with depression, data of non-adherence varies between 40–80% (Mendis and Salas, 2003; Martin-Vazquez, 2017). In psychosis, up to 74% of service users who are prescribed antipsychotics discontinue their treatment within 18 months (Lieberman et al, 2005), although rates vary from 42% to 95% (Sendt et al, 2015). This may be related to the reported lack of choice and involvement in their treatment decisions (Goss et al, 2008; Morant et al, 2018). Studies also indicate that healthcare professionals may not be amply receptive of people's experiences and support requirements during periods of debating and managing antipsychotic cessation (Read, 2009; Salomon and Hamilton, 2013). This may result in people stopping medicines covertly, without support from their clinical team. At the same time as prescribing increases, one fifth of patients under mental services have not had a formal review in the last 12 months, and a quarter have not agreed what care they will receive with a clinician (Mental Health Taskforce, 2016).
Polypharmacy has also become increasingly common, with the average number of items prescribed per person per year in England having increased by 53.8% in the last decade; 58% of the population were prescribed one drug, 22% were prescribed five or more drugs, and 5% were prescribed 10 or more drugs (Duerden and Payne, 2013).
Iatrogenesis, the noxious, unintended, and undesired effect of a drug (World Health Organization (WHO), 1972) is the fifth leading cause of death in the world (Peer and Shabir, 2018) with up to 8% of deaths worldwide attributed to adverse drug reactions (ADRs) (Peer and Shabir, 2018). ADRs to medicines are connected to 6–11% of hospital admissions in adults (Pirmohamed et al, 2004; Mitchell et al, 2016; Oscanoa et al, 2017). Patients admitted with one drug side effect are more than twice as likely to be admitted with another (Pirmohamed et al, 2004). Patients on multiple medicines are more likely to suffer adverse drug reactions drug side effects, this being related to the number of comorbidities a patient has than rather to the patient's age (Pirmohamed et al, 2004). Other major risk factors, in addition to polypharmacy, that influence the development of ADRs seem to be age, gender, ethnicity, pregnancy, multiple pathologies, drug dosage, frequency of administration and genetic polymorphism (Valeanu et al, 2020).
Patients are prescribed and may continue taking medicines that cause adverse effects and those where the harm of the medicine outweighs the benefit (Guthrie et al, 2011). It is also acknowledged that people who once derived benefit from medicines once prescribed may not continue to do so; despite this, their treatments may carry on without being reviewed (Duerden and Payne, 2013).
Deprescribing is the optimisation of medication, and is a vital part of improving outcomes, managing chronic conditions, and avoiding adverse effects. The goal of deprescribing is to lessen medication burden and enhance quality of life (Bruyère Research Institute, 2019). It is a positive intervention, rather than a reduction in the level of care (Gupta et al, 2018).
The five step model of deprescribing (Woodward, 2003) outlines the importance of joint working within the multidisciplinary team, with the pharmacist and prescribers having a key role, and working collaboratively with the patient in question. This personalised model remains seminal, forming the foundations of current guidance and deprescribing approaches (Tenni and Dunbabin, 2016; Michiels-Corsten et al, 2020).
Once a potentially inappropriate prescription is identified, it is important to identify if withdrawal is possible, agreeing to a timeframe for the deprescribing process. Only through the actual deprescribing can the benefit of the intervention be wholly assessed (Reeve et al, 2014). Once deprescribing is achieved, full and clear documentation of the intervention detailing the process is needed. This documentation should minimise medication errors and the future reinstation of previously ceased drugs (Reeve et al, 2014).
This article will focus on deprescribing in mental health, including the specialty of learning disabilities, using case studies to demonstrate the process.
Deprescribing process
1.
Review current medication
The first step in reviewing current medication is to take a comprehensive medication history. Deprescribing is a patient-centred process and the patient should be the primary source of information when compiling this history. Obtaining additional information from carers and other healthcare providers can also be helpful. Previous medication allergies, intolerances and adverse drug reactions should all be documented in the history. The patient should be asked what medications they value the most, which medications they feel they no longer need and whether any medications are causing side effects (Reeve et al, 2014).
2.
Identify medications for cessation
Medication that is providing more harm than benefit should be identified for cessation. Identifying these medications will involve clinical knowledge and be specific to that individual patient. Given the complexities involved, this should be a multi-disciplinary team (MDT) decision involving the patient's psychiatrist and other healthcare professionals involved in patient's care. The views and request of the patient need to be considered throughout (Reeve et al, 2014).
3.
Plan a deprescribing regimen
Once medication for cessation has been identified, a plan needs to be made on how these medications will be stopped. The MDT will need to identify by what dose increment the medication should be reduced and over what timeframe. Ideally, only one medication should be reduced at once. Therefore, if several inappropriate medications are identified, there is a need to prioritise which medication is associated with the most risk (Reeve et al, 2014).
4.
Plan in partnership with patients and carers
Patient and carers need to be involved in this planning process and they should be encouraged to express their views. Whenever reducing or stopping medication, there is always a risk this could destabilise the patient's mental state and the patient needs to be aware of these risks. A contingency plan should be made with patients and carers with advice on what to do if their mental state does start to deteriorate. Planning when to start the reduction of the medication is also important. Ideally, the reduction should start when the patient is not undergoing stressful life events and they have access to support (Reeve et al, 2014).
Figure 1. The five principles of deprescribing 5.
Frequent review and support
As an MDT, a plan should be made to ensure the patient has frequent follow ups and reviews once deprescribing starts. The frequency of these reviews will depend on the individual patient and their presentation. Patient and carers should be supplied with contact details to access support in between reviews if they have concerns (Reeve et al, 2014).
Deprescribing within mental health
There have been numerous studies and articles over the last few years looking at deprescribing in mental health. For example, Bjerre et al (2018) outline that the deprescribing of antipsychotics for adults with behavioural and psychological symptoms of dementia treated by decreasing the dose by 25–50% every few weeks. The article is supported by an algorithm and is the one recommended by the Deprescribing Network (Bruyère Research Institute, 2019). In contrast, Horowitz et al (2020) recommend a much slower antipsychotic tapering – which they name ‘hyperbolic’, and includes sequentially halving the dose over a year or preferably longer.
Gupta et al (2018) suggest that clinicians consider deprescribing, given the limited evidence for indefinite continuation of antipsychotics, the propensity for serious adverse effects, and the growing rate of antipsychotic polypharmacy (Ganguly et al, 2004). Furthermore, a considerable number of patients request to discontinue their antipsychotics, and a proportion do so covertly if their prescriber does not agree.
Warren (2020) argues that long-term antidepressant prescribing in the UK has doubled in the past decade. However, this has not been associated with reduced rates of mental disability or suicide. Furthermore, it seems that 30–50% of patients may be taking antidepressants for longer than necessary based on a lack of evidence-based indication to continue treatment (Cruickshank et al, 2008; Piek et al, 2014). Maund et al (2019) identify some of the barriers to antidepressant discontinuation as patients' coping skills or information on how to discontinue, past negative discontinuation experiences, and fear of discontinuation. The prescriber's opinion on antidepressant discontinuation, their lack of time, and adequacy in support and guidance was found to be pivotal in contributing towards the patient's decision. Conversely, facilitators contributing to antidepressant discontinuation have been identified to be self-stigma of taking antidepressants, side effects, self-identity, fear of addiction and knowledge on how to taper (Maund et al, 2019). The authors of the systemic review and meta-synthesis recommend that it is the role of prescribers to initiate a discussion about discontinuation if it is appropriate (Maund et al, 2019).
People with a learning disability suffer many physical and mental health disorders at greater rates than the general population (Emerson et al, 2011); they are therefore more likely to be prescribed multiple medications. The STOMP (stopping overmedication of people with a learning disability, autism or both) campaign was launched in 2016 by a range of organisations working together to stop people with a learning disability, autism or both from being overmedicated (NHS England, 2017). A report by Hatton and Glover (2016) from Public Health England highlighted that 30 000–35 000 patients with learning disabilities are prescribed psychotropic medication when they do not have the mental health condition the medicines are indicated for (Hatton and Glover, 2016).
Within deprescribing for learning disabilities, if the re-emergence of challenging behaviour is mild to moderate and manageable in the current setting, the carer is to commence Antecedent Behaviour Consequence charts to identify the possible cause (NHS England, 2017). A care plan needs to be formulated and behavioural interventions implemented. The lowered dose of the antipsychotic should be continued and any further reductions delayed. It is important to monitor the use of any when required (PRN) medication if being prescribed. If the patient has unmanageable severe challenging behaviour, the antipsychotic drug should be increased to the original dose and psychiatry services contacted for advice (NHS England, 2017).
If the patient is settled at the next review, they should be observed for 4 weeks and a further reduction considered. The pre-determined reducing schedule should be followed, with the aim to fully discontinue the drug if the patient remains settled. If the withdrawal is successful, further reduction or withdrawal of other psychotropic medications should be considered (NHS England, 2017).
It is hoped that by reducing psychotropic medicines in this group of patients when there is no evidence of a mental health diagnosis may reduce health inequalities, morbidity and mortality (Adams, 2019).
Medication review, a structured and critical evaluation of a prescribed medication, and a key element of medication optimisation (National Institute for Health and Care Excellence, 2015) is an optimum circumstance for deprescribing to take place. Lack of reviews or lack of time have been identified as obstacles to deprescribing, with some prescribers acknowledging the much faster process of prescribing a repeat prescription, rather than de-prescribing a medicine (Bosman et al, 2016). Moreover, there seems to be substantial variation and little formal guidance on how medication reviews are conducted (Sheehan et al, 2018).
Drug discontinuation problems
Drug discontinuation problems are usually mild and self-limiting (Taylor et al, 2019), but can be difficult to draw out of a person, especially if that person has a learning disability. With antipsychotics, if discontinuation symptoms are experienced the rate of reduction can be slowed. With antidepressants, reassurance is usually sufficient to help with mild discontinuation effects. If severe effects are experienced, the antidepressant can be re-introduced, tapered gradually and symptoms monitored (NHS England, 2017; Taylor et al, 2019).
The rest of this article presents two case studies from clinical practice in a community secondary mental health service. Furthermore, this article highlights the merits of specialist pharmacist-led interventions with respects to medication reviews and deprescribing.
Case study 1
John is a 49-year-old man with a diagnosis of bipolar affective disorder (rapid cycling). John is supported by local community mental health services and has regular medical reviews with a psychiatrist. John has been supported by community mental health services for over 20 years and has had several inpatient hospital admissions. Currently, John lives in 24-hour supported accommodation, where care staff support him with his medication and in managing daily activities. He has no physical health comorbidities.
Presentation
- Presenting as manic with severe pressure of speech, flight of ideas, irritability and poor sleep (approximately 4 hours per night)
- John's support workers report that his episodes of elevated mood are becoming more frequent and severe.
Risks
- Risk to others: low
- When manic, John can be overactive, creating physical risk to self
- Pressure of speech can become so marked it can result in him being unable to eat
- Vulnerable to financial exploitation by others.
Original medication
- Zuclopenthixol Decanoate 200 mg 1/52
- Olanzapine 20 mg every night (ON)
- Lithium Carbonate MR 800 mg ON
- Diazepam 5 mg once daily (OD) + 2mg when required (PRN)
- Zopiclone 7.5 mg ON
- Procyclidine 5 mg twice daily (BD) (Total antipsychotic dose=133% British National Formulary maximum).
Interventions
- Medication history compiled, identifying all the medications that John has previously trialled and his response to these medications
- Medication options discussed with John who expressed preference for oral medication. Considering previous poor response to a variety of antipsychotics, agreed to trial clozapine (unlicensed indication).
- Zuclopenthixol decanoate stopped and clozapine titrated over two weeks
- EPSEs improved on stopping zuclopenthixol, procyclidine stopped as a result
- Once on therapeutic dose of clozapine olanzapine gradually reduced to stop
- Improvement in sleep on clozapine, zopiclone gradually reduced to stop
- Manic episodes less frequent/severe, diazepam gradually reduced to stop.
Problems identified
- High-dose antipsychotics treatment
- Extra Pyramidal Side Effects (EPSEs) reported
- Lack of efficacy with current treatment
- Anticholinergic burden: increased risk of cognitive impairment associated with long-term use.
Current medication
- Clozapine 400 mg OD
- Lithium Carbonate MR 800mg ON
- (Total antipsychotic dose= 44% BNF maximum)
Outcome to date
- EPSEs improved
- Significant improvement in sleep
- Patient satisfaction improved
- Reduction in severity and intensity of manic episodes.
Reflections
How was the change initiated and managed?
John was referred to a community mental health pharmacist by a psychiatrist for support around deprescribing. Deprescribing took place over a period of 12 months. During this period, John had regular follow-up appointments with his psychiatrist and mental health pharmacist. Medication changes were made gradually and only one medication changed at once. At each review, John's mental state and response to medications was monitored.
Medication changes were made after an open and honest discussion with John regarding his beliefs, concerns and treatment goals. John was keen to reduce the amount of medication he was taking and to take only oral medication. A key treatment goal for John was to improve his sleep.
Lessons learnt?
It was important to ensure all services involved with John's care were informed of the medication changes and the deprescribing plan, including the residential home care staff, GP and community pharmacy.
Challenges
The actual practicalities of deprescribing and making medication changes in this situation was challenging, as John's medication was dispensed in a blister pack. Therefore, medication changes had to be communicated carefully with the dispensed community pharmacy to minimise the risk of any medication error.
Case study 2
Robert is 61 years old and lives in a learning disability care home. Robert has a severe learning disability, cerebral palsy and bilateral deafness. He has no verbal communication. Robert had challenging behaviour in the past, but since moving to the home, the carers had not reported any challenging behaviour. Risperidone had been started 6 years ago for challenging behaviour and the dose increased over time. An annual health check had been carried out for Robert by the GP, but there were no changes made to his psychotropic medications.
Presentation
- Robert appeared over-sedated and was drooling. He had gynaecomastia, which could be seen through his t-shirt. He had a mask-like expression on his face.
Risks
- Risk to others: low
- Long-term negative effects from high-dose antipsychotic medication eg increased cardiovascular risk and diabetes
- Increased risk of pneumonia
- Deterioration of physical function leading to negative impact on bone and muscle health.
Original medication
- Risperidone 14 mg OD
- Procyclidine 5 mg BD (for EPSE)
- Mirtazapine 30 mg ON
- Carbimazole 10 mg OD
- Colecalciferol 400 units OD
- Omeprazole 20 mg OD
- Simvastatin 40 mg ON
- Paracetamol 1 g up to QDS PRN
- Macrogol 1-2 sachets BD
- Lactulose 10 mL BD
- Double base gel BD PRN
Interventions
- Risperidone dose reduced by 0.5 mg every 2 weeks
- Procyclidine reduced to 5 mg for one week, then stopped as no longer required
- Laxatives reduced as procyclidine stopped, so less constipation experienced.
Problems identified
- Gynaecomastia
- Hypersalivation
- Recurrent chest infections requiring antibiotics and many visits from paramedics and GP
- Over-sedation.
Outcome to date
- No further chest infections since risperidone stopped
- Improved quality of life
- No longer over-sedated
- No gynaecomastia.
Current medication
- Mirtazapine 30 mg ON
- Levothyroxine 75 micrograms OD
- Carbimazole 5 mg as directed, 2OD
- Colecalciferol 400 units OD
- Omeprazole 20 mg OD
- Simvastatin 40 mg ON
- Macrogol 1-2 sachets BD
- Paracetamol 1 g up to QDS PRN
- Double base gel BD PRN
Reflections
How was the change initiated and managed?
The deprescribing decision was initiated following a visit from the STOMP pharmacist to the care home, who was carrying out a STOMP audit of patients with learning disabilities. Approval was gained from Robert's GP, next of kin and care home manager. A reduction schedule was provided for the home to follow. The community pharmacy was contacted and provided with a schedule also, as well as to discuss the best way to dispense the tablets in boxes. The learning disability nurse offered contact support if there were any behavioural problems encountered during the reduction. Regular contact occurred between the care home manager and pharmacist to check how the reduction was going.
Lessons learnt?
Once antipsychotic medication has been stopped the patient may be more alert/active, so this needs to be considered. Are there appropriate systems in place to help with this? Robert became more tactile once the reduction was completed. The manager asked for support with this and a referral was made to the behavioural support team. Positive behavioural support was provided, which avoided re-administration of any psychotropic medications. A good relationship was built with the pharmacist and care home manager. Despite an annual health check, which includes a medication review, risks of overmedication were not identified and this further highlights the need for specialist pharmacy involvement and the impact this intervention can make on the wellbeing of this patient group.
Challenges
Co-ordinating the different tablet strengths required with the community pharmacist was initially challenging. Instead of including in a blister pack, the GP prescribed several different strengths of risperidone, which the care home manager requested in boxes when required.
Top tips for deprescribing
Shared decision making
Deprescribing should always be patient centred. The potential risks and benefits associated with deprescribing need to be fully explored with the patient in an open and honest discussion. Consider that verbal communication may not always be the best method of communication for that particular patient.
One at a time
When an individual is prescribed significant polypharmacy, there may be temptation to review numerous medications at once. However, this can make it very difficult to monitor the patient's response when multiple medications are stopped at once. Ideally, only one change should happen at once.
Communication
All those involved in the patient's care need to be informed of any medication changes ie primary care, secondary care and next of kin if appropriate. All parties should be aware of the deprescribing plan and the ongoing monitoring in place.
CPD reflective questions
- What is the benefit of de-prescribing?
- How can a pharmacist lead successful deprescribing?
- Do I consider deprescribing in my day-to-day role?