Art: A French pharmacy, Unknown artist, circa 1700.
REVIEW OF: Goldberg JF et al, JAMA Netw Open 2026;9(2):e260043
STUDY TYPE: Expert consensus (Delphi survey)
Psychiatric textbooks tell us when to start medications, but say little about when to stop. This American Society of Clinical Psychopharmacology (ASCP) task force polled 45 international experts about 50 deprescribing statements. Most (88%) achieved high consensus, and below are some practical highlights.
General Principles
- Before concluding a drug isn’t working, verify adherence. Poor adherence is common, assessment of it is unreliable, and deprescribing a medication the patient wasn’t actually taking creates the false impression that it wasn’t working.
- When a drug has clearly failed — less than 25% symptom reduction after an adequate trial — stop it. Efficacy is difficult to assess; before-and-after rating scales and collateral input help.
- Deprescribing is also appropriate when goals have been met and long-term relapse prevention isn’t the objective.
- When you deprescribe, change only one thing at a time, increase visit frequency, and use measurement-based care to catch early decompensation.
What to Deprescribe
- Anticholinergics prescribed preventatively for antipsychotic side effects (EPS, stiffness) should be stopped if the side effect never occurred, and consider tapering if it occurred long ago.
- Benzodiazepines in older adults warrant regular re-evaluation of risk-benefit, with consideration of falls, cognitive status, auto accidents, interactions (eg, opioids), and respiratory health.
- Valproate should be deprescribed in women of childbearing age, though surprisingly this didn’t reach full consensus (67%), which the authors found disappointing given the unambiguous teratogenicity data (several guidelines discourage valproate in this population).
- Lithium, by contrast, should not be automatically stopped in pregnant patients with bipolar I — the relapse risk is too high.
How to Taper
- Most medications benefit from a taper. The paper did not go into detail on this, but a minimum is 2 weeks and usually a few months. Longer tapers are needed for short half-life agents, high doses, high potency drugs, and those with known withdrawal syndromes (SSRIs, SNRIs, benzos, anticholinergics, lithium, possibly antipsychotics).
- Long half-life agents — like fluoxetine, aripiprazole, cariprazine — can generally be stopped without taper because they auto-taper themselves.
- Taper potent anticholinergics over 2-4 weeks to avoid cholinergic rebound, which can cause anxiety, insomnia, confusion, and “wet” symptoms like sweats, drooling, diarrhea. This means a sudden switch from Unisom, Benadryl, or hydroxyzine to another hypnotic may worsen insomnia, giving the impression that new med doesn’t work (doxepin is another anticholinergic used for sleep, but it is not very anticholinergic in the sleep doses). Other potent anticholinergics include benztropine, tricyclics, clozapine, and olanzapine. Switching from anticholinergic antipsychotics to non-anticholinergic ones requires a cross taper.
Psychology Matters
- Patients may fear discontinuation represents abandonment, or that stopping a medication delegitimizes their illness. These concerns are real and need to be named and addressed directly.
Practice Implications
This paper is a major step forward, but much is missing. In practice, we encounter patients on medications with scant evidence to work, like
- Lamotrigine in unipolar depression
- Oxcarbazepine in bipolar disorder
- Benzo-stimulant combinations
- Stimulants in depression, bipolar, or psychotic disorders
- Multiple sleep medications
- High doses of medications
But we can’t just stop medications because they failed in research. Deprescribing is detective work, requiring us to figure out what didn’t work and what is unsafe for each patient. That means sorting through years of psychiatric history, overlapping with life changes, stress, medical problems, substance use, etc.
Learn more in our deprescribing Carlat Podcast
Share Your Input in Comments
- What are the top meds you deprescribe in practice?
- What unanswered questions do you have about deprescribing?
