Consensus on the when and what of tapering (but not the how)
STUDY: Looi JCL et al, British Journal of Psychiatry 2026
STUDY TYPE: Expert consensus
FUNDING: Independent
Background
This review explains a new consensus statement from the American Society of Clinical Psychopharmacology on deprescribing psychotropic medications in major depressive disorder and bipolar disorder.
Start the conversation early. Tell patients how long treatment might last. This sets a collaborative tone from the start.
The review focuses on when to deprescribe, but gives little guidance on tapering schedules because there is little research on that. That’s where we need to collaborate with patients and pay close attention to their symptoms, distinguishing these two risks of deprescribing:
- Withdrawal shows up within days to weeks of stopping a drug, and includes physical and mental symptoms.
- Relapse takes longer, often 3-6 months, and tends to bring back symptoms that resemble prior episodes.
Table from Difficult to Treat Depression, Chapters 45-47 on Deprescribing
Major Depression
For non-recurrent major depression, wait six to twelve months of full remission before considering discontinuation. After three or more lifetime episodes, treat indefinitely. Two SSRIs at once? Stop one rather than layering on more medication.
Bipolar Disorder
Deprescribing in bipolar disorder calls for more caution. In bipolar I, preventative mood stabilizers are necessary. In bipolar II, medication-free periods are more feasible, particularly if psychotherapy is on board.
Antidepressants are a class to consider deprescribing in bipolar disorder, but first check if earlier cessation triggered a new episode. Avoid deprescribing in those cases. On the other hand, patients with these features are likely to benefit from gradually tapering off:
- Rapid cycling (including four or more depressive episodes per year)
- Frequent mania, hypomania, or mixed features, particularly if they come on within three months of starting or raising an antidepressant
While most medications benefit from a gradual taper, lithium requires it. Taper over at least six weeks, in unipolar and bipolar, and preferably longer. Stopping abruptly raises the suicide and relapse risk.
Augmentation Agents
Augmentation agents like antipsychotics have their own timelines. Deprescribe antipsychotics if weight gain, metabolic problems, or tardive dyskinesia shows up, or after roughly six months of stability in patients without psychotic features.
Benzodiazepines and benzodiazepine receptor agonists need faster action: taper within one to three months of starting to avoid dependence. Low-dose quetiapine used for sleep should come off after three to six months.
Psychotic Depression
The review did not address psychotic depression, but one trial tested olanzapine continuation vs tapering off (both groups stayed on sertraline) after recovery. After 36 weeks, relapse rates were higher with olanzapine discontinuation (55% vs 20%), but side effects were worse with continuation.
Practice Implications
- This is a good start, but the guidance assumes we are working with clear diagnoses and textbook-based regimens.
- In the real world, patients come to us with multiple comorbidities and medication regimens that strain the evidence: benzos with stimulants; anticonvulsants for depression; supplements, buspirone, clonidine, etc. I address those scenarios more in Difficult to Treat Depression and the Much Too Medicated Patient.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
