Joseph F. Goldberg, Holly A. Swartz, Roger S. McIntyre, Rajnish Mago, Gin S. Malhi, Manish K. Jha, Michael Berk, Siegfried Kasper, Marlene P. Freeman, Michael J. Gitlin, Martha Sajatovic, Michael J. Ostacher, Leslie Citrome, Dan V. Iosifescu, Roy H. Perlis, Toshi A. Furukawa, Eduard Vieta, Michael E. Thase, Allan H. Young, Mauricio Tohen, Andrew A. Nierenberg, Matt Macaluso, Richard C. Shelton, Christoph U. Correll, Scott T. Aaronson, Joshua D. Rosenblat, Philip Gorwood, Arifulla Khan, Ralph Kupka, Lawrence J. Cohen, Philip B. Mitchell, Mark A. Frye, Gerard Sanacora, John M. Kane, Jose M. Rubio-Lorente, David W. Goodman, Joseph Zohar, Lori Davis, Swapnil Gupta, Sandra Steingard, Carlos A. Zarate, Anita H. Clayton
The American Society of Clinical Psychopharmacology convened a 45-member international expert task force to identify circumstances supporting the deprescribing of core psychotropic medications for major depressive disorder (MDD) and bipolar disorders. Three Delphi survey rounds plus a selective literature review identified points of consensus (predefined as ≥75% agreement) about when antidepressant, antipsychotic, mood stabiliser and sedative-hypnotic deprescribing is warranted. Twenty out of 32 statements (63%) achieved consensus across seven thematic areas. In MDD, panellists favoured discontinuing antidepressants when mechanisms of action are duplicative, adequate trials produce ≤25% improvement or loss of prior efficacy cannot be regained through dose increases or augmentations. Indefinite antidepressant maintenance in MDD was favoured after three or more lifetime episodes. In bipolar disorder, antidepressant deprescribing was favoured in the setting of rapid cycling, mixed features or emerging mania/hypomania symptoms; and discouraged if prior antidepressant cessation led to relapse. In nonpsychotic mood disorders, panellists favoured deprescribing antipsychotics that caused significant weight gain or tardive dyskinesia over adding pharmacological antidotes. Deprescribing to achieve an eventual medication-free status was considered inappropriate, in bipolar type 1, but not necessarily bipolar type 2 disorder. Although individualised circumstances necessarily inform psychopharmacology management, clinical presentations that misalign with existing pharmacotherapies may signal the desirability of cautious deprescribing.