Deprescribing

What Deprescribing Is

Deprescribing refers to the careful, medically supervised reduction or discontinuation of medications — particularly psychiatric medications, sedatives, and pain medications — that are no longer serving their intended purpose, or whose risks and side effects have come to outweigh their benefits.

This is more common than is often acknowledged. Many people have been on the same medications for years, sometimes decades, without any serious reassessment of whether the original indication still applies. Others have accumulated multiple medications over time, prescribed by different physicians at different moments, that interact in ways no single clinician has fully evaluated. Still others simply want to be on less medication and don't know how to do that safely.

Why It Requires Careful Management

Stopping psychiatric medications — antidepressants, antipsychotics, mood stabilizers, sedatives — is not as straightforward as stopping most other medications. Many of these drugs cause physiological dependence even when taken as prescribed and even when they are not producing obvious clinical benefit. The mechanisms vary by drug class.

Antidepressants, particularly SSRIs and SNRIs, produce a discontinuation syndrome driven by the sudden removal of serotonergic and noradrenergic support that the brain has adjusted its receptor density around — a syndrome that includes dizziness, paresthesias, anxiety, and flu-like symptoms, and that is frequently severe with shorter-acting agents like paroxetine or venlafaxine. Antipsychotics, with chronic use, cause upregulation of dopamine D2 receptors; their abrupt discontinuation can unmask supersensitivity psychosis and cholinergic rebound. Mood stabilizers carry their own discontinuation risks, including rebound seizure risk for anticonvulsants used in this context.

The most clinically significant issue across all of these is misattribution: withdrawal symptoms are consistently interpreted as relapse or recurrence of the original condition, which is then used to justify resuming or even increasing the medication. This interpretation is not always wrong — but it is frequently wrong, and distinguishing between the two requires a clinician who understands what physiological withdrawal from each class of medication actually looks like and how long it lasts.

Benzodiazepines and Opioids

The deprescribing of benzodiazepines and opioids occupies a particular area of clinical complexity and is a significant part of what I see. Both classes produce substantial physiological dependence through mechanisms that make abrupt or rapid discontinuation genuinely dangerous — seizure risk for benzodiazepines, severe neurological destabilization for both. Both require gradual, carefully managed tapers calibrated to the individual's clinical situation, with close monitoring throughout.

How I Approach It

I approach deprescribing as a clinical process requiring time, attention, and ongoing reassessment — not a protocol to be applied uniformly. The rate of taper, the sequencing of medications when multiple are involved, and the management of any symptoms that arise along the way are decisions that need to be made in the context of a specific person's history, current clinical state, and the pharmacology of the particular drug.

Alongside the medication work, the underlying conditions the medication was addressing need to be understood and, where possible, approached through other means. Deprescribing is most durable when it happens in the context of a broader treatment — not as an isolated withdrawal process.

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