While psychotropic medications can be remarkably helpful in the management of many behavioral health disorders, it is not infrequently the case – particularly with children and adolescents— that revisions in established medication regimens are appropriate as the patient goes through the developmental process and as symptoms and diagnostic understandings evolves.  While is can be very difficult at times to achieve optimized symptom relief, it is critically important for prescribers to carefully assess the ongoing appropriateness of a youngster’s medication regimen and one of the important opportunities to consider may well be to reduce dosages and or discontinue medications over the course of time.

There is a natural tendency for providers to add medications to fine tune treatment as doing so reaffirms prior decisions to start a medication and there is a natural bias against reducing interventions that previously were deemed to be highly appropriate.  Today’s edition of the SmartCare newsletter speaks to the processes and considerations that need to be considered over time to refine care by reducing the medication burden by lowering dosages or eliminating medications.

Deprescribing can be a vital part of managing conditions, avoiding adverse effects, and cautiously challenging prior clinical assumptions that can ultimately improve outcomes and improve a patient quality of life.   Particularly in complex and clinically challenging cases, there is often a tendency for what has been described as “prescribing cascades” that results in unnecessary polypharmacy as when a drug administered causes subtle adverse signs and symptoms, that may be misinterpreted as a new condition, resulting in a new medication being added, when the prior prescribed regimen may more appropriately be better managed by dose reduction or drug discontinuation.  In other circumstances, the utility of a previously prescribed medication may be marginal and the patient may better be served with a less complex regimen.   In other circumstances stopping medications can sometimes produce withdrawal effects that may be difficult to interpret, so deprescribing needs to be done carefully in partnership between a patient, their caregiver and their healthcare provider.

Deprescribing psychopharmacologic medications should entail a careful tapering or discontinuation of a psychiatric medications that may no longer be necessary or beneficial for a patient. This process requires a thorough assessment of the individual’s mental health status, current medication regimen, and any potential risks or benefits associated with deprescribing.

1. Assessment: The first step is to assess the patient’s current mental health status, including symptoms, functioning, and any changes in their condition since starting the medication.
2. Review: Conduct a comprehensive review of the patient’s medication history, including the indication for each medication, previous response(s), side effects, and any attempts to taper or discontinue medications in the past.
3. Risk Benefit Analysis: Evaluate the potential risks and benefits of continuing each medication. Consider factors such as the severity of the underlying condition, the potential for relapse, the presence of side effects, and the patient’s preferences and goals of care.
4. Shared Decision-Making: Engage the patient in shared decision-making regarding the deprescribing process. Discuss the reasons for considering deprescribing, the potential benefits and risks, and alternative treatment options.
5. Tapering: Monitor the patient closely during the tapering process and after discontinuing the medication. Regular follow-up appointments allow for ongoing assessment of symptoms, monitoring for any adverse effects or withdrawal symptoms, and adjustments to the tapering plan as needed.
6. Monitoring: Monitor the patient closely during the tapering process and after discontinuing the medication.  Regular follow-up appointments allow for ongoing assessment of symptoms monitoring for any adverse effects or withdrawal symptoms, and adjustment to the tapering plan as needed
7. Supportive Interventions: Offer supportive interventions to help manage any withdrawal symptoms or rebound effects that may occur during the tapering process. This may include psychotherapy, lifestyle modifications, or non-pharmacologic treatments.
8. Reevaluation: Periodically reevaluate the patient’s mental health status and medication regimen to ensure that the deprescribing process is proceeding safely and effectively.  Adjustments to the treatment plan may be necessary based o changes in symptom or other clinical factors.

It is important to approach deprescribing with caution and to involve the patient/caregiver as an active participant in the decision-making process. Consultation with behavioral health professionals including both psychotherapist and psychiatrists can help ensure that deprescribing is done safely and in line with the individual’s and the family’s treatment goals and preferences.

Withdrawal from benzodiazepines is similar to withdrawal from alcohol—problems may include: feeling jittery, elevated blood pressure and heart rate, anxiety, insomnia and irritability. With more severe dependence, life-threatening effects like withdrawal seizures and delirium tremens may occur.  The longer a patient has been taking daily benzodiazepines, the longer the taper process should be. If a patient is using a short-acting benzodiazepine, the taper process is smoother and more successful if the patient is first transitioned to a long-acting benzodiazepine and then tapered off the long-acting medication.

Clonazepam is a good medication to use for tapering purposes, and it is helpful to dose it twice per day to establish a more even blood level and to give the patient psychological relief by taking the medication more frequently. Clonazepam has a 1:1 ratio dose equivalence to alprazolam (i.e. 1mg clonazepam = 1mg alprazolam) and a 1:2 ratio dose equivalence to lorazepam (i.e. 1 mg clonazepam = 2 mg lorazepam).  Care should be taken when the patient is taking high doses of a benzodiazepine medication and, in certain cases, dosing clonazepam more frequently during the tapering process may be more successful.

Diazepam can also be used in a similar fashion.  It has a 10:1 ratio dose equivalence to alprazolam and a 5:1 ratio dose equivalence to lorazepam.   Some advantages of diazepam are that it has an even longer half-life than clonazapam and is available in smaller effective doses, and so often allows a smoother taper with fewer withdrawal symptoms.  Some disadvantages are that diazepam has a relatively fast onset of action, causing many patients to experience an initial “high” when they take it, much like they may experience with shorter acting medications like alprazolam.  In addition, because of the extremely long half-life (up to 100 hours including its active metabolites), the drug can often accumulate, especially in elderly and patients with liver dysfunction.

Benzodiazepine Dose Equivalents

Depending on how long the patient has been taking daily benzodiazepines, one can reduce the dose by 10% of the current dose every 4-7 days. For example if a patient has been taking 4mg of alprazolam per day in split doses for five years, one option is to change the patient over to clonazepam 2mg BID and then reduce the dose initially by 0.5 mg per week, slowing down the taper to 0.25mg at a time towards the end. This relatively slow taper would take about 2 months to complete. If a patient is having withdrawal symptoms at any point during a taper, consider slowing down the taper.

In certain circumstances, it may be appropriate for a patient to be on a long-term daily benzodiazepine. One example is a patient who has tried non-benzodiazepine medications as adjunctive to a sub-therapeutic response to an SSRI, but they do not work as well as a benzodiazepine medication and the patient is not misusing it. In this clinical situation, the provider could consider switching from a short-acting medication to a longer-acting medication like clonazepam for long-term use, with a decreased risk for dependence.

If it is determined that a patient needs a long term PRN medication for anxiety and long-term benzodiazepine use is deemed problematic, consider alternatives including propranolol or hydroxyzine.  Buspirone (Buspar) can be effective for anxiety, but must be taken daily.

We hope that this step-by-step review on tapering benzodiazepines has been helpful. The important take home point is to not rush a taper, otherwise the patient might give up if he feels uncomfortable in any way or, more seriously, there could be dangerous consequences.

While the intention behind prescribing a benzodiazepine for a patient is to help alleviate emotional or physical pain for the patient, many times the use of the medication gets out of hand. Generally, benzodiazepines, which work to enhance GABA, are helpful in treating anxiety, insomnia, agitation, seizures, muscle spasms, alcohol withdrawal and as a premedication for medical or dental procedures.

Here we will focus on its uses for anxiety disorders. Benzodiazepines can be useful in the short-term for 1-3 months for a variety of anxiety disorders, like Generalized Anxiety Disorder, Social Anxiety Disorder and Panic Disorder, while waiting for the SSRI or other antidepressant/anti-anxiety medication to “kick in”. Benzodiazepines are not particularly helpful for depressive disorders or Obsessive-Compulsive Disorder. When starting a benzodiazepine, it is important to inform the patient that it is a short-term intervention, explaining the reason is to avoid long-term side effects, like tolerance, cognitive effects, and physiological and psychological dependence. When choosing a benzodiazepine, it is important to try to avoid short-acting medications like alprazolam if possible, because patients can develop a quick dependence to it because they can experience a “high” with it, and it has a short half-life, which can lead to rebound anxiety and can make it very difficult to taper off the medication. Also alprazolam is not a good medication for insomnia because of its short half-life. Patients may complain of being able to fall asleep okay but then waking up in the middle of the night. Alternative benzodiazepines to consider on a short-term basis for sleep include: clonazepam and temazepam.

If a patient is requiring adjunctive medication on a long-term basis for anxiety, consider non-benzodiazepine alternatives like diphenhydramine, hydroxyzine, propranolol, or buspirone. In the rare case when a long-term daily benzodiazepine is indicated, for example with Generalized Anxiety Disorder which responds well to a combination of SSRI + benzodiazepine, consider clonazepam. If a patient has infrequent panic attacks and a daily SSRI is not indicated, one could consider lorazepam on a prn basis. Lorazepam works well as a prn medication for acute anxiety and panic attacks, because it works relatively quickly but does not build up in the bloodstream. If one is prescribing long-term benzodiazepines, it is important to make sure the use is not slowly escalating, because that is a sign of tolerance and dependence.  Also, when helping a patient taper off a medication after he has been on it for some time, it is important to conduct a slow taper to avoid serious withdrawal symptoms, and to provide an alternative to treat the ongoing anxiety symptoms. Guidelines for appropriately tapering off benzodiazepines are discussed in another e-Weekly.

The goal of this article is to help the primary care provider be more informed about the decision to prescribe a benzodiazepine to a patient in a safe and helpful way, because this class of medication has a role in treatment for anxiety disorders and can be helpful when used appropriately. It is therefore useful to look at some guidelines for appropriate prescribing practices for this class of medications.