Top Strategies for Deprescribing in Depression Care

In part 2 of this interview, Andrew Penn, MS, PMHNP, a clinical professor at the University of California, San Francisco, and Saundra Jain, MA, PsyD, LPC, an adjunct clinical affiliate at the University of Texas at Austin, continue their discussion on deprescribing in depression treatment. Following their presentation, "Mastering the Art of Deprescribing," at the 2023 Psych Congress NP Institute meeting held in Boston, Massachusetts, Nurse Penn examined hyperbolic tapering, using liquid medications, the half-life and pharmacokinetics of fluoxetine, discussing processes with patients, and more.

Catch up on Part 1: Deprescribing in Depression Treatment

Save the date for this year's NP Institute In-Person, March 20-23, 2024, in San Diego, California! For more information, visit the meeting website. Keep up with pre-conference meeting coverage in the newsroom on Psych Congress Network.

Read the Transcript:

Saundra Jain, PsyD: Andrew, I'm thinking about the conversation yesterday, and there was so much interest in deprescribing and the actual technical aspects, the strategies of how to do it. Would you spend a little bit of time- I'm just so curious to hear what else clinicians might be considering.

Andrew Penn, PMHNP: Well, there's this idea called hyperbolic tapering, which really is about reducing the dose very slowly in line with how much is actually acting in the body. And I think a lot of people in the audience yesterday were surprised that even very low doses of medication continue to occupy, say the serotonin transporter when we're talking about antidepressants. And so what this means is that we have to really slow it down, especially as we get towards the end. And you might reduce by say 10% every time period that you're reducing, but it's an increasingly smaller 10%. So if you're going from 20 milligrams, reducing by 10%, you're going to 18 milligrams. But then the next reduction would be 1.8 milligrams. So you're getting smaller and smaller. It's this sort of funnel, if you will. And while that's tricky to do, because most of our pills can't be cut up into those tiny little fragments, there are sort of hacks that we can do.

One way is to use a liquid medication, so substitute, say an SSRI for one that comes in a liquid formulation like fluoxetine. Or another trick that can be done is the fluoxetine taper where you add fluoxetine at a modest dose, like 20 milligrams to an existing antidepressant regimen, continuing both for a period of time, usually 3 or 4 weeks while that fluoxetine is coming up to steady state. And then you start reducing the medication you want to stop very gradually while maintaining the fluoxetine. And then when you finally get to the end, you just go ahead and stop the fluoxetine. And because it has such a long half-life, the active metabolite sticks around in the body for about 5 weeks, that then slowly fades out of the system. And it's this gradual reduction of medications that allows for people to do this more comfortably.

Dr Jain: So it would seem like the fluoxetine would be the safety net to soften and even out that more difficult part of the titration.

Nurse Penn: Exactly. Exactly. Well, we're taking advantage of the pharmacokinetics of fluoxetine, which is that it has a very long half-life, and so the longer the half-life of a drug, the more slowly it fades out. You can think of as a dimmer switch. It's a very gradual fade out. And because you're not making an abrupt change, you don't have that physiologic withdrawal symptoms. Now, of course, the other thing we have to be careful of when taking somebody off of medication is that they can have a return of symptoms. There's a reason why people started on these medications in the first place, and sometimes when we're reducing it, we can see symptoms return. And we have to be thoughtful about how we differentiate those symptoms. Are they withdrawal symptoms or are they actually the return of the illness? And that's sometimes a little tricky to tease out, but those are both phenomenon that can happen during the tapering process.

Dr Jain: And it seems like that last piece you touched on, Andrew, would be really important to have that conversation with the patient so that if there was a return of symptoms or a rebound effect or withdrawal effect, they wouldn't be frightened by it, they'd kind of anticipate the possibility of either thing happening.

Nurse Penn: That's right. That's right.

Dr Jain: I love that. I was thinking, so that is a technical deprescribing medication strategy. And yesterday we talked a lot about the non-pharmacological strategies.

Nurse Penn: We sure did.

Dr Jain: Those are so powerful. The data's really supportive around using CBT, mindfulness, relaxation techniques. And it just gives our patients more tools in their pocket to anticipate and be prepared for the whole process. I really want to mention psychoeducation. The data really supports that even not face-to-face information about deprescribing, but just literature, written paper information about.

Nurse Penn: Because we forget what we get told in office sessions, right?

Dr Jain: That's right. So I think these are great strategies for our viewers, attendees to really home in on.

Nurse Penn: Absolutely.

Saundra Jain, MA, PsyD, LPC, is an adjunct clinical affiliate, School of Nursing, at The University of Texas at Austin, and a psychotherapist in private practice. Dr. Jain is a co-creator of the WILD 5 Wellness Program and co-author of a well-received workbook written for those interested in improving their mental wellness - KickStart30: A Proven 30-Day Mental Wellness Program. She is co-creator of the Psychedelics and Wellness Survey (PAWS) exploring the intersect between psychedelics and wellness. She serves as a member of the Psych Congress Steering Committee providing direction regarding educational gaps/needs for mental health practitioners, and Sana Symposium providing psychedelics education for mental health and addiction professionals.

Andrew Penn, MS, PMHNP, is a clinical professor in the University of California, San Francisco, School of Nursing, where his teaching has received the UCSF Academic Senate Distinction in Teaching Award, among other recognitions. He has practiced as a psychiatric/mental health nurse practitioner, treating veterans and training residents at the San Francisco Veterans Administration Hospital. As a researcher, he collaborates on psychedelics studies of psilocybin and MDMA in the Translational Psychedelics Research (TrPR) lab at UCSF, serving as Co-PI on a phase 2 study of psilocybin for depression and is currently working on a study using psilocybin to treat depression in patients with Parkinson’s disease. A leading voice in nursing, he is a cofounder of the Organization of Psychedelic and Entheogenic Nurses (OPENurses.org).

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