Maudsley Deprescribing Guidelines

Mark Horowitz, BA, BSc(Med), MBBS(Hons), MSc, GDipPsych, PhD, is a trainee psychiatrist and Clinical Research Fellow at North East London NHS Trust, where he runs a psychiatric drug deprescribing clinic. He is an Honorary Research Fellow at University College London and he co-authored the Royal College of Psychiatrists guide on 'Stopping antidepressants'. He has authored multiple academic papers on how to safely stop psychiatric drugs in high impact journals, and lectured on this topic around the world to doctors, pharmacists and the public. He was commissioned by Health Education England to prepare a module on safe deprescribing of antidepressants for prescribers in the National Health Service (NHS). He has lived experience of stopping psychiatric drugs which informs most of his work.David Taylor, PhD, FFRPS, FRPharmS, FRCPEdin, FRCPsych(Hon), is Director of Pharmacy and Pathology at the South London and Maudsley NHS Trust and Professor of Psychopharmacology at King's College, London. He is the lead author of the Maudsley Prescribing Guidelines in Psychiatry and Editor-in-Chief of Therapeutic Advances in Psychopharmacology. He co-authored the Royal College of Psychiatrists guide on 'Stopping antidepressants'. His pharmacy department ran a medication help-line for a decade which fielded queries largely related to withdrawal from psychiatric drugs. He has personal experience of stopping psychiatric drugs.

• Preface ixAcknowledgements xiiNotes on Using the Maudsley® Deprescribing Guidelines xiiiAbbreviations List xvChapter 1 Introduction to Deprescribing Psychiatric Medications 1Deprescribing as an Intervention 1The context for deprescribing 2Why deprescribe? 7Barriers and facilitators to deprescribing 11Withdrawal Effects from Psychiatric Medications 13Mis-diagnosis of withdrawal effects as relapse 13Pathophysiology of psychiatric drug withdrawal symptoms 16Clinical aspects of psychiatric drug withdrawal 19Specific issues in psychiatric drug withdrawal 23How to Deprescribe Psychiatric Medications Safely 27The neurobiology of tapering 28Practical options for prescribing gradually tapering doses 36Psychological aspects of tapering 43Tapering psychiatric drugs in practice 45Further topics 52Chapter 2 Safe Deprescribing of Antidepressants 57When and Why to Stop Antidepressants 57Adverse effects of antidepressants 66Discussing deprescribing antidepressants with patients 72Withdrawal Effects from Antidepressants 76Recent developments in the understanding of antidepressant withdrawal 76Pathophysiology of antidepressant withdrawal symptoms 80Clinical aspects of antidepressant withdrawal 87How common, severe and long‐ lasting are withdrawal symptoms from antidepressants? 92Protracted antidepressant withdrawal syndrome 96Post‐ SSRI sexual dysfunction 98Factors influencing development of withdrawal effects 99Stratfiying risk of antidepressant withdrawal 105Distinguishing antidepressant withdrawal symptoms from relapse 107Distinguishing antidepressant withdrawal symptoms from new onset of a physical or mental health condition 111Withdrawal symptoms during antidepressant maintenance treatment or switching medication 113How to Deprescribe Antidepressants Safely 115Tapering antidepressants gradually 119Hyperbolic tapering of antidepressants 125Practical options in prescribing gradually tapering doses of antidepressants 131Psychological aspects of antidepressant tapering 140Tapering antidepressants in practice 143Managing complications of antidepressant discontinuation 153Tapering Guidance for Specific Antidepressants 158Agomelatine 159Amitriptyline 163Bupropion 168Citalopram 174Clomipramine 183Desvenlafaxine 188Dosulepin 193Doxepin 198Duloxetine 203Escitalopram 209Fluoxetine 216Fluvoxamine 223Imipramine 228Lofepramine 233Mirtazapine 238Moclobemide 243Nortriptyline 248Paroxetine 253Phenelzine 259Sertraline 264Tranylcypromine 270Trazodone 275Venlafaxine 280Vilazodone 288Vortioxetine 292Chapter 3 Safe Deprescribing of Benzodiazepines and Z-drugs 297When and Why to Stop Benzodiazepines and Z-drugs 297Discussing deprescribing benzodiazepines and z-drugs 304Withdrawal Symptoms from Benzodiazepines and Z-drugs 309Physical dependence vs addiction in use of benzodiazepines and z-drugs 311Pathophysiology of benzodiazepine withdrawal syndrome 313Variety of withdrawal symptoms from benzodiazepines and z-drugs 316Protracted benzodiazepine withdrawal syndrome 320Distinguishing benzodiazepine withdrawal symptoms from return of an underlying condition 323Withdrawal symptoms during benzodiazepine maintenance treatment 326How to Deprescribe Benzodiazepines and Z-drugs Safely 327Tapering benzodiazepines and z-drugs gradually 330Hyperbolic tapering of benzodiazepines and z-drugs 332Switching to longer-acting benzodiazepines to taper 335Making up smaller doses of benzodiazepines and z-drugs practically 338Other considerations in tapering benzodiazepines and z-drugs 342Psychological aspects of tapering benzodiazepines and z-drugs 345Tapering benzodiazepines and z-drugs in practice 348Management of complications of benzodiazepine and z-drug discontinuation 358Tapering Guidance for Specific Benzodiazepines and Z-drugs 362Alprazolam 364Buspirone 375Chlordiazepoxide 380Clonazepam 388Clorazepate 396Diazepam 404Estazolam 412Eszopiclone 418Flurazepam 423Lorazepam 429Lormetazepam 440Nitrazepam 446Oxazepam 452Quazepam 461Temazepam 467Triazolam 474Zaleplon 480Zolpidem 485Zopiclone 490Chapter 4 Safe Deprescribing of Gabapentinoids 495When and Why to Stop Gabapentinoids 495Discussing deprescribing gabapentinoids 504Overview of Gabapentinoid Withdrawal Effects 507Physical dependence vs addiction in use of gabapentinoids 510How to Deprescribe Gabapentinoids Safely 512Principles for tapering gabapentinoids 512Making up smaller doses of gabapentinoids practically 516Other considerations in tapering gabapentinoids 520Psychological aspects of tapering gabapentinoids 523Tapering gabapentinoids in practice 525Management of complications of gabapentinoid discontinuation 532Tapering Guidance for Specific Gabapentinoids 537Gabapentin 538Pregabalin 546Index 553