The Maudsley Deprescribing Guidelines: Antidepressants, Benzodiazepines, Gabapentinoids and Z-drugs

The Maudsley^® Deprescribing Guidelines

Comprehensive resource describing guidelines for safely reducing or stopping (deprescribing) antidepressants, benzodiazepines, gabapentinoids and z-drugs for patients, including step-by-step guidance for all commonly used medications, covering common pitfalls, troubleshooting, supportive strategies, and more.

Most formal guidance on psychiatric medication relates to starting or switching medications with minimal guidance on deprescribing medication. In 2023, the World Health Organisation and the United Nations called for patients, as a human right, to be informed of their right to discontinue treatment and to receive support to do so.

The Maudsley Deprescribing Guidelines fills a significant gap in guidance for clinicians by providing comprehensive and authoritative information on this important aspect of treatment.

This evidence-based handbook provides an overview of principles to be used in deprescribing. This is derived from fundamental scientific principles and the latest research on this topic, combined with emerging insights from clinical practice (including from patient experts).

Building on the recognised brand of The Maudsley Prescribing Guidelines, and the prominence of the authors’ work, including in The Lancet Psychiatry on tapering antidepressants (the most read article across all Lancet titles when it was released). The Maudsley Deprescribing Guidelines covers topics such as:

• Why and when to deprescribe antidepressants, benzodiazepines, gabapentinoids and z-drugs
• Barriers and enablers to deprescribing including physical dependence, social circumstances, and knowledge about the discontinuation process
• Distinguishing withdrawal symptoms, such as poor mood, anxiety, insomnia, and a variety of physical symptoms from symptoms of the underlying disorder that medication was intended to treat
• The difference between physical dependence and addiction/substance use disorder
• Explanation of why and how to implement hyperbolic tapering in clinical practice
• Specific guidance on formulations of medication and techniques for making gradual reductions, including using liquid forms of medication, and other approaches
• Step-by-step guidance for safely stopping all commonly used antidepressants, benzodiazepines, gabapentinoids and z-drugs, including fast, moderate and slow tapering regimens or schedules for each drug, and guidance on how to tailor these to an individual
• Troubleshooting issues which can arise on stopping these medications, including akathisia, withdrawal symptoms, acute or protracted, and relapse.

Written for anyone interested in safe deprescribing of psychiatric medications including psychiatrists, GPs, pharmacists, nurses, medical trainees, and interested members of the public. The Maudsley Deprescribing Guidelines is an essential resource on the subject that provides practical guidance on how to improve patient outcomes in this field of medicine.

 

TABLE OF CONTENTS

Preface ix

Acknowledgements xii

Notes on Using the Maudsley® Deprescribing Guidelines xiii

Abbreviations List xv

Chapter 1 Introduction to Deprescribing Psychiatric Medications 1

Deprescribing as an Intervention 1

The context for deprescribing 2

Why deprescribe? 7

Barriers and facilitators to deprescribing 11

Withdrawal Effects from Psychiatric Medications 13

Mis-diagnosis of withdrawal effects as relapse 13

Pathophysiology of psychiatric drug withdrawal symptoms 16

Clinical aspects of psychiatric drug withdrawal 19

Specific issues in psychiatric drug withdrawal 23

How to Deprescribe Psychiatric Medications Safely 27

The neurobiology of tapering 28

Practical options for prescribing gradually tapering doses 36

Psychological aspects of tapering 43

Tapering psychiatric drugs in practice 45

Further topics 52

Chapter 2 Safe Deprescribing of Antidepressants 57

When and Why to Stop Antidepressants 57

Adverse effects of antidepressants 66

Discussing deprescribing antidepressants with patients 72

Withdrawal Effects from Antidepressants 76

Recent developments in the understanding of antidepressant withdrawal 76

Pathophysiology of antidepressant withdrawal symptoms 80

Clinical aspects of antidepressant withdrawal 87

How common, severe and long‐ lasting are withdrawal symptoms from antidepressants? 92

Protracted antidepressant withdrawal syndrome 96

Post‐ SSRI sexual dysfunction 98

Factors influencing development of withdrawal effects 99

Stratfiying risk of antidepressant withdrawal 105

Distinguishing antidepressant withdrawal symptoms from relapse 107

Distinguishing antidepressant withdrawal symptoms from new onset of a physical or mental health condition 111

Withdrawal symptoms during antidepressant maintenance treatment or switching medication 113

How to Deprescribe Antidepressants Safely 115

Tapering antidepressants gradually 119

Hyperbolic tapering of antidepressants 125

Practical options in prescribing gradually tapering doses of antidepressants 131

Psychological aspects of antidepressant tapering 140

Tapering antidepressants in practice 143

Managing complications of antidepressant discontinuation 153

Tapering Guidance for Specific Antidepressants 158

Agomelatine 159

Amitriptyline 163

Bupropion 168

Citalopram 174

Clomipramine 183

Desvenlafaxine 188

Dosulepin 193

Doxepin 198

Duloxetine 203

Escitalopram 209

Fluoxetine 216

Fluvoxamine 223

Imipramine 228

Lofepramine 233

Mirtazapine 238

Moclobemide 243

Nortriptyline 248

Paroxetine 253

Phenelzine 259

Sertraline 264

Tranylcypromine 270

Trazodone 275

Venlafaxine 280

Vilazodone 288

Vortioxetine 292

Chapter 3 Safe Deprescribing of Benzodiazepines and Z-drugs 297

When and Why to Stop Benzodiazepines and Z-drugs 297

Discussing deprescribing benzodiazepines and z-drugs 304

Withdrawal Symptoms from Benzodiazepines and Z-drugs 309

Physical dependence vs addiction in use of benzodiazepines and z-drugs 311

Pathophysiology of benzodiazepine withdrawal syndrome 313

Variety of withdrawal symptoms from benzodiazepines and z-drugs 316

Protracted benzodiazepine withdrawal syndrome 320

Distinguishing benzodiazepine withdrawal symptoms from return of an underlying condition 323

Withdrawal symptoms during benzodiazepine maintenance treatment 326

How to Deprescribe Benzodiazepines and Z-drugs Safely 327

Tapering benzodiazepines and z-drugs gradually 330

Hyperbolic tapering of benzodiazepines and z-drugs 332

Switching to longer-acting benzodiazepines to taper 335

Making up smaller doses of benzodiazepines and z-drugs practically 338

Other considerations in tapering benzodiazepines and z-drugs 342

Psychological aspects of tapering benzodiazepines and z-drugs 345

Tapering benzodiazepines and z-drugs in practice 348

Management of complications of benzodiazepine and z-drug discontinuation 358

Tapering Guidance for Specific Benzodiazepines and Z-drugs 362

Alprazolam 364

Buspirone 375

Chlordiazepoxide 380

Clonazepam 388

Clorazepate 396

Diazepam 404

Estazolam 412

Eszopiclone 418

Flurazepam 423

Lorazepam 429

Lormetazepam 440

Nitrazepam 446

Oxazepam 452

Quazepam 461

Temazepam 467

Triazolam 474

Zaleplon 480

Zolpidem 485

Zopiclone 490

Chapter 4 Safe Deprescribing of Gabapentinoids 495

When and Why to Stop Gabapentinoids 495

Discussing deprescribing gabapentinoids 504

Overview of Gabapentinoid Withdrawal Effects 507

Physical dependence vs addiction in use of gabapentinoids 510

How to Deprescribe Gabapentinoids Safely 512

Principles for tapering gabapentinoids 512

Making up smaller doses of gabapentinoids practically 516

Other considerations in tapering gabapentinoids 520

Psychological aspects of tapering gabapentinoids 523

Tapering gabapentinoids in practice 525

Management of complications of gabapentinoid discontinuation 532

Tapering Guidance for Specific Gabapentinoids 537

Gabapentin 538

Pregabalin 546

Index 553