Effective Deprescription in BPD

[hippopotamusoath]

I'm doing mostly outpatient work, and I have a bunch of patients with BPD. Many of them are on polypharmacy. Think "borderline cocktail" type regimens.

As a matter of trying to practice good medicine, I am very interested in deprescribing drugs that are not needed. I'm curious if anyone else takes an assertive approach to de-prescription in this population and has gotten good at it.

The barriers I run into:

1. I generally work well with this population and the working alliance tends to be quite strong (not to toot my own horn, but it's true). So if I have contributed to the polypharmacy, there is often a strong placebo effect and reluctance to talk about tapering medication--I think as a transference effect. I prescribed it, so the medicine is over-valued as far as its contribution to the patient's stability.

2. We have essentially nothing as far as ancillary services to refer to. I live smack-dab in the middle of the country, nowheresville USA, with a near-useless CMH system, few therapists, no PHP/IOP, etc. And if you're talking about a good-quality therapist who practices solid DBT or DBT-informed therapy, AND takes the patient's insurance, AND is accepting referrals, we're getting into needle-in-a-haystack territory real quick. So the patients are habituated to expect medication for their problems, as, culturally, it's all they've ever had access to (for psychiatry and most other problems). Conversations about deprescription are quickly met with quite understandable push-back--"I won't have anything then!"

3. My own anxiety--some of these patients really have achieved a lot of stability. I have one patient who was in the ICU after a near-fatal over-dose several years ago has remained semi-productive with no hospitalizations or suicide attempts in the interval. On a borderline cocktail--an anti-psychotic, antidepressant, benzodiazepine, you know the drill. I hate it, but I'm really reluctant to do anything besides discuss risks/benefits of the medications and be hands-off, which is the patient's preference. I strongly suspect that too much muddling will cause an acute anxiety exacerbation, which leads to impaired sleep, which historically leads to suicide attempts (including the near-fatal one).

4. Figuring out how to discuss the interval distress. When we do start to de-prescribe, ANY exacerbation of anxiety/mood problems is quickly attributed to "I must really need that medication" and a strong push-back to re-start it. I haven't figured out a reliable way to talk about this and convince my patients to ride out these ups and downs (which, I suspect are happening regardless of what we do with medication).

5. Patient preference. The people who come to me WANT polypharmacy, in general. I feel like the healthcare system as a whole is oriented that way, too. To the patients, any pushback against that is experienced as having a bad roof, hiring a roofer, and the roofer tells them that roofs don't actually keep water out and I'm not going to fix your roof, sorry.

So if anyone feels particularly skillful at de-prescribing, how do you do it? In patients with BPD, but also just in general.

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[Celexa]

It is really hard.

One thing it is very important to do is to not feel you need to make a med change every visit. If your rec is to decrease something, and the patient doesn't want to, just kindly and calmly explain why this is your rec today, reassure them it's their decision, and make the next appointment in a few months. Acknowledge their worries and ambivalence. Talk about how they may have needed something in the past but that doesn't mean they'll always need it. Plant seeds and watch them grow. These are long conversations.

In line with the above, release yourself from timeline pressure unless there's something acute going on which makes decreasing the med urgent. Go slow. Go creatively slowly. Know what tablets can be split, what capsules opened. Get creative with schedules--pt wants to take alternating doses each day on the way down? Wants the option to go back up to the higher dose one day per week? Sure! You're working more with psychology than pharmacology here. It doesn't have to make sense with the pharmacokinetics if it's what the pts needs to feel comfortable. Present it as an experiment--can we see how you do for two weeks on this lower dose? Ask them to specifically track their moods.

Discuss frankly the stability you've seen and praise any progress and life changes people make. Patients hear this shockingly infrequently! The default mode is 'I'm seeing a doctor so I must be broken'. It flips the script a little if you can ground them in reality of what is going well.

Reply to their concerned phone calls reliably, but not quickly. If they call you in crisis on the lower dose but it's not am actual medical crisis, call them back in a day or two. Teach them you will always call back but also that they can get through these things. Often the crisis will have resolved when you talk to them.

All of the gravitational force is our Healthcare system pushes towards polypharmacy and against deprescribing. Grant yourself grace that you care to really try.

 

[Celexa]

I also offer pts who are willing to do some self-directed learning this podcast which is aimed at the public and does a decent job of teaching basic dbt skills:

Edit: link is broken when I try and copy it in. Can Google "the skillful podcast" and it comes up

No substitute for good live therapy, but better than nothing, especially if they already listen to podcasts etc.

 

[littlefred]

This book might be a good read for you.

Handbook of Good Psychiatric Management for Borderline Personality Disorder: 9781585624607: Medicine & Health Science Books @ Amazon.com

Handbook of Good Psychiatric Management for Borderline Personality Disorder: 9781585624607: Medicine & Health Science Books @ Amazon.com

a.co

I'm not getting any kickbacks off the above link.

 

[forchinet121]

It is really hard.

One thing it is very important to do is to not feel you need to make a med change every visit. If your rec is to decrease something, and the patient doesn't want to, just kindly and calmly explain why this is your rec today, reassure them it's their decision, and make the next appointment in a few months. Acknowledge their worries and ambivalence. Talk about how they may have needed something in the past but that doesn't mean they'll always need it. Plant seeds and watch them grow. These are long conversations.

In line with the above, release yourself from timeline pressure unless there's something acute going on which makes decreasing the med urgent. Go slow. Go creatively slowly. Know what tablets can be split, what capsules opened. Get creative with schedules--pt wants to take alternating doses each day on the way down? Wants the option to go back up to the higher dose one day per week? Sure! You're working more with psychology than pharmacology here. It doesn't have to make sense with the pharmacokinetics if it's what the pts needs to feel comfortable. Present it as an experiment--can we see how you do for two weeks on this lower dose? Ask them to specifically track their moods.

Discuss frankly the stability you've seen and praise any progress and life changes people make. Patients hear this shockingly infrequently! The default mode is 'I'm seeing a doctor so I must be broken'. It flips the script a little if you can ground them in reality of what is going well.

Reply to their concerned phone calls reliably, but not quickly. If they call you in crisis on the lower dose but it's not am actual medical crisis, call them back in a day or two. Teach them you will always call back but also that they can get through these things. Often the crisis will have resolved when you talk to them.

All of the gravitational force is our Healthcare system pushes towards polypharmacy and against deprescribing. Grant yourself grace that you care to really try.

Can’t all tablets be split? As long as it’s not like an extended release or something unique I assume every tablet can be split?

 

[hippopotamusoath]

This book might be a good read for you.

Handbook of Good Psychiatric Management for Borderline Personality Disorder: 9781585624607: Medicine & Health Science Books @ Amazon.com

Handbook of Good Psychiatric Management for Borderline Personality Disorder: 9781585624607: Medicine & Health Science Books @ Amazon.com

a.co

I'm not getting any kickbacks off the above link.

Yes! I have it and refer to it regularly. It's much more practical than swirling a glass of scotch and cracking open Kernberg.

 

[hippopotamusoath]

I also offer pts who are willing to do some self-directed learning this podcast which is aimed at the public and does a decent job of teaching basic dbt skills:

Edit: link is broken when I try and copy it in. Can Google "the skillful podcast" and it comes up

No substitute for good live therapy, but better than nothing, especially if they already listen to podcasts etc.

Thanks for the reminder, I have listened to a few episodes of this and really found it useful. A lot more accessible for a patient who is on the fence about therapy, too.

 

[Celexa]

Can’t all tablets be split? As long as it’s not like an extended release or something unique I assume every tablet can be split?

Sadly more complicated than that. Yes ER can't be split usually. But also some tablets are too small to be practical to split, for some pts (older folks often struggle with the small pills). Some come with weird warnings (learned at one point splitting olanzapine carries a warning for contact dermatitis, apparebtly--had to pursuade the pharmacist it was still OK and tell the pt to wash their hands afterward.) some the pill kind of crumbles, so they might get the half dose but you need to prescribe them the higher dose and tell them to throw away the other half bc it won't stay together in a useful way. Some capsules are ok to open and portion out a bit and some aren't. And on and on....

There's no way to know it all off the top of your head but eventually you get a sense of what flexible dosing you can do and what smallest increments you can work with.

 

[watto]

Sometimes I think they might be better served by...I can't believe I'm writing this...a naturopath. At least the prescriptions may be more benign if vitamins, herbs, etc. I wish someone had research on naturopaths and BPD. Meanwhile, you could continue the therapy and support the transition to these more "natural" interventions.

 

[Psychresy]

Some evidence for Omega 3s in BPD. Sometimes I pull that one out and hope for strong placebo effect.

 

[forchinet121]

Some evidence for Omega 3s in BPD. Sometimes I pull that one out and hope for strong placebo effect.

Any risks to omega 3? Anything we need to counsel about or can anyone literally take it with no issues?

 

[splik]

The first rule of deprescribing is that deprescribing should be led by the patient, not the physician. While we can and should suggest when a patient may benefit from reducing their medication, ultimately, it is doomed to failure unless the patient wants it. There are complex dynamics regarding prescribing in borderline pts. Tapering is likely to activate attachment anxiety in patients and will inevitably lead to an exacerbation of symptoms and masochistic behaviors due to fear of abandonment. This is something that can be effectively managed if patients have very close follow up. Otherwise no. It is pretty common for BPD pts (even Linehan's pts) to remain on polypharmacy even after they have completed DBT. That does not necessarily represent a failure. If the patients are doing well, and want to continue on their meds, just continue them.

 

[Psychresy]

The first rule of deprescribing is that deprescribing should be led by the patient, not the physician. While we can and should suggest when a patient may benefit from reducing their medication, ultimately, it is doomed to failure unless the patient wants it. There are complex dynamics regarding prescribing in borderline pts. Tapering is likely to activate attachment anxiety in patients and will inevitably lead to an exacerbation of symptoms and masochistic behaviors due to fear of abandonment. This is something that can be effectively managed if patients have very close follow up. Otherwise no. It is pretty common for BPD pts (even Linehan's pts) to remain on polypharmacy even after they have completed DBT. That does not necessarily represent a failure. If the patients are doing well, and want to continue on their meds, just continue them.

Whats your feeling when a patient is demanding of med changes seemingly at every appointment. Not benzos/controlled meds, but wanting a new antidepressant, buspar, etc at evey sign of distress. I had a patient recently where there was a big falling out because I wouldn't rx the way they wanted me to.

 

[SmallBird]

The first rule of deprescribing is that deprescribing should be led by the patient, not the physician. While we can and should suggest when a patient may benefit from reducing their medication, ultimately, it is doomed to failure unless the patient wants it. There are complex dynamics regarding prescribing in borderline pts. Tapering is likely to activate attachment anxiety in patients and will inevitably lead to an exacerbation of symptoms and masochistic behaviors due to fear of abandonment. This is something that can be effectively managed if patients have very close follow up. Otherwise no. It is pretty common for BPD pts (even Linehan's pts) to remain on polypharmacy even after they have completed DBT. That does not necessarily represent a failure. If the patients are doing well, and want to continue on their meds, just continue them.

I think this is the first time I have disagrees with you in 10 years

The manner and extent to which we prescribe medication sends powerful messages about how we think recovery occurs, and to add or continue multiple medications when we don't believe the problem will be addressed by them can lead to a disempowered treatment perspective.

My approach to this is to develop a detailed recovery narrative with the patient where we understand what a good treatment outcome might look like and then identify specific barriers, and which might be ones that medication could address. We then agree to pursue medication only for those issues which are plausibly brain based and discontinue medications that aren't clearly in support of broader goals. I would say about 1/4 patients switch to a doctor who is willing to prescribe and the rest make substantial gains as they are forced to redirect their efforts to other aspects of treatment. Patients aren't going to figure this out on their own because since the first time they were prescribed a medication the response has been to add or increase no matter what specific problem was reported.

 

[FlowRate]

Whats your feeling when a patient is demanding of med changes seemingly at every appointment. Not benzos/controlled meds, but wanting a new antidepressant, buspar, etc at evey sign of distress. I had a patient recently where there was a big falling out because I wouldn't rx the way they wanted me to.

You're between a rock and a hard place due to what sounds like lack of ability to see these patients frequently, yourself, and lack of local therapy resources. The problem is that it's entirely enactment. The patient needs/wants to feel held/contained/cared for and the way they feel that is through your behavior of prescribing because (I'm assuming) you're not otherwise seeing them weekly/frequently enough for them to maintain some sense of connection between appointments (because they have BPD and poor object constancy.) If you want to go above and beyond, you can simulate this in some other ways, like with 5 minute phone calls more frequently, or inviting the patient to leave voicemails for you or send you messages, with the express boundary setting that you can't message with them frequently/are not going to write or call back unless there's a very specific ask and need.

On the other hand, if the patient is able to tolerate some reasonable boundary setting around the prescribing (no more than 3 simultaneous meds, no cycling through controlled or unnecessarily heavy stuff like olanzapine or lithium), you could do worse than switching between low-mod doses of primarily SRI's.

 

[nexus73]

Be ready for the patient to be doing exactly the same in 6 months, and then blame you for taking them off all their meds and that's why they're doing so bad now. Might be helpful to predict this phenomenon to the patient.

Plus I've seen this phenomenon, and not that surprising in hindsight, of BPD patients getting into the local IOP program (but not having access to individual therapy before during or after IOP), and they do great in IOP for 8 weeks, then crash when the social support is ripped away from them. Possibly would have been better for them not to do IOP at all, interestingly.

 

[SmallBird]

You're between a rock and a hard place due to what sounds like lack of ability to see these patients frequently, yourself, and lack of local therapy resources. The problem is that it's entirely enactment. The patient needs/wants to feel held/contained/cared for and the way they feel that is through your behavior of prescribing because (I'm assuming) you're not otherwise seeing them weekly/frequently enough for them to maintain some sense of connection between appointments (because they have BPD and poor object constancy.) If you want to go above and beyond, you can simulate this in some other ways, like with 5 minute phone calls more frequently, or inviting the patient to leave voicemails for you or send you messages, with the express boundary setting that you can't message with them frequently/are not going to write or call back unless there's a very specific ask and need.

On the other hand, if the patient is able to tolerate some reasonable boundary setting around the prescribing (no more than 3 simultaneous meds, no cycling through controlled or unnecessarily heavy stuff like olanzapine or lithium), you could do worse than switching between low-mod doses of primarily SRI's.

I think that is one common unmet need that drives requests for further medication adjustment; I believe another is continued experiences of intolerable negative emotions and the earnest (and highly reinforced) belief that this can be corrected through medication, and that the path to relief is through a process of adjustment and addition until this is reached. In both cases I can't get behind the idea of simply switching between low risk medications as it reinforces the maladaptive dynamic. Instead validate that they are in tremendous distress and reassure them that you see that and want to do anything that can be helpful and then offer a subsequent visit at a regular interval but don't do something that makes no sense.

 

[nexus73]

Whats your feeling when a patient is demanding of med changes seemingly at every appointment. Not benzos/controlled meds, but wanting a new antidepressant, buspar, etc at evey sign of distress. I had a patient recently where there was a big falling out because I wouldn't rx the way they wanted me to.

commend them on assertive communication and boundary setting.

 

[SmallBird]

Be ready for the patient to be doing exactly the same in 6 months, and then blame you for taking them off all their meds and that's why they're doing so bad now. Might be helpful to predict this phenomenon to the patient.

Plus I've seen this phenomenon, and not that surprising in hindsight, of BPD patients getting into the local IOP program (but not having access to individual therapy before during or after IOP), and they do great in IOP for 8 weeks, then crash when the social support is ripped away from them. Possibly would have been better for them not to do IOP at all, interestingly.

Yes, I actually have a worksheet for this where I get them to write down an inventory of unpredictable uncomfortable emotional and somatic phenomena, and then get them to commit to not blaming any of these experiences on a medication in the future because we are prior to initiating a prescription agreeing that these things were always part of the picture.

 

[G Sheb]

Whats your feeling when a patient is demanding of med changes seemingly at every appointment. Not benzos/controlled meds, but wanting a new antidepressant, buspar, etc at evey sign of distress. I had a patient recently where there was a big falling out because I wouldn't rx the way they wanted me to.

Spend a lot of time talking about the symptoms, context in which they develop, how they deal with them, validate the feelings, show genuine care. That's really what they are looking for, but they just see you through a prescriber lens.
Don't jump into a "no", or put on the counseling hat, because that's not going to fly.
Most of the time you'll be surprised that by the end, they may have forgotten about the medication change.

 

[G Sheb]

The first rule of deprescribing is that deprescribing should be led by the patient, not the physician. While we can and should suggest when a patient may benefit from reducing their medication, ultimately, it is doomed to failure unless the patient wants it. There are complex dynamics regarding prescribing in borderline pts. Tapering is likely to activate attachment anxiety in patients and will inevitably lead to an exacerbation of symptoms and masochistic behaviors due to fear of abandonment. This is something that can be effectively managed if patients have very close follow up. Otherwise no. It is pretty common for BPD pts (even Linehan's pts) to remain on polypharmacy even after they have completed DBT. That does not necessarily represent a failure. If the patients are doing well, and want to continue on their meds, just continue them.

I agree with this.
You could suggest changing the medications, and you have to be very careful because rocking the ship in a BPD patient will almost inevitably lead to some decompensation. Ultimately, if it's not broke, don't fix it.

 

[splik]

Whats your feeling when a patient is demanding of med changes seemingly at every appointment. Not benzos/controlled meds, but wanting a new antidepressant, buspar, etc at evey sign of distress. I had a patient recently where there was a big falling out because I wouldn't rx the way they wanted me to.

That is completely different from the scenario of a patient on less than ideal polypharmacy who is is relatively stable.
I have a therapy heavy practice. Some pts see me only for therapy and either aren't on meds or see another psychiatrist for their meds. I am quite selective in whom I take on but I certainly have pts who came to me on multiple meds including multiple controlled meds and we carefully manage this but I don't make a big deal of tapering them.

In terms of patients who want new meds every visit, I think that is quite common amongst anxious patients or those were certain personality disorders to behave that way. Many younger patients nowadays also seem to want a pill for every ill and want to obliterate any distressing feeling. I formulate what is going on (e.g. what are they really asking for? Do they want a gift, relief, a badge of honor or emblem of their suffering, to feel loved, is it safety behavior, an avoidance strategy, do they want a transitional object etc) and manage accordingly. It is much easier to manage this sort of thing when you are seeing pts weekly or more frequently. I often explain to patients that prescribing a medication now will be therapy interfering and negatively affect treatment. I use scales like the PHQ-9, GAD-7 etc, and use the scores/graphs to show pts that they are actually doing better over time and may be experiencing an understandable blip. I often explain to patients that their current emotional state is understandable, and we will keep an eye on things and if their symptoms persist we can consider changing. For example, a lot of patients tend to feel worse around this time of year, and I usually reassure them that this is likely temporary and we will continue to monitor.

 

[Celexa]

The first rule of deprescribing is that deprescribing should be led by the patient, not the physician. While we can and should suggest when a patient may benefit from reducing their medication, ultimately, it is doomed to failure unless the patient wants it. There are complex dynamics regarding prescribing in borderline pts. Tapering is likely to activate attachment anxiety in patients and will inevitably lead to an exacerbation of symptoms and masochistic behaviors due to fear of abandonment. This is something that can be effectively managed if patients have very close follow up. Otherwise no. It is pretty common for BPD pts (even Linehan's pts) to remain on polypharmacy even after they have completed DBT. That does not necessarily represent a failure. If the patients are doing well, and want to continue on their meds, just continue them.

I agree that many of these patients need med long terms and even after adequate therapy treatment they may be on multiple meds long term. And I agree you need patient buy in if doing this. I disagree that reducing polypharmacy isn't a worthwhile goal in and of itself, though--SO many patients are on high dose antipsychotics and are obese and have diabetes, are the on two meds with the same mechanism, tons of anticholinergic agents... I've had two patients in the last two months with bad lithium toxicity on the CL service. Extensive due diligence including reliable collateral yielded absolutely no reason they needed lithium, but they'd been on it for years! Sent both on their way with just their SSRIs. Both lucky they didn't end up with more permanent kidney damage.

With so many of these patients if their regimen isn't pared down at some point it just means they're gonna get older, have more medical problems, and it'll become an overt problem at a much less convenient time in their life.

 

[annoyedpsychiatrist]

I usually have BPD patients on anywhere from 1-3 medications depending on the presentation. Typically an SSRI and often an SGA because mood swings/irritability can be a big deal, and a lot of them deal with depression so it adds to adjunct antidepressant effect. Most of my BPD patients actually want to come off medication or be on less when they get to me which I support. The ones that already have the diagnosis its a little easier because theyve been down the road of 200 meds and are probably sick of it. The ones who someone hasnt had the "you're BPD" chat its a bit more tricky

 

[SmallBird]

I usually have BPD patients on anywhere from 1-3 medications depending on the presentation. Typically an SSRI and often an SGA because mood swings/irritability can be a big deal, and a lot of them deal with depression so it adds to adjunct antidepressant effect. Most of my BPD patients actually want to come off medication or be on less when they get to me which I support. The ones that already have the diagnosis its a little easier because theyve been down the road of 200 meds and are probably sick of it. The ones who someone hasnt had the "you're BPD" chat its a bit more tricky

This is reasonable, the data for one mood stabilizing agent to target emotional lability is actually quite strong, i just meta analyzed this with some colleagues (under review, will post citation in future). I think including an SSRI is probably reasonable to the extent we can assume the literature from antidepressant trials applies, or indeed the studies of SSRIs for mood lability but these were mostly in PMDD.

The polypharmacy that I will not agree to continue is usually something like an SSRI plus a second antidepressant, a benzo, lamotrigine plus an atypical, and then off course gabapentin. This is the bottomless pit approach where nothing will ever be enough and we foster dependence and a lack of self efficacy by doing this.

 

[Tangerine123]

PGY2 here, also having deprescribing. I actually bought a book about this yesterday (in German).

Psychopharmaka absetzen? Warum, wann und wie? von Gerhard Gründer | ISBN 978-3-437-23585-6 | Fachbuch online kaufen - Lehmanns.de

Psychopharmaka absetzen? Warum, wann und wie? von Gerhard Gründer (ISBN 978-3-437-23585-6) bestellen. Schnelle Lieferung, auch auf Rechnung - lehmanns.de

www.lehmanns.de

If you ask me, the saying "Good surgeons know how to operate, better ones when to operate, and the best when not to operate" applies to Psych too. Knowing who not to medicate and when to deprescribe has its merits.

National guidelines (Germany) are somewhat vague when it comes to this topic, and every attending had their own take on things.

I honestly feel kinda "dirty" reading this book. I feel that talking about deprescribing and avoiding medication in certain circumstances is sometimes seen as "anti-psychiatry".

Then again, I'm just a PGY2, maybe I'm just missing something due to lack of experience

 

[Psychresy]

I usually have BPD patients on anywhere from 1-3 medications depending on the presentation. Typically an SSRI and often an SGA because mood swings/irritability can be a big deal, and a lot of them deal with depression so it adds to adjunct antidepressant effect. Most of my BPD patients actually want to come off medication or be on less when they get to me which I support. The ones that already have the diagnosis its a little easier because theyve been down the road of 200 meds and are probably sick of it. The ones who someone hasnt had the "you're BPD" chat its a bit more tricky

I believe the best evidence is for low dose SGA, so this doesnt seem unreasonable; i..e ssri + sga

 

[Stagg737]

So if anyone feels particularly skillful at de-prescribing, how do you do it? In patients with BPD, but also just in general.

Get good at MI. Developing a good understanding of where your patient is regarding their current stage of change is essential, as they're not going to be amenable to change if they don't feel prepared. Helping your patients develop insight into the positive aspects of less/lower doses to advance their motivation is key to accomplishing this. There's many ways to do this, my favorite is pointing out that it's probably overwhelming and anxiety-inducing having to remember to take 20+ pills every day and that only taking 5-6 would probably be a lot easier and less annoying. Identifying what the meds are actually for and eliminating redundant meds is a great way to discuss decreasing.

It's also important to understand that this is a process that takes (a lot) of time for most patients. I've gotten a lot of patients to points where they've cut the number of pills they're taking daily down significantly, but it almost always takes a significant amount of time (think years) short of something major causing a forced change. This will be especially true for patients with PDs and patients who are averse to feeling any emotions.

I think this is the first time I have disagrees with you in 10 years

The manner and extent to which we prescribe medication sends powerful messages about how we think recovery occurs, and to add or continue multiple medications when we don't believe the problem will be addressed by them can lead to a disempowered treatment perspective.

My approach to this is to develop a detailed recovery narrative with the patient where we understand what a good treatment outcome might look like and then identify specific barriers, and which might be ones that medication could address. We then agree to pursue medication only for those issues which are plausibly brain based and discontinue medications that aren't clearly in support of broader goals. I would say about 1/4 patients switch to a doctor who is willing to prescribe and the rest make substantial gains as they are forced to redirect their efforts to other aspects of treatment. Patients aren't going to figure this out on their own because since the first time they were prescribed a medication the response has been to add or increase no matter what specific problem was reported.

I don't see this and Splik's general concept as mutually exclusive. If a patient doesn't want meds changed/tapered and you are going to force or strongly encourage it without their buy-in, it's not going to work and they'll end up feeling disempowered by you instead of the meds. It doesn't have to be "patient-led", but it certainly helps if they believe that or at the very least believe it's a cooperative effort.

Yes, I actually have a worksheet for this where I get them to write down an inventory of unpredictable uncomfortable emotional and somatic phenomena, and then get them to commit to not blaming any of these experiences on a medication in the future because we are prior to initiating a prescription agreeing that these things were always part of the picture.

This sounds fantastic, mind sharing that if you can? DM me if you prefer.

 

[Candidate2017]

1. I generally work well with this population and the working alliance tends to be quite strong (not to toot my own horn, but it's true). So if I have contributed to the polypharmacy, there is often a strong placebo effect and reluctance to talk about tapering medication--I think as a transference effect.

What do you mean work well with borderlines? Do you mean you get along well? There is a tendency for doctors to allow themselves to be split on to the good side because it feels good and causes less hassle. But borderlines (and patients) generally don't improve without occasionally being angry with your advice.

By getting along well with borderlines, you are impeding their development and colluding with them to maintain their illness.

2. We have essentially nothing as far as ancillary services to refer to.

You are not responsible for systemic societal issues.

3. My own anxiety--some of these patients really have achieved a lot of stability. I have one patient who was in the ICU after a near-fatal over-dose several years ago has remained semi-productive with no hospitalizations or suicide attempts in the interval. On a borderline cocktail--an anti-psychotic, antidepressant, benzodiazepine, you know the drill.

Maybe they do need that cocktail for mood. The benzo, probably not. Just creating avoidance.

Psychiatric patients sometimes die as a result of their mental illness. Have you accepted this? Death is rather rare compared to specialties like oncology, surgery, EM, and even primary care, which is why it provokes so much anxiety in psychiatrists than those other doctors.

4. Figuring out how to discuss the interval distress.

You have to control your own anxiety in order to effectively model such behavior, as well as convince patients anxiety is ok. It's simply, "Yeah you may feel terrible for a bit." It applies to everything, whether starting/stopping an SSRI, tapering off BZDs, opioid withdrawal, enforcing phone rules, discharging a patient etc.

5. Patient preference. The people who come to me WANT polypharmacy, in general.

Of course people want pills. A pill for every ill. Especially the real good stuff.

Don't be afraid to say, "I'm sorry, I don't have a pill for that." I conceptualize my job as dispensing medical opinions, rather than slinging pills like an online NP. I also can't fix anything because I'm not god, or even a surgeon. I just point off stuff I think may be useful, which people may or may not choose to incorporate.

"No" is also a good word.

In sum, boundaries, for both you and the patient.

 

[SmallBird]

I don't see this and Splik's general concept as mutually exclusive. If a patient doesn't want meds changed/tapered and you are going to force or strongly encourage it without their buy-in, it's not going to work and they'll end up feeling disempowered by you instead of the meds. It doesn't have to be "patient-led", but it certainly helps if they believe that or at the very least believe it's a cooperative effort.

I get that response a lot from people who almost never take patients off meds. It can't be some milquetoast 'you bring the ideas, I bring my license' - if a medication is not indicated you shouldn't continue it.

 

[G Sheb]

I get that response a lot from people who almost never take patients off meds. It can't be some milquetoast 'you bring the ideas, I bring my license' - if a medication is not indicated you shouldn't continue it.

It's not that simple.
You have to weigh the risks of stopping the medication.
It's not always a good idea to stop a medication if that means a likely decompensation (if it's a PD) or a break in the therapeutic alliance, and another possible decompensation.
It also depends whether this is an SSRI or lithium.

 

[SmallBird]

It's not that simple.
You have to weigh the risks of stopping the medication.
It's not always a good idea to stop a medication if that means a likely decompensation (if it's a PD) or a break in the therapeutic alliance, and another possible decompensation.
It also depends whether this is an SSRI or lithium.

I agree it's not simple - you have to be thoughtful, strategic, slow and supportive - but the contrast I'm emphasizing is that I don't see this as patient led and I don't leave meds that don't have an indication. That doesn't mean stopping them all at once or without preparation.