Maudsley Deprescribing Guidelines

From publication to practice

Tuesday 30 July 2024

 Agenda
• Welcome and Acknowledgements A/Commissioner Deborah Howe
• Maudsley Deprescribing Guidelines Dr Mark Horowitz
• Overview of anti-depressant prescribing in Australia Professor Katharine Wallis
and deprescribing using a tapering protocol
• Role of the GP in translating the Maudsley Dr Karen Spielman
Deprescribing Guidelines into practice
• What lived experience looks and feels like and Anna King
how it could be improved
• Q&A Dr Rebekah Hoffman (facilitator)

Maudsley Deprescribing Guidelines

From publication to practice
 Continuous Professional Development
By the end of this session, you should be able to:

1. Describe the neurobiology of psychotropic withdrawal.

2. Outline the risks associated with psychotropic medicine.
3. Compare symptoms of withdrawal with the relapse of the psychiatric condition.
4. Identify when, why and whom to stop antidepressant and benzodiazepine medications.
5. Execute appropriate cessation of antidepressant and benzodiazepine medications.
6. Integrate effective communication strategies when supporting patients through
medication cessation.

Maudsley Deprescribing Guidelines

From publication to practice
 Maudsley Deprescribing Guidelines – Dr Mark Horowitz

Maudsley Deprescribing Guidelines

From publication to practice
The art and science of deprescribing
psychiatric drugs: The Maudsley
Deprescribing Guidelines approach

Dr Mark Horowitz BA, BSc, MBBS, MSc, PhD (IoPPN, KCL)

Trainee psychiatrist
Clinical Research Fellow in Psychiatry (UCL, NELFT)
Lead clinician – Psychotropic drug Deprescribing Clinic (NELFT)
[email protected]
Australian antidepressant use

• 1 in 7 people (1 in 6 adults) in Australia on an antidepressant, about 3.5 million people

• Average duration of use is 4 years

• Most guidelines recommend 6-12 months of use for an episode of anxiety or depression
Long-standing Australian guidance on antidepressant withdrawal

Therapeutic Guidelines, RANZCP, etc:

“Discontinuation symptoms are usually mild and last 1-2 weeks (but can last a month or longer in some
patients).”

• This description was influenced by papers produced by drug companies in the 1990s, which
focused on people who had used antidepressants for 8 -12 weeks
 Australian guidance on management of antidepressant withdrawal syndrome
• TG: “Reduce the antidepressant dose by 25 to 50% every 1 to 4 weeks until the daily dose is half
the lowest unit strength available. Continue at the lowest dose for 2 weeks then stop.”
• Similar from RANZCP.
• Identical guidance in the UK was based on one study that showed that abruptly stopping caused
too severe withdrawal effects (Rosenbaum et al., 1998), and that 4 weeks was considered a
reasonable time by the committee (i.e. no evidence).
• Recent RCT (REDUCE in UK) found that at least 60% of long-term antidepressant users(identified
as low risk for relapse) cannot stop their medication in this way (actually even more slowly).
• I.e. up to 2 million Australians may be trapped on their medications with current approaches.
Consequence: people turn to peer support websites online for guidance

750,000 hits a month 150,000 hits a month

• Commonest story: my doctor told me to stop taking my antidepressant over between 0 and 4 weeks.
• The effects were so horrendous that I had to go back on them.
• The doctor told me there shouldn’t be a problem with coming off them, so that it must be my original
condition coming back, diagnosed me with relapse, informed me I should be on this drug life-long.
• But it felt different to my original condition eg I had dizziness/brain zaps/panic attacks for the first time
• So, I have lost faith in my doctor. The advice on this website was more helpful than my doctor.
• Coming off much more slowly than they suggest – at 10% of the most recent dose every month (so that
reductions become smaller and smaller as the total dose lowers - has made the process much easier
(although still not easy).
Antidepressant withdrawal syndrome
• Physiological symptoms that occur on stopping – or reducing the dose – of an antidepressant.
• They can manifest in either psychological or physical symptoms (these drugs affect multiple bodily systems).
• Occur because changes (adaptation) to the brain caused by the drug use take time to resolve.

• Withdrawal symptoms do not require addiction

(compulsion/craving etc) but only adaptation (often called physical
dependence – though this term has become conflated with
addiction unfortunately) - addiction involves craving, compulsive
use etc – not relevant to antidepressants
• Caffeine, etc cause physical dependence which predicts
withdrawal on stopping (no need for ‘high’, misuse, abuse, etc) –
as for antidepressants.
Antidepressant withdrawal syndrome
Most common withdrawal symptoms are (Fava et al. 2015) :
– Dizziness, insomnia, impaired concentration, fatigue
– Headache, tremor, tachycardia, nightmares
– Affective symptoms: depressed mood, irritability, anxiety, panic attacks
– Sensory symptoms: ‘Electric-shock’ sensations in the head (often on moving eyes), or in limbs
– Gastrointestinal symptoms: nausea, vomiting, diarrhoea
– Increase in suicide attempts in the 2 weeks after stopping an antidepressant (Valuck et al., 2009)
– Akathisia – this is most recognised as a side effect of long-term antipsychotic use but can occur in withdrawal from antidepressants
(and other psychiatric drugs) – involving pacing, a sense of terror, often described as the ‘feeling like the nervous system is on fire’ –
high risk of suicide. Often mis-diagnosed as agitated depression, mania when clinicians are not familiar
 Time taken for
Duration of withdrawal symptoms down-regulation
(and downstream
• In many studies, withdrawal symptoms went for months or years. effects) to return
to ‘pre-drug’
• How can symptoms last so long after the drug is out of the body?
conditions
• It is the time taken for adaptations (changes) to the drug to
resolve that determines the length of the time for withdrawal –
not how long it take the drug to be eliminated from the body
(sound analogy).
• Long-term use of antidepressants can cause long-term changes to
the brain that might account for long-term symptoms:
– In patients there are changed to the serotonin system (reduced
receptors) that has been detected for up to 4 years after
stopping (Bhagwagar, 2004).
– In animal studies (Renoir, 2013) there are changes to the
hormonal system and serotonin system that persist for more
than a year (in human equivalent time) after stopping.
How common, severe and long-lasting are withdrawal symptoms

• A review found from an average of 14 trials that

measured incidence that about half of patients
(56%) experienced withdrawal symptoms
(Davies and Read, 2018).
• In surveys, about half (46%) of patients reported
that their symptoms were ‘severe.’
• The longer patients take antidepressants the
more likely they are to experience withdrawal
symptoms and for those symptoms to be severe.
• A more recent review found that for shorter term
use (< 6months) withdrawal effect were rarer (1
in 6, severe effects 1 in 30) but:
– Average duration of use of antidepressants in Australia is
4 years.
– Studies not well designed to detect withdrawal.
Mis-diagnosing antidepressant withdrawal effects as relapse

• Reported to occur by patients often but not studied in detail

• We surveyed 1300 people out of the 180,000 on peer support websites for tapering off antidepressants
(and other similar drugs) – main reason given for being there
• Withdrawal symptoms can include anxiety, depressed mood, insomnia, appetite changes (even in people
with no underlying mental health condition e.g. those prescribed for migraine)
• Easy to confuse with relapse of depression or anxiety (especially when withdrawal thought to only be
‘mild and brief’)
• Clues to distinguish withdrawal from relapse:
– Quick onset, but can be delayed (?perhaps because of slower dissociation from central compartment)
– Specific symptoms (dizziness, electric shock, other symptoms not present in baseline condition)
– Often quick resolution on re-instatement of antidepressant (hours, day or two)
• Can also be mis-diagnosed as chronic fatigue syndrome, medically unexplained symptoms, neurological
disorder, onset of a new psychiatric disorder, etc
 0-33%
34-66%
Protracted antidepressant withdrawal syndrome 67-100%

Experienced Experienced new

any severity of onset or
● Withdrawal syndromes that can last for months or years increasingly this symptom worsening of this
BEFORE starting symptom AFTER
recognised for antidepressants (Hengartner, 2020; Guy, 2020; Cosci 2020) antidepressants stopping

●
Psychological Impaired 41.4% 93.0%
Now a diagnostic code on SNOMED . concentration

●
Worsened mood 57.3% 92.5%
These can be debilitating and involve neurological, psychological and other Feeling suicidal 29.6% 60.7%
Emotional numbing 42.6% 74.1%
bodily symptoms (similar to symptoms for acute withdrawal).
●
Neurological Electric shocks (‘brain 5.6% 76.8%
People can be bed-bound, lose jobs, relationships, experience financial zaps’)
Akathisia/internal 11% 63.5%
difficulties. sensation of buzzing
and tension
● They can also receive further psychiatric treatments for diagnosed
Increased sensitivity to 22.3% 79.2%
psychiatric conditions. light, sound

● Very poor recognition by medical community, due to limited education, Tinnitus 17.6% 60.7%
Vivid dreams 27.9% 73.4%
who generally perceive it as relapse (despite numerous distinguishing Somatic Nausea 15.2% 71.1%
Muscular problems
features) or other physical conditions (Guy et al, 2020).
● Now, 10,000s of people on peer support sites looking for support for these Dizziness/light-
headedness
17.9% 88.7%

Fatigue 61.5% 93.0%

problems because they can’t get suitable help from their medical Diarrhoea 24.4% 73.7%
Sexual numbing/ 28.3% 66.1%
providers (White et al 2020, Read et al 2023). unpleasant genital
arousal

Moncrieff et al, JAD Reports, 2024

Updated guidance in the UK
• In 2019 the Royal College of Psychiatrists reported that patients should be informed of “the
potential in some people for severe and long-lasting withdrawal symptoms on and after
stopping antidepressants.”

• NICE in 2021: “[Withdrawal symptoms] can last longer (in some cases, several weeks,
occasionally several months) and can sometimes be severe, particularly if the antidepressant
medication is stopped suddenly.”

• Guidance not updated in Australia, most clinicians still believe withdrawal is brief and mild.
How to minimise withdrawal
symptoms by safely tapering
What causes depression?
• For many years there has been messaging that antidepressants
work by ‘rectifying an underlying chemical imbalance’, normally
said to be low serotonin.
• Often translated to patients as ‘antidepressants for depression is
like insulin for diabetes.’
• Initially a scientific hypothesis, amplified by the manufacturers of
antidepressants.
• Six decades of research has found no evidence of a difference
between depressed people and healthy volunteers.
• 85% of the Australian public believes this explanation (Pilkington,
2013).
• The Royal College of Psychiatrists (UK) said: “the old idea that ADs
[antidepressants] correct a chemical imbalance in the brain is an
over-simplification and we do not support this view,”
– Their leaflet on depression no longer mentions low serotonin as a
potential cause of depression.
How do antidepressants work?

• If antidepressants do not rectify an underlying lack of serotonin, how do they

work?
• There are other biological theories:
– Neurogenesis (growth of new brain cells)
– Inflammation
– Stress hormones.
• Most common from animal studies, not proven in humans
– Summary of all studies (meta-analysis) conducted finds no support for these theories in
depression (Kennis et al 2020).
• Growth of new neurons could be beneficial or evidence of response to insult
– E.g. blunt trauma to the head, chemical damage and stroke cause the growth of new
neurons.
Emotional restriction

• Reported by 50-70% of people on antidepressants in surveys (Read and

Williams, 2018; Goodwin et al 2017).
• Reduced intensity of negative and positive emotions
• May be related to genital numbing reported by many people on
antidepressants.
• If you chew up many antidepressants they will numb the mouth.
• Some suggest it is the depression causing the numbing but recent high-
profile study finding emotional numbing in healthy volunteers (no
mental health issues) given antidepressants (Langley et al 2023) – and
this impaired emotional learning processes.
• This effect may provide relief from strong emotions in the short term but
may have consequences to relationships, quality of life.
• It is the number one reason patients give for wanting to stop their
antidepressants.
Royal College of Psychiatrists guidance on ‘Stopping antidepressants’

• Published in October 2020.

• Recommends patients who have been on antidepressants for
more than a few weeks weeks taper off over “months or
longer.”
• Suggest going down to very small doses (<1mg) before
stopping.
• Recommends going down in smaller and smaller sized
reductions .
• Rate titrated to the individual’s ability to tolerate the process.
Management of the antidepressant withdrawal syndrome

• We used brain imaging (PET) data

of antidepressant action to develop
rational tapering guidance for
antidepressants.
• E.g. Citalopram’s effect on the
serotonin transporter, its major
target.

Effect on the brain

• This also applies to all other
psychiatric medications.

Citalopram
What happens when you taper linearly?

• Citalopram usually used at 20mg or

40mg dose
• Smallest tablet in Oz is 20mg
• 20mg to 15mg -> 3% change
• 15mg to 10mg -> 6% change
• 10mg to 5mg -> 13% change
• 5mg to 0mg -> 58% change
• This correspond to the increasingly
severe withdrawal symptoms reported
by patients as dose gets lower
• Most common tapering by clinicians
is: 20mg, 10mg, 5mg, stop. Citalopram
What happens when you taper by fix amounts of effect on the brain?
Hyperbolic dose decrease

• Tapering according to equal change in effects at the

serotonin transporter.
• Yields hyperbolically reducing regimen.
• Final dose before stopping will need to be very
small.
• Can be approximated by reducing by e.g 10% of the
most recent dose per month so that reductions get
smaller and smaller as the total dose gets lower.
• Requires forms of drug other than widely available
tablets eg. Liquids or specially made-up capsules:
an important barrier to implementation in
Australia.

0.8mg 5.4mg
2.3mg Citalopram
Royal College of Psychiatrists guidance on ‘Stopping antidepressants’

• Importantly, recommends individualizing rate of

reduction to the rate that can be tolerated by the
patient.
• If withdrawal symptoms become too severe, then
reduction should be halted or dose increased until
symptoms resolve. Then reduction should
proceed at a slower pace.
• Many patients can only reduce their dose at 10%
of the most recent dose per month (which means
reductions get smaller and smaller).
How to make these small doses?
• Tablet cutters will be needed to divide tablets – into halves and quarters.
• Liquid preparations can be used – but only currently available for escitalopram in Oz.
• Compounded medications (e.g. tapering strips).
• Don’t skip doses (except for fluoxetine) – can precipitate withdrawal effects because of large
changes in plasma levels – most antidepressants have half-lives of 24 hours and so every
second day dosing will mean that levels fall to ¼ of peak levels.
• Switching to fluoxetine based on a manufacturer’s study. Fluoxetine has substantial
withdrawal effects (incidence: 50%), cannot be stopped abruptly, switching process more
difficult than textbooks suggest. May be considered in some circumstances.
 Off-label options for tapering
• There are also ’off-label’ options such as compounding pharmacies, opening up capsules to
count beads.
• Or crushing tablets (or opening capsules) and dispersing them in water. This is
recommended by pharmaceutical authorities in the UK for example for giving small doses of
medication to children.
• Manufacturers could make liquids as they have in the UK.
Maudsley Deprescribing Guidelines: Antidepressants, Benzodiazepines,
Gabapentinoids and Z-drugs
• This clinical handbook covers all the information a GP,
psychiatrist, or other clinician (or interested member of the
public) would need:
– To distinguish withdrawal effects from relapse.
– To be able to safely taper each specific antidepressant,
etc
• with fast, moderate and slow schedules
• advice on how tailor it for an individual.
– Covers all the formulations of medications available in
Australia to safely taper with licensed and off-label uses.
– Has just been accepted as a clinical resource by RACGP.
Example of citalopram tapering regimen (faster)
A slower taper for citalopram for people with greater difficulties
Other psychiatric drug classes

• The relationship between dose of drug and

effect on target receptors is hyperbolic for all
psychiatric drug classes and so the same
principles of hyperbolic tapering will apply to
all these classes as well:
– Benzodiazepines
– Z-drugs
– Gabapetinoids
– Mood stabilisers
– Antipsychotics
– Stimulants
– Opioids.
Thank you for listening
• Questions will be taken at the end of the
presentations.

• My email for any further questions:

[email protected]
Implementing the Maudsley Deprescribing
Guidelines in Australian general practice

Katharine Wallis
Mayne Professor and Head, Mayne Academy of General Practice
Head, General Practice Clinical Unit
Lead, RELEASE: REdressing Long-tErm Antidepressant uSE in general practice
The University of Queensland

NSW Mental Health Commission

2024 July 30
GPs prescribe most antidepressants in Australia (92%)

A call to action: AJGP 2021

Wallis KA, Donald M, Moncrieff. 2021. AJGP

Australian Institute of Health and Welfare. Mental health-related prescriptions 2021-22.

2023 https://www.aihw.gov.au/mental-health/topic-areas/mental-health-prescriptions. 34
(Accessed: 30 Jan 2024)
Increasing sertraline & escitalopram 2013-2021

Sertraline & escitalopram are now in the top 10

prescriptions in Australia (year to 30 June 2023)

https://australianprescriber.tg.org.au/articles/top-10-drugs-2022-
23.html?utm_source=mailchimp&utm_medium=edm&utm_campaign=decemberissue2023

Wallis KA, Dikken PJS, Sooriyaarachchi P et al. 2023. 35

Aus J Prim Health.
 To redress long-term antidepressant use in general practice
 The outcomes of our research include practical resources
where currently there are none

• MRFF 2020 Clinician Researchers Applied Research in Health (MRFAR000079) $1,912,691

• NHMRC 2021 Partnership Projects PRC3 $652,769
RELEASE 3As brief intervention: to prompt and support safe cessation
 Ask
- How long have you been taking antidepressants?
- Have you ever tried to stop?

 Advise
- Not harmless - emotional numbing, sexual dysfunction, lethargy & fatigue, weight gain, falls
- Not recommended - clinical guidelines recommend 6-12 months
- Not a long-term condition caused by a chemical imbalance in the brain, not scientifically valid
- Withdrawal is not relapse; withdrawal symptoms are common & can be severe.

 Assist
- Printable tapering protocols – practical step-by-step guidance for decreasing dose
- Mini doses – instructions for DIY liquids or compounded capsules

37
Tapering protocol: ‘Faster’, ‘Slower’, ‘Even slower’

Decrease in serotonin transporter occupancy: ‘Faster’ 10% , ‘Slower’ 5%, ‘Even slower’ 2.5% 38
Sertraline - ‘slower’ tapering protocol
Case study (true story)
2024 June 23rd 2024 June 26th
Dear Professor Wallis, Thank you for your work on Oh WOW! This is amazing! Extremely helpful!
hyperbolic tapering. I want to wean off my My GP appointment is in about 2 weeks. So I'll let
SSRI. My GP wants me to reduce it in 25% you know how I get on after that. Once again, thank
increments over a few months. However, I have you so much
been on an SSRI for almost 30 years and am
concerned about the risks of reducing so quickly. I
want to do hyperbolic tapering. 2024 July 5th
Can you suggest any Australian guidelines or Hi Prof Katharine, I saw my GP again yesterday
official documents I could provide to my GP to help and he was open to hyperbolic tapering!
persuade him to let me try hyperbolic tapering? He had never heard of it before and was most
I am on Zoloft [sertraline] 100mg. I have been on it interested in the tapering schedule you provided!
for almost ten years. Prior to that, I was on paxil He even ended up commenting that some people
[paroxetine] (I was advised to switch ahead of do seem to have trouble weaning! Thanks again so
pregnancy). I was on paxil for almost 20 years. much for your help. I am much more at ease
weaning at this slower pace.
40
Antidepressant mini doses

41
“it takes a little bit of the fear away”

“It’s really good to have an individual [tapering protocol]… You

feel more like it’s set for you rather than generic ... I think it
takes a little bit of the fear away … to know that I can do it
more gradually if I wanted to.” (P10, female)

42
McDonald S, Wallis KA, Horowitz M, et al. 2023. BJGP.
‘Stopping antidepressants’ brochure

43
‘How family and friends can help’ brochure

44
‘Fear of relapse’

“The ‘fear of relapse’ is definitely what resonates with me.

That’s the sole reason I’m still taking them.” (P07, female)

45
McDonald S, Wallis KA, Horowitz M, et al. 2023. BJGP.
“the difference between withdrawal and relapse”

“It hadn’t really occurred to me to think about the difference between the
‘withdrawal symptoms and relapse’. So that’s useful information.” (P06, female)

46
McDonald S, Wallis KA, Horowitz M, et al. 2023. BJGP.
“I wish I had that information”

“… I could have done something; my life could have been quite different … I
have suffered ‘weight gain, low sex drive, inability to achieve orgasm, emotional
numbing, fatigue, lack of motivation and sleep disturbance’ for the last 18 years.
I only needed to go through that for one year. I wish I had that information … I
would have not been on them for so long ...” (P08, female)

“I just thought once you’re on them, you’re on them forever.” (P10, female)

“I’m blown away by the ‘1 in 7’” (P10, female)

47
McDonald S, Wallis KA, Horowitz M, et al. 2023. BJGP.
Decision Aid

48
“If you show this to your GP …”

“It's nice to see it broken down into a pretty straightforward pros and cons
type list. I think that helps a lot of people really put into perspective what their
options are.” (P14, female)

“And if you show this to your GP, for example, they can then gain a lot of
information from that as well and you don't have to try and put all your
thoughts into words as well. So, I think it's quite helpful.” (P13, female)

49
McDonald S, Wallis KA, Horowitz M, et al. 2023. BJGP.
“I wish that every GP and psychiatrist …”

“I wish that every GP and psychiatrist who's prescribing this

drug had this amount of information and awareness … make
life so much better for people who've been prescribed this
drug and want to come off.” (P08, female)

50
McDonald S, Wallis KA, Horowitz M, et al. 2023. BJGP.
 Principal Investigators:
Funding: • Prof Katharine Wallis, UQ

Acknowledgements •
•
Mayne Bequest
Medical Research Future Fund
•
•
A/Prof Maria Donald, UQ
Prof Joanna Moncrieff, UCL
• Dr Mark Horowitz, NHS
• National Health and Medical
• Prof Nick Zwar, Bond
Research Council
• Prof Ian Scott, UQ
• Participants Partners:
• Prof Mark Morgan, Bond
• Royal Australian College of General
• GPs and practices Practitioners
•
•
A/Prof Chris Freeman, UQ
Prof Rob Ware, Griffith

• Steering committee • Australian College of Rural & Remote • Prof Josh Byrnes, Griffith
Medicine Associate investigators:

• Consumer Advisory • Australian Society of Psychological • A/Prof Adam Geraghty, Soton

• A/Prof Nancy Sturman, UQ
Group Medicine
• A/Prof Riitta Partanen, UQ
• Brisbane North Primary Health Network
• Dr David King, UQ
• CareMonitor
• Dr Johanna Lynch, UQ
• Prof Neeraj Gill, Griffith

51
Professor Katharine Wallis
https://medical-school.uq.edu.au/release
Thank you
[email protected]

RELEASE resources and tapering protocols

@WallisKatharine
are available via:
CRICOS code 00025B
Role of the GP in
translating the
Maudsley
Deprescribing
Guidelines into
practice

Dr Karen Spielman
What do we do?

One long consultation (A/Prof Karen Price)

Holding the complex whole (Dr Johanna Lynch)

The backbone of the system

Jack of all trades but master of none

Just a rubber stamp……… GANYFYD….

The role of the GP

GPs, more than

most, exist at
the interface of
mind and body
Some stats

• 38% of presentations to GPs are mental health related (47% for female GPs)
• GPs deliver 80% of Medicare mental health services
• GP is 5% of health budget
• GPs prescribe 92% of antidepressant scripts

*Delivering mental health care in General Practice: Implications for practice and policy
Research FindingsSurvey commissioned by the General Practice Mental Health Standards Collaboration (GPMHSC) Survey conducted by Cecile Thornley and Dean Harris of The Navigators Community
Pty Ltd 15 December 2021
Segmentation of GPs by disposition to mental health
“GPs are as diverse as their patients”

• Where they practice

• How they practice
• Special interest GPs

Find the right person/tool for the job for

you!
When we prescribe we may have already……
• prevention • coordination of care and
• health promotion/advocacy communication between team
members
• detection - early identification
• early intervention - best chance
• assess safety and appropriate
level of care
for recovery
• diagnosis
• liaison with family and carers
• identification and management of
• rehabilitation - safety plan, check
in
comorbidities
• explaining physiology - education
• relapse prevention and
management
/ psychoeducation - patient and
family
• treatment - and/or refer for
appropriate level of EBM
• monitoring and medical
management
Implementing Maudsley deprescribing guidelines
• Dont be reactive – remain patient centred.
• Careful patient selection — are they stable and ready to trial deprescribing.
• Why are we considering de-prescribing now – tried before etc.
• Medication is only one part of the treatment – so there should be scaffold in place to
make it possible – have they done the psychological work.
• Talk about it right at the beginning – set the scene moving forward.
• Review often – each time you script.
• Prepare carefully – ? compounding pharmacist.
• Relapse prevention.
Barriers to care

Patient
level

System Doctor
level level
Changes in my practice since the launch of the guidelines

• More awareness of differences in how people manage the process

• Raise it earlier and more often
• Highlight the difference between withdrawal and relapse
• ? slower at the end
Some thoughts on the system

• Crazy idea – solve this issue by putting GPs back at centre of mental health (we GPs are already
doing it)
• Bread and butter
• It takes time (flatten medicare rebate)
• GPs love to get people off meds
• Whole person care

• It’s not what is wrong with you it’s what happened to you (or didn’t happen)

• Pathologising distress

• Put GPs back in centre of system - cost effective

 Thank you

Maudsley Deprescribing Guidelines

From publication to practice