JAMA did not print my comment on the JAMA news piece on deprescribing so putting my comments here: Guidelines for Safe Deprescribing Are Long Overdue in Psychiatry and Should Be Embraced as a Part of High-Quality Prescribing It is unfortunate that the APA and ASCP have responded so unconstructively to HHS's proposals to improve infrastructure for safe deprescribing through guidelines and reimbursement. Psychiatric training and guidelines have devoted far more attention to starting psychiatric medication than to stopping it safely. A substantial proportion of patients experience severe, prolonged and sometimes disabling withdrawal effects when psychiatric drugs are discontinued according to current practice.[1] More than 100,000 Americans patients belong to online support groups seeking advice on safely stopping psychiatric drugs after inadequate guidance from prescribers. HHS is right to address this unmet clinical need. It is a strawman to characterise HHS proposals as "restricting" antidepressant prescribing. In many countries, psychological therapies, exercise and other non-pharmacological treatments are routinely and uncontroversially recommended alongside or ahead of antidepressants, and deprescribing guidelines are increasingly being published.[2] It is striking that the clinically neutral term deprescribing - used for decades across medicine - provokes such resistance within psychiatry. The APA and ASCP also conflate the risks of stopping antidepressants too quickly with the risks of not being on antidepressants. These are different issues. Antidepressants have never been robustly shown to reduce suicide overall [3], so increased suicidality after discontinuation cannot simply be attributed to the absence of treatment. By contrast, withdrawal effects can include severe anxiety, agitation, insomnia and akathisia, which can precipitate suicidal behaviour.[4] Likewise, relapse-prevention studies are routinely interpreted without acknowledging a major methodological flaw. Most discontinuation trials stop antidepressants over days or weeks, despite increasing evidence that such rapid discontinuation commonly produces withdrawal symptoms. Because these studies do not distinguish withdrawal from relapse, withdrawal symptoms are frequently misclassified as depressive recurrence, exaggerating estimates of relapse prevention.[5] Relapse certainly occurs, but evidence suggests its risk can be reduced by slower, carefully supervised hyperbolic tapering over months.[6] It is therefore misleading to conflate the risks of rapid discontinuation with those of gradual, patient-centred deprescribing. The recent deprescribing textbook by Stahl and Strawn simply reiterates current practice. It presents relapse-prevention studies without discussing these methodological problems, recommends rapid linear tapers despite growing evidence favouring gradual, hyperbolic tapering, and suggests adding further psychiatric medication when patients struggle, risking misdiagnosis of withdrawal as relapse and contributing to unnecessary polypharmacy. More than half of Americans (55.9%) have now been prescribed an antidepressant during their lifetime, and one in six adults is currently taking one.[7] In this context, claims of widespread under-treatment are difficult to sustain. Rather than opposing HHS, the APA and ASCP would better serve patients by helping develop evidence-based deprescribing guidelines and improving clinicians' ability to recognise and manage withdrawal safely. References [1] Read et al. J Psych Res. 2023. [2] NICE Depression Guideline. 2022. [3] Hengartner et al. J Epi Comm Health. 2021 [4] Moncrieff et al. JAD Reports. 2024 [5] Hengartner. Ther Adv Psychopharm. 2020. [6] Maudsley Deprescribing Guidelines. 2024. [7] Perlis et al. BMJ Mental Health. 2026. jamanetwork.com/journals/jama/…
