Download Discontinuing Psychotropic Medication for

Discontinuing Psychotropic Medication
for California Foster Youth
Mark D. Edelstein MD
Board Certified Child and Adolescent Psychiatrist
Medical Director, EMQ FamiliesFirst
2015
Presentation
Topic: When & how psychotropic
medications should be discontinue
 Audience: Foster youth and any adults
involved in their care
 “Youth” refers to anyone < 18 years old

Psychotropic Medication
Psychotropic meds act in the brain to reduce
symptoms of mood, cognition, behavior, etc.
 Psychological and environmental contributors
are addressed with psychosocial interventions
 Examples of target symptoms of medication:

◦ ADHD: hyperactivity, impulsivity, inattention
◦ Depression, anxiety, labile mood, rage outbursts,
manic episodes
◦ PTSD: Anxiety, intrusive memories, etc.
◦ Hallucinations, delusions, cognitive disorganization
◦ Severe insomnia
Collaborative Medication
Management

Med management
◦ Initial and ongoing assessment
◦ Decision-making, including when & how to
discontinue medicine

Best practice: youth-centered & collaborative
◦ Youth – preferences; especially teens
◦ Prescriber (physician, NP or PA) – applies & shares
expertise; offers options
◦ Judge – informed consent
◦ Other adults – caregivers & family, CPS, attorneys,
probation officer, CASA et al.
Psychotropic medication is usually
needed for months or years

Two reasons
◦ Most mental health conditions that we treat
with meds persist for months or years
◦ Meds keep symptoms in check, they don’t “cure”
(like blood pressure meds)

Common exceptions
◦ Acute stress
◦ Effective therapy or coping skills for
depression, anxiety or insomnia
When to discontinue meds ?
Max dose is not working
 Med is causing significant side effects (and
changing dosage or timing is not an option)
 Second med is effective for same symptoms
 The med was unnecessary in the first place
 Irresponsible behavior: misuse of med, not
coming to follow-ups, not getting labs, etc.
 Pregnancy: consider risk vs. benefit
 Youth has taken effective med for some time;
can they do well now without it…?

How could a med that worked no
longer be needed?

Brain may change over time
◦ Major depression less likely to return if medicine
taken for 9-15 months
◦ ADHD-based hyperactivity/impulsivity commonly
improve in adolescence


Coping mechanisms may improve
Environment may change
◦ Less stress or more support

Prognosis may have been incorrect due to
inaccurate diagnosis or heterogeneous
disorder
When to discontinue a med that
has worked?
Consider:
◦ Likelihood of recurrence and associated
risks (including clinical course)
◦ Current and upcoming stressors
◦ Coping skills and supports
◦ Long-term risk of medication
◦ Youth and family preference
 Alternative: lower dose a little at a time
How to discontinue meds
Tapering is important for some meds
Antidepressants – risk of withdrawal
symptoms (insomnia, irritability, headache, flulike symptoms, etc.)
 Anticonvulsants (Depakote, Lamictal, Tegretol,
Topamax, Trileptal et al.) – risk of seizure
 Adrenergic agonists (Guanfacine, Clonidine) –
risk of high blood pressure
 Benzodiazepines – risk of withdrawal
symptoms (insomnia, irritability, anxiety, etc.)

Tapering
Usually reduce dose gradually meds over
a period of weeks (sometimes days)
 Prudent with other meds that are longacting, e.g., atypical antipsychotics
 Generally unnecessary with

◦ low dose
◦ short duration of treatment (weeks)

Unnecessary with stimulants
Parting thoughts

If you take medicine
◦ Share your questions, concerns and preferences
◦ Talk with prescriber before stopping any medicine

If you prescribe medicine
◦ Explain your reasoning to youth and family
◦ Offer recommendations and options

If you are an adult in the life of a foster youth
◦ You can take part in the med management process