Margaret Weiss, M.D., Ph.D.
Director, Child and Adolescent Psychiatry
University of Arkansas Medical Sciences
Our practice guidelines, text books, journals and drug labels tell us a great deal about the diagnostic indications for use of medications, how long to maintain them, and how to start them. However, there are few if any protocols to guide clinicians as to how and when to reassess when medications are still needed, to guide discontinuation strategies, or to distinguish withdrawal effects from true return of symptoms.
This is a clinical concern. Children may be started on medication during a difficult period, and then maintained on the drug because ‘it worked when we started it’ and ‘they get worse when it is stopped’. Patients do not distinguish acute rebound after abrupt discontinuation of medication from a true off-medication baseline. Children are admitted to our inpatient unit, often on many different medications and off label, and provided a medication ‘washout’, but we have no guidance as to how sequence or pace medication discontinuations. Patients who have been maintained on the same drugs for long periods of time may be receiving their follow up care in primary care clinics or walk in clinics where the time, effort, education and care needed to undergo a change in medication are not routinely attended to.
Quite simply, it is easier to start drugs than stop them. We need to put as much care into the development of reassessment procedures, discontinuation protocols and careful and systematic re-evaluation for ongoing need for medication as we do into starting medications. This is most especially true where polypharmacy has become so extensive that it is difficult to evaluate any unique medication outcome or the patient’s true current baseline.