In this episode, Dr. Ben Everett is joined by Dr. Joseph F. Goldberg, clinical professor of psychiatry at the Icahn School of Medicine at Mount Sinai and deputy editor-in-chief of the Journal of Clinical Psychiatry. Dr. Goldberg recently completed his term as president of the American Society of Clinical Psychopharmacology (ASCP), during which he led a 45-member international task force that produced a landmark series of consensus statements on deprescribing psychotropic medications, the principal findings of which were published in JAMA Network Open.

The decision to stop a medication is among the most common—yet least formalized—clinical acts in psychiatry. Despite decades of prescribing guidance, the field has lacked systematic frameworks for determining when, why, and how to discontinue treatment. This episode examines the ASCP task force's Delphi methodology, the areas of consensus and expert disagreement, and the practical implications for managing polypharmacy, navigating discontinuation phenomena, counseling pregnant patients, and training the next generation of prescribers.

🎯 KEY EPISODE HIGHLIGHTS:

📋 MEDICINES AS EMPLOYEES: THE PERFORMANCE REVIEW FRAMEWORK [03:30]

“I often like to think of medicines like employees on a payroll, and from time to time, it's a good thing to do a performance review of everybody on the payroll and ask what's your job, and are you doing it well, and is your job still there, or is that niche no longer present?”

Dr. Goldberg's core framework reframes deprescribing as a structured, periodic clinical evaluation—shifting the default from indefinite continuation to deliberate reassessment.

⚠️ PSEUDOTREATMENT RESISTANCE: THE LAI LITMUS TEST [22:00]

“Up to eighty percent of people don't take their medicines as prescribed, and oftentimes that could be quite substantial. It does run the risk of erroneously concluding this drug didn't work for you.”

Before deprescribing in schizophrenia, the task force emphasizes ruling out non-adherence—including a strong recommendation to consider long-acting injectable antipsychotics as a diagnostic and therapeutic step.

🧠 THE PSYCHOLOGY OF STOPPING: MEDICATION AS TRANSITIONAL OBJECT [34:30]

“To say I'm gonna take away this tangible thing that's meant to alleviate your suffering could mean I think you're doing pretty well and you don't need this anymore. Or it could also mean I'm not sure you're really suffering as much as you think you are.”

The decision to deprescribe carries significant psychological weight for patients—and clinicians who overlook this dimension risk undermining therapeutic alliance and triggering distress independent of pharmacology.

CHAPTERS:

00:00 – Introduction and Defining Deprescribing

07:00 – Why Now: ASCP's Task Force and the Political Landscape

13:30 – Delphi Methodology: Consensus and Divergence

15:30 – The Lithium Overdose Dilemma: When Stopping Defies a Rule

20:00 – Adherence, Pseudotreatment Resistance, and Schizophrenia

25:30 – Complex Polypharmacy and Medication Performance Reviews

29:30 – Valproate and Women of Reproductive Potential

34:00 – The Psychology of Stopping: Medication Attachment and Placebo

37:30 – Long Half-Life Drugs and Auto-Tapering

40:30 – Discontinuation Phenomena, Brain Zaps, and Hyperbolic Tapering

45:30 – Pregnancy, Special Populations, and Relapse Risk

49:30 – Training Gaps and the Future of Deprescribing Education

LINKS:

Full transcript and show notes:

https://www.psychiatrist.com/jcp/ep17-art-deprescribing-framework-ending-medication-joseph-goldberg/

Journal of Clinical Psychiatry

https://www.psychiatrist.com/jcp/

Publisher of peer-reviewed research discussed in this episode.

Dr. Joseph Goldberg – LinkedIn

https://www.linkedin.com/in/joseph-goldberg-922b5317/

American Society of Clinical Psychopharmacology (ASCP)

https://www.ascpp.org/

The organization that convened the 45-member international deprescribing task force discussed in this episode.

ASCP Deprescribing Consensus Statement — JAMA Network Open

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2845497

The parent consensus paper on general principles of deprescribing psychotropic medications.

#Deprescribing #Psychopharmacology #Polypharmacy #MedicationManagement #ClinicalPsychiatry