RATIONAL DEPRESCRIBING: ASCP EXPERT CONSENSUS FOR MOOD DISORDERS

Background

Deprescribing in mood disorders remains inconsistently applied despite known risks of polypharmacy, adverse effects, and illness destabilization. The American Society of Clinical Psychopharmacology (ASCP) convened an expert task force to establish consensusbased, clinically actionable criteria for rational deprescribing across major depressive disorder (MDD) and bipolar disorder.

Methods

A 45-member expert panel employed a Delphi methodology to identify highconsensus clinical triggers for deprescribing antidepressants, antipsychotics, lithium, and sedative-hypnotics. Consensus thresholds were predefined, and agreement levels were quantified across domains, including treatment response, illness course, adverse effects, and diagnostic context.

Results

Consensus supported deprescribing in cases of mechanistic redundancy (100%) and inadequate antidepressant response ( < 25% improvement; 87%). Strong agreement discouraged deprescribing in patients with ≥3 lifetime depressive episodes (86%), supporting maintenance treatment. In bipolar disorder, antidepressant tapering was strongly endorsed in the presence of rapid cycling or emergent manic symptoms (95–99%), while prior relapse following discontinuation was a contraindication to deprescribing (77%). Experts favored discontinuing offending antipsychotics rather than adding “antidotes” for adverse effects such as tardive dyskinesia ( > 83%) or ≥5% weight gain (98%). Time-limited use was recommended for benzodiazepines and Z-drugs (1–3 months; 98%) and low-dose quetiapine for insomnia (3–6 months; 93%). Lithium tapering over ≥6 weeks was endorsed to reduce relapse risk (90%).

Conclusions

This consensus framework defines specific, clinically grounded triggers for deprescribing across mood disorders, balancing relapse risk with medication burden. The findings support a shift from indefinite pharmacotherapy toward individualized, mechanisminformed treatment optimization, with clear thresholds for when continuation, tapering, or discontinuation is appropriate.