Running Head: WEEK 1
Week 2 Problem Identification
Student’s Name
Institutional Affiliation
WEEK 2
Week 2 Problem Identification
Problem Statement
Mental illness has been on the rise in the US. It is estimated that nearly one in five US
adults lives with a mental illness (NIMH, 2021). While hospitals have adopted a wide range of
modalities such as psychotherapy, one or more psychotropic medications are prescribed for the
management of mentally ill persons. The use of psychotropic drugs also extends to the elderly
especially among those with dementia. Psychotropic drugs are largely prescribed for problems
with emotions, nerves of mental health. Omnibus Budget Reconciliation Act (OBRA) of 1987
restricted the use of psychotropic medications in residents with long-term care facilities. In 2006.
Center for Medicare and Medicaid Services (CMS) published a guideline on the use of
psychotropic drug therapy outlining specific conditions and noting that the lowest possible dose
should be administered for the shortest period and continually undergo gradual dose reduction.
The goal of GDR is to ensure that patients are free from the unnecessary use of psychotropic
drugs. It also ensures that the use of the drugs is based on the appropriate differential diagnosis
of current behavioral symptoms. However, there is limited research and publication that prohibit
or restrict GDR in some circumstances. This paper thus seeks to answer the research question:
1. For mentally ill persons and the elderly, what risk factors can lead to a relapse after
GDR?
Literature Review
Most healthcare guidelines in the US recommend gradual dose reduction when tapering
to minimize withdrawal symptoms. The CDC recommends a rate of 10 percent per week.
Enough literature seems to agree that this rate of dose reduction is well tolerated by patients who
are tapering their psychotropic drugs. However, a study by Berna et al. (2015) which reviewed
WEEK 3
117 peer-reviewed articles noted that there is limited evidence regarding optimal dose reduction
rates in other clinical settings. Darnall et al. (2018) in a community of experts revealed that
anecdotal reports indicated that patients using long-term opioids were being forced to taper their
dose involuntary. The experts also raised issues with mandated opioid tapers that required
aggressive opioid reduction reductions over a defined period even when that period was an
extended one.
Several studies have also pointed out GDR is not suitable in some situations. Tjia et al.
(2015) noted that abrupt discontinuation or significant dose reduction of psychotropic
medications can cause physiological withdrawal symptoms including disruptive behaviors,
insomnia, nausea, and restlessness. However, the study on Tjia et al. (2005) examined abrupt
discontinuation of dosage among patients receiving high doses for long-duration rather than
those undergoing gradual dose reduction. The authors however noted a need to recognize the
withdrawal symptoms and other negative clinical outcomes when initiating dose reduction. The
findings by Tjia et al. (2019) are supported by Dowell et al. (2019) whose study noted that rapid
dose tapering among physically dependent patients was not recommended since it was associated
with serious withdrawal symptoms, psychological distress, uncontrolled pain, and suicide.
However, the study was concerned with rapid discontinuation. It thus follows that there is a need
to examine the impact of gradual dose reduction among patients under psychotropic medications.
Taking into consideration the recommendation against rapid and abrupt dose reduction, there is a
need to examine under what circumstance GDR is contraindicated even when following
standards and the symptoms that may show up.
WEEK 4
References
Berna, C., Kulich, R. J., & Rathmell, J. P. (2015). Tapering long-term opioid therapy in chronic
Noncancer pain. Mayo Clinic Proceedings, 90(6), 828-
842. https://doi.org/10.1016/j.mayocp.2015.04.003
Darnall, B. D., Juurlink, D., Kerns, R. D., Mackey, S., Dorsten, B. V., & Humphreys, K. (2018).
International Stakeholder Community of Pain Experts and Leaders Call for an Urgent
Action on Forced Opioid Tapering. Pain Medicine, 20(3), 429-433.
https://doi.org/10.1093/pm/pny228
Dowell, D., Haegerich, T., & Chou, R. (2019). No shortcuts to safer opioid prescribing. New
England Journal of Medicine, 380(24), 2285-
2287. https://doi.org/10.1056/nejmp1904190
NIMH. (2021, January). Mental Illness. National Institute of Mental
Health. https://www.nimh.nih.gov/health/statistics/mental-illness
Tjia, J., Reidenberg, M. M., Hunnicutt, J. N., Paice, K., Donovan, J. L., Kanaan, A.,
Briesacher, B. A., & Lapane, K. L. (2015). Approaches to gradual dose reduction of
chronic off-label antipsychotics used for behavioral and psychological symptoms of
dementia. The Consultant Pharmacist, 30(10), 599-
611. https://doi.org/10.4140/tcp.n.2015.599