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Thinking about coming off psychiatric drugsComing off psychiatric drugs

Over the years I have met numerous people who have quite suddenly stopped taking their mental health drugs.

Amazingly, some people seem to have got away with this sudden jolt to their central nervous system. But many have hit a personal crisis and ended up back on them again.

In my experience, countless people have little understanding of:

  • how to prepare for coming off psychiatric drugs
  • how to gradually reduce (to give the brain time to adapt to being without the drugs)
  • how to recognise withdrawal symptoms (as these can so easily be mistaken for a relapse)
  • how to live without the drugs once they are off them.
Psychiatric drug warning

With this in mind, here I take a brief look at some of those key issues that might influence whether coming off works or doesn't work out. That said, please understand that this is not a 'how to guide' - what I write here is in no way intended as a substitute for personal medical or other professional advice (please follow the SAFETY ADVICE image-link).

For some people, reducing and/or coming off can be virtually trouble free - especially for those who have been on low doses of medication and for only a short time, perhaps a month or two. But for those people who have been on high doses; on a combination of drugs at the same time (such as antipsychotics, antidepressants, and anti-anxiety drugs); and taking them for some years - coming off can be much more complex and risky.

This is not a recommendation to reduce or stop medications...that is a very personal decision

Each person's circumstances are of course unique, and it is for each person, with the support of trusted friends and, where appropriate, the advice of a trusted doctor too, to decide whether reducing or working towards being drug-free is right for them. Ultimately, it is a very personal decision that requires careful consideration.

As we will see, learning to live with less (or even no) reliance on mental health drugs, involves not only an understanding of how to reduce them, but also learning how to live without them and perhaps discovering new ways of learning to deal with crises too.

  As we will see, learning to live with less (or even no) reliance on mental health
drugs, involves not only an understanding of how to reduce them, but also
learning how to live without them and perhaps discovering new ways of learning
to deal with crises too.

   

Important considerations for those who have been on psychiatric drugs for many years

Choosing to live with less reliance on psychiatric drugs after many years of intensive in-patient and out-patient mental health care (usually involving a psychiatrist) can lead to quite different challenges compared to those people who have just had low level support from a GP. With this in mind, I briefly touch on some of these issues too, such as having (or not having) the support of your psychiatrist, here; some of the potentially more serious risks ('sleeping tigers') that can occur when withdrawing, here; and whether or not years of psychiatric drug damage can make it too risky to fully come off them, here.

As deciding whether or not to come off psychiatric drugs can be a cause of considerable anxiety, some people choose to take just one step at a time and, with their doctor's support, work towards gradually lowering the dose, and see how they get along. They might (or might not) then choose to make further small reductions if this works out fine. In this way the focus is not about finally coming off them and the whole idea becomes less of a big ordeal.

A look at some reasons why people may want to reduce or stop

People have their own reasons for wanting to reduce or even come off their psychotropic medications (drugs for depression, anxiety, psychosis, mood swings etc). It may be that they are no better even though they are taking the drugs; in fact, they may actually think they are worse off taking the drugs. And for many people the side-effects are unbearable, such as: decreased ability to think clearly, debilitating movement disorders (e.g. TD), memory problems, disrupted sleep, drained of energy or vitality, intense restlessness and agitation, sexual dysfunctions, putting on excessive weight, feeling removed and detached from life, and some potentially life-threatening health risks too (especially with long-term use). As you may have seen, I consider some of the limits and some of the risks of these drugs in this web site.

Liberty, John Stuart Mill

For other people, wanting to cut back on these drugs is more a matter of personal preference - they are just not keen on being dependent on any type of medication unless it's absolutely necessary - and once over a mental health crisis they want to be free to manage their own lives and also, if possible, be free of mental health services too. This may include a wish for privacy and a feeling that "this is my life, and I want to be trusted with it". As in the words of John Stuart Mill, ideally "each is the proper guardian of his own health, whether bodily, or mental or spiritual." Though the liberty not to take these drugs is sometimes removed if a person is sectioned under the Mental Health Act here in England, see here.

Better safe than sorry: why medical support and advice is vital

In my experience, some people think that coming off psychiatric drugs is simply about will-power - stopping abruptly, gritting your teeth and bearing the withdrawals - a sort of cold turkey approach. In practice, this may be not only unhelpful but decidedly dangerous. As we saw here, our brains (and other parts of the body too) adapt to the presence of these drugs; thus, withdrawal is not simply a case of mind over matter.

It is therefore wise to maintain regular contact with a supportive GP whilst reducing/coming off mental health drugs to help deal with any medical concerns that might arise. Although a very gradual reduction works for many people there can sometimes be moderate and even serious reactions to reduced doses of mental health drugs. In fact, a number of these drugs carry a risk-warning (US "Black box warning") of suicidal behaviour and/or violent behaviour when changing doses. As we will see, there are other risks too.

If you are on multiple drugs and are planning on reducing, your doctor will also be able to advise on which drug to reduce first.

  In my experience, some people think that coming off psychiatric drugs is simply
about will-power - stopping abruptly, gritting your teeth and bearing the
withdrawals - a sort of cold turkey approach. In practice, this may be not only
unhelpful but decidedly dangerous.

 

Most mental health drugs are more addictive than drug companies readily admit

There is often an enormous gulf between what the drug companies admit about withdrawal problems and the experiences of millions of people who struggle to come off them. To avoid speaking about withdrawal problems (as this is bad PR and could prejudice sales/profits) the drug companies have encouraged acceptance of the term “discontinuation syndrome” – a euphemism for withdrawal syndrome. The fact that people do not usually crave mental health drugs in the same way as with some street drugs does not mean that they are not addictive and sometimes difficult to withdraw from.

Knowing that these drugs are addictive can help people feel more prepared for any physical and emotional or psychological withdrawal problems that might arise - otherwise people may just think they are becoming mentally unwell - when in reality they are experiencing withdrawal symptoms.

Learning how to stop before you start

When learning to drive, one of the first things to master is how to stop the car. Unfortunately, people are not routinely taught how to carefully and safely withdraw from psychiatric drugs when they are initially prescribed them. Because of this, many people are ill-prepared, reduce far too suddenly, experience distressing withdrawal effects, and may then be forced to resume the medications (that some people may not actually need). We take a closer look at how to slowly withdraw here.

“Don't ever take a fence down until you know why it was put up.” (Robert Frost)

A plan to reduce the use of mental health drugs might reasonably begin with the question: why are you taking these drugs? In other words, are the drugs to make you feel more energetic, to lift your spirits, to slow you down, to relax you, to try and help you sleep, to try to reduce or control unwanted thoughts, to try to balance more extreme moods, or some other reasons? Once you are clear about this, alternative ways of meeting these needs (or learning to live with the problems) can then be considered. And there is also the possibility that you felt under pressure to start the drugs and never really wanted or needed them in the first place.

Considering other ways of meeting the needs being met by the drugs

In my work with people, this question (why have the drugs been prescribed?) usually leads on to a discussion about other ways of meeting these needs, such as: dealing with stress and distress, being more in control and discovering a new sense of harmony too. In this way the person is not simply left stranded; rather, there is a careful transition from trust and dependence on the drugs to greater self-confidence, self-understanding, and trust in other ways of meeting their needs.

It is often the practical matters that can tip our lives into crisis; consequently, help with budgeting, managing the children, finding decent affordable housing, and regular opportunities to work through the stresses and strains of everyday living with the right person/s can be vital ingredients of a plan to become less reliant on psychotropic drugs. And it's also worth bearing in mind that switching from prescribed drugs to street drugs is unlikely to reduce either dependence or risks.

Recognising that the drugs may be the problem

Any of these could actually be directly caused by mental health drugs: feelings of anxiety, agitation, depression, paranoia, suicidal thoughts, feeling hyper or manic, psychotic experiences (including hallucinations), panic, and mood swings. So it is easy to see how these unwanted drug-effects can be mistaken for the very problems for which the drugs were prescribed; hence, gradually coming off the drugs could itself be the answer a person is looking for.

Why does the psychiatrist/doctor think the drugs are necessary?

If the psychiatrist/doctor thinks you really need the drugs - why is this? Does s/he think the drugs are necessary to control violent behaviour against yourself and/or others, for example? It this is so, then the doctor will likely want to know your safeguards and alternative ways of reducing these risks. It is also important to bear in mind that psychiatric drugs can actually cause suicidal and/or violent feelings and behaviour. Unfortunately doctors may not recognise that the drugs may be culpable and may even increase the drug doses to try and counter these problems.

The NHS supports “using other alternatives to medicines” if this is a person’s choice, BUT

It can be helpful to recognise that, in principle, the NHS (here in England) does actually support the choice for a person not to take mental health medications.  This has particular relevance to those who have had some years of in-patient and out-patient psychiatric treatment. In fact, a report by what was then the Healthcare Commission stated that NHS “Trusts should consider using other alternatives to medicines and to helping people manage and live with a condition without medicines if this is their informed choice 1”. The context of this report is specifically on mental health services.

Psychiatric drug warning

In practice, NHS mental health services are heavily swayed in favour of medical treatments and it may not be easy to find doctors and other MH professionals who are supportive of less reliance on these drugs, especially when it comes to antipsychotics and drugs for so-called bipolar disorders. That’s because there is a widely held belief (though increasingly being challenged) that these are by far the best treatments; consequently, non-medical alternatives tend to be viewed as an adjunct to drug treatments and not as a valid alternative in their own right.

As the NHS consultant psychiatrist Dr Joanna Moncrieff writes: “Remember that although most doctors and other professional staff will not recommend stopping psychiatric medication, they cannot force people to take it unless they are subject to the Mental Health Act.  Unless you are in this situation, it is down to you whether you take psychiatric medication or not.  If you make a thoughtful and considered decision to try and stop or reduce your drug treatment, your mental health team should support you through this process 2”.

Unfortunately, if NHS staff don't whole-heartedly support a person's wish to try to manage without the drugs (and/or NHS staff have a poor understanding of alternatives) there is an increased chance of this not working out. Having the right moral and medical support can be so important in helping make this work out successfully.

If your doctor is not initially supportive of you wanting to be less dependent on medication, it could be that a careful, thoughtful, and practical alternative plan could help convince him/her that this could work out for you. A reasoned approach is more productive than simply a clash of conflicting opinions.

As the right medical support can make such an enormous difference, some people choose to try and find a doctor and/or psychiatrist who they feel are more sympathetic towards their wish to be less reliant on medications.

Having some idea of what to expect when deciding to reduce and/or withdraw can help

In one-to-one work with people who have expressed a wish to come off psychotropic drugs I discuss what to expect. We consider the withdrawal syndromes - that's groups of particular symptoms such as disturbed sleep, anxiety, feeling sick etc - associated with the various types of drug (whether antipsychotics, antidepressants, mood stabilisers etc) as they each have a range of fairly predictable withdrawal symptoms. There are sub groups too as SSRI antidepressants have some different withdrawal symptoms compared to tricyclic antidepressants for example. The withdrawal syndromes associated with the different groups of drugs are of course simply useful guides for what might be expected - in practice, people don't respond in the exactly the same way.

Some of the short half-life drugs (those which don't last long in the body) have a reputation for being more difficult to withdraw from. These include drugs such as clozapine/Clozaril, alprazolam/Xanax, venlafaxine/Efexor, paroxetine/Seroxat (US Paxil), and sertraline/Lustral (US Zoloft). However, research does not show that the "shorter the half-life, the more a drug is likely to induce a withdrawal syndrome" 7 - it is more complex than this. (This could be attributed in part to the drug potency, says Dr Healy, here). Having said that, these short half-life drugs have a reputation for withdrawal difficulties.

Prof David Taylor on his experiences of coming off antidepressants

Many people start on antidepressants with very little thought that they might be difficult to come off. Prof David Taylor, currently Director of Pharmacy and Pathology, at the Maudsley Hospital, London has written about his personal experience of trying to come off antidepressants some years ago:

“The real truth is that, for many people, antidepressant withdrawal syndrome is neither mild nor short-lived. For six weeks or so, I suffered symptoms which were at best disturbing and at worst torturous. This was despite following a cautious, decremental withdrawal schedule.” He then asks: “Why do clinicians continue to tell people that withdrawal symptoms are mild and really nothing to worry about?” (Full article here).

Though there are those who have come off these drugs with relative ease, his experience is not unusual.

Feeling worse to get better - beware of sleeping tigers!

Once the ill-effects of the drugs begin to wear off during the withdrawal process, aside from any withdrawal effects, a person may quite soon experience benefits.

But unfortunately, some things can, initially at least, seem to get worse - and I am not just thinking of withdrawal syndromes. This may be the rebound effects which are often the opposite to the main action of the drugs. So (for example) with reducing antidepressants a person may feel depressed; with reducing anti-anxiety drugs the person may well experience anxiety and panic; with reducing anti-convulsants (used for so-called mood disorders) the person may have seizures; and with reducing antipsychotic drugs a person may experience psychotic reactions such as hallucinations.

Psychiatric drug rebound problems

This is what Prof D.G. Grahame-Smith refers here to as "a sleeping tiger": "Chronic [long-term] drug therapy may induce a sleeping tiger, which awakens when the drug therapy is stopped and results in rebound withdrawal effects with serious consequences, as with many drug addictions." This happens as chemicals that have been reduced or increased in the brain by the drugs may now rush (like a burst dam) or be overly restricted (depending on the drug mechanism). This then takes time to re-balance.

When reducing antipsychotics, one "sleeping tiger" could be the symptoms of tardive dyskinesia (TD) that may become more obvious once stopping antipsychotic drugs. Although the uncontrollable TD body movements may gradually cease over time, some people find it necessary to reinstate the antipsychotic drug to try and limit the effects as there isn't a known cure. Though "some research has suggested that very gradually lowering neuroleptics may reduce the severity of TD." 8

"Cases of neuroleptic malignant syndrome [NMS] have also been documented upon neuroleptic [antipsychotic] withdrawal 9" and "the risk of developing NMS has been reported to last for 10–20 days after oral neuroleptics are discontinued and even longer when associated with depot [injection] forms of the drugs 10" as the latter last longer in the body. NMS is not a common reaction but reinforces the need to withdraw carefully - with friends around to help keep an eye on how you are getting on and to have your doctor's professional support too. (More about NMS in this web site here)

Coming off antipsychotic drugs can sometimes lead to what doctors might describe as a "psychotic episode" - another sleeping tiger. This is sometimes referred to as a "supersensitivity psychosis" (though the concept is disputed by some researchers) 3. This seems in part to be a reaction to higher levels of brain dopamine when reducing/stopping the drugs and the doctor may want to reinstate the antipsychotic drug dose and, when stability has returned, withdraw much more gradually - this time with smaller reductions and over a longer period of time. As we consider next, adverse reactions to reducing the drug (including "supersensitivity psychosis") might easily be mistaken by the doctor for a relapse.

It’s a common mistake – to think that withdrawal problems are actually a relapse

If a person fails to complete a course of antibiotic treatment the infection may return: in this case the symptoms - possibly pain and inflammation - are clearly recognisable. But it’s not as straightforward with mental health drugs as the withdrawal symptoms of these drugs are often virtually identical to the concerns being treated. So, possible withdrawal effects, such as: depression, anxiety, panic, sleep difficulties, paranoia, and psychosis, for example, might be some of the very concerns for which the drugs are prescribed. As you can see, it is easy for drug withdrawal problems to be mistaken for a relapse; in fact, it is likely that this often happens, but as Dr Moncrieff writes: “this occurrence should not simply be taken as confirmation of the need for long-term treatment.”3

Does coming off mental health drugs suit everyone?

This is an extremely important question and one that I have discussed with various doctors/psychiatrists in this country and beyond.  The dilemma is clear: we know that the risks from these drugs tend to increase with long-term use - but - it may be impossible to manage without them because of the damage they have caused on the brain and other organs, especially when they have been used for many years, perhaps 10-20 years or more.

Although mental health problems have not, in the main, been shown to be neurobiological diseases, psychotropic drug use does in a sense create medical problems, including the possibility of a physical dependency. This means that, according to some doctors, it may be that after long-term use, some people may not be able to manage without some level of medication, as the drugs have created permanent damage.

This view is even shared by some who are usually outspoken critics of mental health drugs. Dr Breggin writes: “Unfortunately, if a patient has been taking drugs for many years, especially neuroleptic or antipsychotic drugs, it can become impossible to stop them.  The withdrawal becomes too painful and hazardous, especially outside hospital 4.” Similarly, the late Dr Loren Mosher (founder of Soteria) conceded that, with people who have used antipsychotic drugs continuously long-term, trying to come off completely may not be wise and could lead to "a serious crisis". Co-writing with Dr Lorenzo Burti, they add: "Instead, we try to get them down to the vicinity of 25 mg. Thorazine [UK chlorpromazine] equivalent a day. That usually keeps dopamine receptors happy enough 6."

Dr Stuart Shipko has expressed his doubts too: "I used to feel that anyone on the SSRIs or atypical antipsychotics who is no longer symptomatic would be better off stopping the drugs.  Now I am not so sure.  The problems unleashed when slowly tapering drugs can be severe and difficult or impossible to reverse.  Even if patients get past the withdrawal symptoms, within the year these 'withdrawal' symptoms may recur - or worse (Source)." This is echoed by the findings of this study on SSRI and SNRI antidepressants that concluded: "but even with extremely slow tapering [drug reductions], some patients will develop some symptoms or will be unable to completely discontinue the drug 11."

It is also true that many people do successfully withdraw from mental health drugs, even from antipsychotics after long-term use. But it does take time, and a willingness to go very slowly. Optimistically, Dr Josef Zehentbauer writes: "a withdrawal psychosis can be avoided if a careful, step-by-step withdrawal is chosen" when reducing antipsychotic drugs.5

Again I quote the psychiatrist Joanna Moncrieff: “It is important to acknowledge that despite possible adverse outcomes, some people do successfully stop antipsychotic drugs…Clinicians should therefore be willing to help patients who request to reduce or stop their drugs. However, both parties need to be aware of the possibility that this process of withdrawal or reduction may itself provoke psychotic symptoms. This occurrence should not simply be taken as confirmation of the need for long-term treatment, although it may need treatment in its own right. Gradual reduction may reduce risk 3.”

Choosing the best time to come off

Clearly it makes sense to plan reducing when life is relatively stable with no expected upheavals in the near future. An obvious exception would be if there is a serious reaction to the drugs and your doctor needs to take immediate action. If an attempt at coming off hasn't gone according to plan - don't be discouraged - sometimes simply trying again at a later time can work for some people.

How slow is a slow withdrawal? Some different opinions

Coming off psychiatric drugs slowly

The idea that a slow withdrawal (often referred to as tapering) from mental health drugs is usually best is not a new one. For example, back in 1997 a study observed that “abrupt discontinuation of long-term psychotropic medication can be followed by a high risk of early relapse” and "gradual discontinuation" showed more favourable results. And a more recent study echos the same concerns and recommends that "these medications should be gradually tapered to minimize all types of adverse discontinuation effects" 17. However, there is no consensus on what defines a slow withdrawal.

It’s not easy to find clinical guidelines for coming off antipsychotic drugs (though guidelines are readily available for antidepressants): I presume this is because there is a strong tradition within psychiatry that assumes that these drugs should be used long-term – often for life – even though they carry such awful side effects and health risks.

In England, the NICE clinical guidelines for coming off antipsychotic drugs are imprecise: "If withdrawing antipsychotic medication, undertake gradually and monitor regularly for signs and symptoms of relapse." (NICE clinical guideline 82 - Schizophrenia)

As there seems to be a dearth of precise clinical guidelines for antipsychotic withdrawal, we will instead take a look at what some doctors think is a gradual withdrawal, based on their clinical experience.

Dr Edward Podvoll, who developed the Windhorse Communities, favours, as a basic principle, reducing antipsychotic drugs by 10% of the original dose - and then repeating this in 10 stages (each of 10% of the original dose) - with breaks of at least one week (depending on withdrawal problems) in between reductions 12.

Dr Josef Zehentbauer describes using the same basic approach: “After use of long-term medication, gradual, step-by-step withdrawal using the 10% formula can be used: the original daily dose (e.g.100 mg of a psychiatric drug) is reduced by 10% (thus in our example to 90 mg)…If there are no withdrawal symptoms such as sleep disturbances, inner agitation or depression after two weeks, the dose can be reduced by a further 10% (to 80 mg). The subsequent dose reductions then continue in steps of one to two weeks until zero dose is finally arrived at." 5

Dr Breggin and Prof Cohen's overall position is that “with all psychiatric drugs, withdrawal…should be gradual and tapered…except in emergencies” (such as where there is immediate and serious risk from the drugs) and this applies “even if the early stages of withdrawal present no difficulties.”9 They take a test-and-see approach: “If a long withdrawal is planned, it may be useful to begin with a reduction nearer to 10 percent for the first dose reduction. It’s a matter of testing the waters.  If this small reduction turns out to be relatively painless, then a larger dose reduction, such as 25 percent, could be attempted the next time.”

Although there is little in the way of clinical guidelines for withdrawing from antipsychotic drugs, there are published guidelines for withdrawing from antidepressants. The GP Notebook website for example, shows that the Maudlsey Prescribing Guidelines recommend that antidepressants “should be withdrawn slowly, preferably over four weeks, by weekly increments”, but adds the proviso that withdrawal be further slowed if withdrawal symptoms occur. The GP Notebook site shows that the NICE (National Institute for Health & Clinical Excellence) guidance for withdrawing from antidepressants is similar to the Maudsley: to “gradually reduce the dose over 4 weeks" (but even more slowly with particular drugs). And the Drug and Therapeutics Bulletin recommends that antidepressant treatment should be tapered off over a 6-8 week period - but with “an even more gradual tapering" after longer-term use. Details for all these are on the GP Notebook website.

Dr Glenmullen in his book The Antidepressant Solution 15 (also published in paperback as Coming Off Antidepressants) suggests specific reduction plans for each type of antidepressant (whether fluoxetine/Prozac or venlafaxine/Efexor etc). With his approach most people, if successful, will come off antidepressants within 2-4 months – though he recognises that those with more severe withdrawal reactions will need longer than this. Glenmullen writes that tapering should not be necessary if the person has been on the antidepressant for less than 1 month.

For antidepressant withdrawal, the Royal College of Psychiatrists says that "research suggests (source):

  • if treatment has lasted less than 8 weeks, stopping over 1-2 weeks should be OK
  • after 6-8 months treatment, taper off over 6-8 weeks
  • if you have been on maintenance treatment [i.e. longer-term], taper more gradually: e.g. reduce the dose by not more than ¼ every 4-6 weeks."

Dr Healy's guidelines (in conjunction with RxISK.org) for coming off antidepressant drugs are yet another different process (sometimes involving switching to a drug that might be easier to withdraw from). You can check it out here. But his simple taper goes like this:
"Convert to a liquid form of the drug you are on. Reduce by a comfortable amount in weekly steps. This may mean reducing as little as 1 mg per week and being prepared to stop and stabilize if things get too difficult. Another approach is to reduce by 10% each week. For some people depending on the drug and their own physiology, there may be a need to go very slowly, others may be able to go faster."17

In my opinion, there is no universal technique for reducing (and/or coming off) psychiatric drugs, as in real life there are many variables: the person's history, including the severity (and nature) of personal crises; the risks and characteristics of the particular drug; the person's physiological and psychological reactions to reducing; how long the drug has been taken; the level of dose (high being a greater risk factor); whether used short- or long-term; the person's overall state of health; and the quality of ongoing advice and support available.

Psychiatric drug rebound problems

In this chart I show how reducing by 10% of the current dose (so if starting at 100 mg, then reducing down to 90 mg, then 81 mg etc) might work out.

But as I have said, there are many variables and it really isn't possible to have a universal formula to suit every person's withdrawal needs. For some people reducing a drug by just 1mg can be too sudden a drop. As Dr Healy says: "If there are difficulties at any particular stage the answer is to wait at that stage for a longer period of time before reducing further."14

With severe reactions (such as seizures, mania, deep depression, feelings of violence and/or suicidality, excessive disturbance to sleep, psychosis) a doctor will likely reinstate the dose to the previous level and slow the process down.

If a person does not wait long enough after making a reduction they may wrongly assume that the reduction has been trouble free. This is because some drugs take a long time to clear out of the body. There is then the danger of making a few reductions on the false assumption that everything is going smoothly. Fluoxetine (Prozac), for example, typically takes around 25 days for 90% of it to be eliminated from the body. 15

As shown in the illustration above, a very gradual tapering-down near the end may be helpful and/or even necessary. Even reducing by just 1 mg in one go can be too much for some people, especially in the end stages. I know from what people tell me, that some doctors don't believe such small amounts have an effect and think the problem is psychological. However, there is no doubt that tiny amounts can be significant to some people.

A few practical considerations, such as how to reduce drugs into small amounts

Reducing psychiatric drugs slowly

As most drugs don't come in small sizes that suit a 10% or even smaller reduction I advise people to ask their GP for a liquid version of their medication. Also, many drugs are not suited to being divided - either because they come in capsule form or are tablets that should not be cut/broken (such as those that have an enteric coating). For drugs that don't come in a liquid form, Dr Healy points out that it should be possible for your doctor to ask your local primary care pharmacist to apply for a liquid formulation from a specialist company (this should be available for almost any drug). See details: 16

Your GP and/or pharmacist can ensure that the liquid dose is equivalent to the tablet/capsule form and can advise you how to reduce gradually. Using a syringe to measure the amounts for an oral dose seems the easiest way - it is much easier to reduce small amounts by diluting the liquid drug. Your GP may think that you are being over-cautious in wanting to reduce by such small amounts; and yet, even a cursory look across the internet will likely show many people struggling to reduce from psychiatric drugs, even in tiny reductions (sometimes less than 1 mg).

In conclusion

As this is an overview there are many aspects and details of drug reduction/withdrawal that I do not even touch on - I realise I do not even mention in passing the coming off of benzodiazepine drugs (such as diazepam, previously called Valium), stimulant drugs (such as Ritalin) or the the so-called mood stabilisers (including lithium) which can be tricky and hazardous. Neither do I look at helping children and young people off mental health drugs. As I said at the start of this page, this is not a 'how to guide'. For some people this may be an encouragement to find out more, for others it might be a warning of hazards to avoid.

We have noted that, although it is widely held that a slow reduction can be safer and more effective than an abrupt one, a slow reduction is no guarantee of a problem-free or successful withdrawal. As Dr Healy writes with reference to SSRI antidepressants: “Tapering slowly does not guarantee success. Many people who taper extraordinarily slowly still have problems.” (source)

I think this summary by Dr Healy regarding antidepressant withdrawal is a helpful one as we draw this to a conclusion:

“Before starting to withdraw, it should be noted that many people will have no problems on withdrawing. Some will have minimal problems, which may peak after a few days before diminishing. Symptoms can remain for some weeks or months. Others will have greater problems...Finally however there will be a group of people who are simply unable to stop whatever approach they take. Some others will be able to stop but will find problems persisting for months or years afterwards.”13

Although I strongly encourage having the medical support of an understanding and compassionate doctor; ultimately, whether or not to reduce is a personal decision. In addition, it can be invaluable to have emotional and practical encouragement/support along the way from someone who is familiar with helping people as they reduce: that person may not be medically trained, but will be well-informed and able to be a helpful guide.

"Stay within your own comfort zone when pacing your withdrawal. Keep in mind that the longer you were taking the drug, and the higher the dose, the more gradual your taper should be...It's not unusual to require a month of withdrawal for every year of drug exposure...Overall, most people are able to carefully and safely withdraw from psychiatric drugs."9 [p. 166]

“And since physicians often withdraw patients too abruptly from psychiatric drugs, above all else you must feel free to slow the process down.”9 [p. 143]

As we have seen, psychiatric drugs have serious limitations and risks. It is therefore understandable that some people may wish to try to be less dependent on them. But this is just one aspect of life, just one piece in the puzzle of life. We need decent friends too (including ones who will disagree with us at times, to help test our opinions, ideas and sense of reality). We need nourishing food - far too often the importance of nutritional balance is underplayed when it comes to mental and physical health. We also need adequate exercise - even if this means very gradually becoming more active: this is good for the mind, and helps restore the brain and the rest of our bodies too. And also, re-discovering restorative sleep can be essential in re-balancing our lives. For some people, simply being more at home in the world of nature can help towards greater inner peace and harmony.

And finally. One of the frustrations of psychiatric drugs can be the way they sap energy, de-motivate, detach us from our emotions and make our minds foggy. With patience, determination and some good fortune too, some people will feel considerably better off, in time, with less or even none of these drugs - though living without them may raise new challenges too. And if this isn't your time for coming off these drugs, you haven't failed. I wish you well too. Whoever you are, I trust you will find a greater sense of purpose and meaning in your life too.

 

References - Bibliography - Further reading

1 Healthcare Commission 2007. Talking About Medicines: The management of medicines in trusts providing mental health services. Available here.

2 Moncrieff, J. (2009) A Straight Talking Introduction to Psychiatric Drugs. UK: PCCS Books Ltd

3 Moncrieff, J. (2006) Does antipsychotic withdrawal provoke psychosis? Review of the literature on rapid onset psychosis (supersensitivity psychosis) and withdrawal-related relapse. Acta Psychiatr Scand 2006: 1-11

4 Breggin, P. (2001) The Antidepressant Fact Book. US: Da Capo Press

5 Lehmann, P. (1998) Coming Off Psychiatric Drugs. Germany: Peter Lehmann Publishing

6 Mosher, L. & Burti, L. (1989) Community Mental Health: Principles and Practice. New York: W.W. Norton & Co. Inc.

7 Healy, D. (2012) Data Based Medicine Paper: Medicine Induced Stress Syndromes. RxISK. Available here.

8 Watkins, J. (2006) Healing Schizophrenia: Using Medication Wisely. Australia: Michelle Anderson Publishing Pty Ltd

9 Breggin, P. & Cohen. D. 2007 (Update of 1999) Your Drug May Be Your Problem. US: Da Capo Press

10 Adnet, P. et al. (2000) Neuroleptic malignant syndrome. Br. J. Anaesthesia.  Available here.

11 Kotzalidis, G. et al. (2007) The adult SSRI/SNRI withdrawal syndrome: A clinically heterogeneous entity. Clinical Neuropsychiatry (2007) 4, 2, 61-75

12 Podvoll, E. (1990) The Seduction of Madness. New York: HarperCollins

13 Healy, D. (2012) Data Based Medicine Paper: Halting Antidepressants. RxISK. Available here.

14 Healy, D. (2012) Data Based Medicine Paper: Dependence and Withdrawal. RxISK. Available here.

15 Glenmullen, J. (2005) The Antidepressant Solution. New York: Free Press

16 Either: Rosemont Pharmaceuticals (Tel 0113 244 1999), Cardinal Health, Martindale (Tel 0800 137 627)
Large chain pharmacies e.g. Boots

17 Howland, R.H. (2010) Potential adverse effects of discontinuing psychotropic drugs. Part 3: Antipsychotic, dopaminergic, and mood-stabilizing drugs. J Psychosoc Nurs Ment Health Serv. 2010 Aug;48(8):11-4. doi: 10.3928/02793695-20100708-01. Abstract here.

18 RxISK eCLINIC Medical Team and RxISK.org (2014). Available here.

       
   
 
     
 
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