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There are no foolproof methods or blueprints for withdrawing from psychiatric drugs. Unexpected hazards can arise at any time. The following guidelines are drawn from a combination of the author's clinical experience and the scientific literature but cannot possibly cover all of the potential hazards involved in withdrawing from psychiatric drugs.
When health care providers decide to supervise withdrawal from psychiatric drugs, they must pay careful attention to the feelings or emotions of their patients or clients. Not only do patients de serve this respect and concern, their emotional reactions are the best gauge of how well the tapering process is going. Drug withdrawal requires a patient-centered approach.
When withdrawing a patient from psychiatric drugs, the health care provider should stay in close touch with the individual, especially at the start of the taper and toward the end, the times that serious problems are most likely to surface. In my practice, I try to see the patient at least once per week throughout the withdrawal process. Early in the taper or at other times of concern, I may arrange for phone call contacts in between sessions. If necessary, I will also stay in touch with family members who are informed about the drug withdrawal.
Once again, the patient's feelings are the most important barometer during tapering, and the health care provider and patient should stay in close communication.
In general, because the brain fights back against drug effects, withdrawal reactions tend to produce symptoms that are more or less the opposite of the drug's primary effect. That is, when the drug effect is removed, the brain's compensatory mechanisms are unmasked and take over.
For example, cigarettes "calm the nerves," and cigarette withdrawal causes the brain to generate extreme nervousness. Alcohol tends to sedate and suppress brain function, and alcohol withdrawalleaves the unmasked brain to react with overstimulation, anxiety, and even seizures. Similarly, sedative or antianxiety drugs such as the BZs can produce reactive overstimulation with insomnia, anxiety, and seizures during withdrawal. Conversely, stimulating drugs such as Ritalin (methylphenidate) and Adderall (amphetamine) tend to cause the brain to react during withdrawal with fatigue, sleepiness, and "crashing" during withdrawal. Lithium, a drug used to suppress manic episodes, causes manic episodes during withdrawal. The antipsychotic drugs can cause a new or worsening psychosis during withdrawal (tardive psychosis).
The most common withdrawal symptoms are emotional in nature, However, the same principle-that withdrawal reactions are the opposite of the primary drug effect-also applies to physical symptoms of withdrawal. A drug that controls blood pressure is likely to result in a reaction with excessively high blood pressure during withdrawal, and a drug that controls seizures can result in seizures during withdrawal.
There are exceptions, so very unexpected symptoms can surface during withdrawal, but it is helpful to keep in mind that withdrawal symptoms tend to be the opposite of the drug's primary or direct effect.
The literature on how to withdraw from psychiatric drugs is surprisingly sparse and fails to adequately describe the severity of the problem, the extreme care that must be taken. and the frequent need for collaboration. Nor does the literature mention how withdrawal spellbinds individuals, often rendering them unable to perceive their mental anguish as related to drug withdrawal (a typically insufficient discussion can be found in Shelton, 2006 [1165]). The most detailed discussion of withdrawal from psychiatric drugs can be found in Breggin and Cohen's Your Drug May Be Your Problem: How and Why to Stop Taking Psychiatric Medications, first published in 1997 and updated in late 2007 [223].
There are several key safety principles that should be observed during withdrawal from psychiatric drugs, especially if the drug exposure exceeds a few weeks or months or if the individual has serious preexisting emotional problems. Some of the most basic safety principles include the following:
1. Drug withdrawal requires collaboration between the health care provider and the patient, in which a great deal of attention is paid to the patient's feelings about withdrawal and to the patient's reactions during withdrawal.
Except in emergencies, withdrawal should be done at a pace dictated by the patient's wishes and feelings of comfort. In no case should the patient's concerns be ignored or minimized. Some examples of emergencies requiring relatively rapid or immediate withdrawal include the development of signs of tardive dyskinesia or neuroleptic malignant syndrome caused by neuroleptics; diabetes or pancreatitis caused by atypical neuroleptics; serotonin syndrome, violence, or suicidality caused by antidepressants; seizures caused by neuroleptics, stimulants, and some antidepressants; and depression or tics caused by stimulant drugs. Many medications can cause emergencies involving severe skin rashes, liver failure, or kidney disease. Many drugs, as this book has documented, can cause mania or psychosis.
2. Someone dose to the individual should help in monitoring potentially dangerous mood changes.
Drug withdrawal, like drug use, tends to be spellbinding. The individual undergoing withdrawal is likely to attribute the subsequent emotional instability and suffering to something other than the drug, resulting in harmful thoughts directed inward or toward other people. Typically, individuals tend to mistakenly attribute their withdrawal symptoms to their own underlying emotional problems, causing them to fear that they need to continue taking the medication.
To help monitor these mood changes, I usually invite the closest family member to a session with the individual undergoing the withdrawal. In the session, I describe typical withdrawal symptoms, especially the more dangerous ones, and warn that the patient may not recognize them. Also, on occasion, I discourage patients from withdrawing from medication on an outpatient basis after years of exposure to antipsychotic drugs, especially if they have an insufficient family or social network to support them during this potentially distressing and psychosis-inducing process.
3. Supervision by an experienced health care provider can be lifesaving.
When drug exposure has lasted for years, when multiple drugs are involved, or when the individual suffers from serious mental problems, clinical supervision during withdrawal is especially important.
If the taper lasts at least 10 days, it will probably avoid potentially life-threatening physical reactions, such as seizures or blood pressure spikes, but most individuals need more time to soften the emotional suffering and instability that commonly accompany withdrawal from psychiatric drugs. As a rough rule of thumb, for every year of drug exposure, a month of drug tapering may be required. I use this very rough estimate to encourage people to be patient during their withdrawal from medications.
5. Informed consent is an ethical and legal requirement, and also necessary part of educating the patient about potential proble during drug withdrawal.
The risks and benefits of withdrawal should be discussed with the patient before and during the process. Consent requires more than the reciting of information by the health care provider. It entails a back-and-forth discussion, in which the patient asks questions and obtains satisfactory answers. In the process, the patient will also become better educated about the pitfalls of withdrawal. Whenever feasible, I include family members in the process of educating the patient.
Many doctors seem to mistakenly believe that informed consent is a one-shot effort; you warn the patient about a few potential adverse effects and then forget about it. In fact, even patients who are functioning on a high intellectual level will misunderstand or forget what they have been told about potential side effects. During routine medication treatment and especially during withdrawal, the caregiver must regularly remind patients about potential adverse effects and to ask questions calculated to elicit information that may unearth a developing problem. For example, if a patient is withdrawing from antidepressants, I will ask each session about emotional instability, irritability, and angry or depressed feelings, as well as other adverse effects such as imbalance or headaches. Surprisingly, patients will often initially report that they have had an uneventful week but when asked will recall that in fact they had a nasty temper tantrum or very bleak few hours of feeling very depressed.
Driven by medication spellbinding, patients frequently fail to identify obvious drug withdrawal reactions, such as an abrupt increase in irritability or mood instability, and some patients must be repeatedly reminded that they are experiencing withdrawal symptoms. As noted earlier, they will tend to attribute their symptoms, such as irritability or mood instability, to their own emotional problems or to provocative actions by other people.
A number of issues routinely arise during withdrawal and are worth addressing. Of course, these are not the only special problems that come up, but they are among the more salient ones.
1. When the patient has been prescribed multiple drugs at once, it is usually easier and safer to taper one drug at a time.
Removing more than one drug at a time can increase the hazards of withdrawal. In addition, it makes it difficult or impossible to determine which drug is causing problems during withdrawal.
2. In the absence of an emergency or a special reason to the contrary, it is usually easiest and safest to begin by tapering the drug that has been most recently started. Drugs that have been taken for a relatively shorter period of time are generally easier to withdraw from.
Commonly, a patient taking several drugs will have started one in the last few weeks. This is usually the easiest and quickest one to taper. Sometimes the most recent drug can be stopped immediately. If that occurs uneventfully, another drug taper can be started the following week. However, I try not to begin a new drug taper until the patient has fully, or nearly fully, recovered from the previous one. If a problem develops while a patient is being withdrawn from more than one drug at a time, it can be difficult to figure out which medication is causing it.
Loss of sleep is very distressing and can seriously impair any attempt to withdraw from drugs. Therefore, unless the sleeping medications are posing a serious problem in themselves, I suggest continuing them until the other drugs are withdrawn. It is especially necessary to delay removing sleeping aids when the individual is taking stimulants or stimulating antidepressants that may generate anxiety and insomnia.
4. Selecting the order of drugs for tapering requires taking a careful history of the patient's relative degree of sedation stimulation.
If the patient is experiencing too "much sedation, then it may be best to taper the sedatives first. Similarly, if the patient is overstimulated, it is a good idea to start by withdrawing stimulants.
5. When the individual is dependent on a controlled substance. such as a benzodiazepine or stimulant, it may be easiest to tapel the patient off other drugs before addressing the drug depeno dence. In general, carry out the easier withdrawals first, leaving the most difficult one untillast. That way, some of the drugs at least can be withdrawn more rapidly before the more prolonged withdrawal begins.
Withdrawing from benzodiazepines can be exceedingly difficult. If a patient has been taking Xanax for several years, it might be preferable to withdraw mood stabilizers or antidepressants first. When the patient gains confidence withdrawing from the other drugs, he or she may feel more confident in approaching the difficult benzodiazepine taper. As in every important clinical decision, this one should be made in collaboration with the patient. Especially in regard to benzodiazepines, treatment in a drug rehab facility may be necessary.
6. When a drug is taken several times a day, weigh the patient's needs in determining which of the doses to initially reduce.
For example, if the patient is taking a benzodiazepine three times a day, be cautious about withdrawing the morning dose since it may precipitate or worsen morning withdrawal. Similarly, be cautious about removing the nighttime dose since it may cause or exacerbate insomnia. Because of these concerns, it may be best to reduce the middle dose first. Also take into account what time of day your patient needs to be most alert.
7. If a physically painful or emotionally distressing withdra reaction develops during the tapering process, returning to previous dose will usually ameliorate it.
For example, if a patient becomes extremely anxious or irritable 1-3 days after reducing Paxil from 20 mg to 15 mg, returning to the 20 mg dose will usually quickly relieve the withdrawal symptoms. Withdrawal might then be resumed at a later date with a 17.5 mg dose or by spacing 20 mg and 15 mg every other day. However, because it can be disruptive to brain function, I prefer not to give doses on alternate days until the end of tapering when the doses are becoming very small.
8. Avoid giving additional psychoactive drugs to treat withdrawal reactions.
For example, if a patient becomes very anxious while withdrawing from Paxil or Xanax, rather than adding another drug, it is best to return to the previous dose. Adding additional drugs makes it more difficult to evaluate the patient's progress and condition during withdrawal. Every psychiatric drug multiplies the biochemical imbalances in the patient's brain and makes it more difficult for doctor and patient alike to evaluate what's happening.
9. Very small doses may be useful and even necessary to stave off withdrawal symptoms during the last stages of tapering.
Although I know of no scientific explanation, some patients get relief in the last days or weeks of tapering by taking very small doses of a medication, for example, by breaking up a tablet of Xanax 0.5 mg into several relatively tiny pieces or by using an eyedropper to dispense 1 or 2 mg of fluid Paxil (paroxetine).
There are two different kinds of life-threatening adverse events associated with drug withdrawal: physical risks and emotional risks. The most common physical risks are seizures and blood pressure spikes. The most common emotional risks are violence against self and others and manic or psychotic reactions.
The physical risks are the easiest to deal with. In the appendix, the drugs listed in Part III: Sedative, Hypnotic, and Anxiolytic Drugs (Tranquilizers and Sleeping Pills) have the potential to cause seizures during withdrawal. The only exception is Rozerem (ramelteon). In Part V: Lithium and Other Drugs Used as Mood Stabilizers, those drugs that are labeled as antiepileptic also pose the risk of withdrawal seizures. In regard to all of these drugs, if the gradual taper lasts at least 10 days, there is much less risk of a withdrawal seizure.
In the appendix, some of the drugs in Part V are antihypertensive agents. If those drugs are stopped abruptly, a dangerous spike in blood pressure may occur. Usually, a short taper is sufficient to reduce this risk. To determine how many days this taper should take, check the drug label in the Physicians' Desk Reference [1034] or another source of drug information.
The SSRI medications, such as Prozac, Paxil, Zoloft, and Lexapro, and the SRIs, such as Effexor, almost always produce withdrawal symptoms (see chapter 6). These often severe symptoms were ignored for years and even today are too often ignored by a psychiatric community bent on blaming the patient's suffering on so-called mental illness.
Consistent with my own clinical experience, Pasadena, California, psychiatrist Stuart Shipko (2002) [1173] listed the following major categories of SRI withdrawal symptoms:
Because of the capacity for antidepressant withdrawal to cause mania (Benazzi, 2002) [124], I would add an additional major category:
9. euphoric or maniclike reactions, most commonly with shallow emotions, giddiness, and poor judgment
Withdrawal symptoms from SSRIs can be very severe and lasting. In a few cases in my clinical practice, patients have chosen to remain on very low doses for sustained periods of time because they were unable to tolerate the dizziness (often a sensation of instability) or emotional turmoil resulting from the final stages of withdrawal. As mentioned earlier, sometimes I prescribe the medication, such as Prozac in liquid form so that the patient can titrate very small doses in the last stages of withdrawal. Shipko (2002) [1173] provided a checklist for SRI withdrawal symptoms that the clinician and the patient may find useful. SRI withdrawal is so spellbinding that patients need to be reminded again and again that they are undergoing a withdrawal reaction, not a mental illness. They need regular reassurance from a health care provider with whom they can remain in contact between sessions.
Tricyclic antidepressants commonly produce withdrawal, frequently in the form of cholinergic rebound, with flulike symptoms such as nausea and vomiting, diarrhea, muscle aches, headache, fatigue, and anxiety (Breggin, 1991b [189]). McMahon (1986) [908] summarized:
"Autonomic symptoms are most common and include gastrointestinal disturbance (nausea, diarrhea), general somatic distress (myalgias, malaise, headache, rhinorrhea), sleep disturbances (insomnia, nightmares), and cardiovascular symptoms (arrhythmias, ventricular ectopy). Psychotic decompensation, withdrawal mania, and general anxietylike symptoms have been attributed to abrupt withdrawal of cyelic antidepressants."
Maxmen and Ward (1995) [892] provided an extensive list of tricyclic antidepressant withdrawal symptoms. One group of withdrawal symptoms includes a flulike syndrome without fever: anorexia, nausea, vomiting, diarrhea, queasy stomach, and cramps. A second group involves sleep disturbances: insomnia, hypersomnia, excessive dreaming, and nightmares. A third group includes mania and hypomania. Maxmen and Ward pointed out that these symptoms can also be experienced between doses as the blood level drops.
In my clinical practice, I have seen relatively few cases of very severe, lasting withdrawal reactions from the older antidepressants in comparison to the newer ones, with which serious withdrawal problems are frequent.
As described in chapter 8, it is now firmly established that withdrawal from lithium causes an increased rate of manic attacks in the 1-2 months after stopping the drug (Suppes et al., 1991 [1228]). Cavanagh et al. (2004) [266], in a 7-year follow-up, found that lithium withdrawal caused both mania and depression, while stopping the medication did not worsen long-term outcome. Most clinicians seem to believe that medication is an absolute necessity for warding off future mamc episodes, but I have not found this to be true, and the study by Cavanagh et al. confirmed that medication treatment leads to withdrawal reactions w'hile doing without the medication does not worsen long-term outcome.
Withdrawing from lithium must be treated as a potentially high-risk event requiring clinical monitoring and as much family support as possible. Although the data are sparse, any drug used as a mood stabilizer should be considered a risk for causing withdrawal mania.
It bears repeating that any mood stabilizer that is also approved for use as an antiseizure drug presents the risk of dangerous withdrawal seizures, and any mood stabilizer used as a treatment for hypertension presents the risk of dangerous blood pressure spikes during withdrawal. Some of these drugs are listed in the appendix.
Many neuroleptics produce withdrawal symptoms that mimic the flu, including emotional upset, insomnia, nausea and vomiting, diarrhea, anorexia and weight loss, and muscle aches (chapter 4). This is particularly strong in drugs that have anticholinergic properties such as Thorazine and Mellaril.
During withdrawal from both the older and newer neuroleptics, the individual can experience severe abnormal movements during withdrawal. They can be painful and frightening and can become persistent in the form of tardive dyskinesia (chapter 4). Severe emotional suffering and psychosis are common withdrawal reactions (chapters 4 and 5). Children may undergo severe behavioral worsening. Depression can occur.
If an individual has been taking neuroleptics for several months or more, withdrawal can be very difflcult. If the individual does not have a strong social and family network, it can be too difflcult to attempt in an outpatient practice. Yet there are very few hospitals that will withdraw patients from neuroleptics, unless they are suffering from severe tardive dyskinesia, neuroleptic malignant syndrome, or some other catastrophic adverse drug reaction. As mentioned earlier, many patients who have come off neuroleptics after developing signs of tardive dyskinesia go on to enjoy a much better quality of life when drug-free.
With the exception of Strattera, all of the stimulants approved for the treatment of attention-deficit/hyperactivity disorder cause potentially serious withdrawal reactions. Typical reactions including crashing with depression, exhaustion, social withdrawal, irritability, and suicidal feelings. They can occur between doses or after missing a single dose. Parents and teachers often mistake a withdrawal reaction for proof that the child needs medication.
Children and adults vary widely in the degree they suffer from withdrawal reactions. Many children are taken off stimulants during weekends, vacations, and summer recess without any serious difficulty. If a particular child is accustomed to these frequent withdrawals lasting a few days or more, he or she can probably withdrawal from the medication with little or no difficulty. However, if the child has been taking the drug regularly without breaks for months or years, withdrawal must be done carefully and cautiously.
When withdrawing children from stimulants, I always work very closely with the parents, encouraging them to stay in close touch with how their children feel. After learning to check on how their children are feeling in the morning before school, in the afternoon and evening, and at bedtime, many parents happily maintain the practice after the withdrawal is over. I also work with parents on any difficulties they are having in developing a consistent plan for rational discipline and unconditional love (Breggin, 2001c [209] & 2002b [211] for more details). Sometimes I work with the child's teachers as well. Every child diagnosed with ADHD that I have removed from stimulants has greatly improved. Almost invariably, the parents have felt that they "have their child back".
The more difficult problems in helping children arise after the unfortunate youngsters have been exposed to long-term drug treatment with multiple medications that cause persistent harm to brain function. To compound the problem in those cases involving children on multiple drugs, the parents or adult caregivers are sometimes too dysfunctional to participate responsibly in therapy aimed at improving their childrearing practices. However, where the parents (or the single parent) are responsible and willing to learn new approaches, I have been able to remove many children from multiple medications administered to them over many years, leading to much happier and more productive lives (Breggin, in press).
Withdrawal signs from benzodiazepines like Xanax, Klonopin, Ativan, and Valium often begin with insomnia, irritability, and nervousness, progressing to more serious reactions such as abdominal cramps, muscle cramps, nausea or vomiting, trembling, sweats, hyperarousal and hypersensitivity to environmental stimuli, confusion, depersonalization, loss of impulse control, anxiety and obsessional states, psychosis and organic brain syndrome, and seizures (see chapter 12). Withdrawal from these drugs can be difficult and prolonged and may require hospitalization. Too abrupt a withdrawal can lead to dangerous seizures. Many people find that it takes months or years to recover after complete withdrawal, and some people manifest continuing long-term problems, including memory difficulties, weakness, and fatigue.
Most sleeping medications present similar withdrawal problems. They are listed in the appendix.
If doctors choose to prescribe BZs, they need to realize that their antianxiety effects are short lived and that long-term effects are potentially disastrous.
Psychotherapy or counseling during the withdrawal process should focus, first and foremost, on monitoring the patient for the development of destructive tendencies such as suicidal or violent ruminations. In addition, therapy should focus on reassuring the individual that any newly developing emotional disturbances or obsessive ideas are almost certainly due to the withdrawal process and will diminish with time. Finally, the individual should be reassured that absent an emergency involving a serious adverse drug reaction such as tardive dyskinesia or antidepressant induced mania, there is no need to rush with the tapering process. During each session, patients should be reminded that if the withdrawal becomes unendurable, then they should communicate with the health care provider and return to the previous dose.
Insight therapy, including delving into the past, should be avoided during withdrawal. Individuals are sometimes tempted to attribute mood swings to their personal problems or to issues from the past, but little or no benefit can be gained from such explorations until withdrawal has been completed. The exploration of painful emotional issues during withdrawal can exaggerate them to a dangerous degree. During withdrawal, patients often feel guilty, frightened, or even horrified by unanticipated changes in their feelings. They may feel aghast at their desire to withdraw from loved ones, by their extreme mood swings, or by self-destructive or angry impulses. At this critical time, it is harmful to examine these emotions as if they have roots in the past or in predisposing factors. Instead, the individual needs to be reminded that he or she is undergoing a time-limited withdrawal. Patients need reassurance and competent supervision, not depth psychotherapy, during medication tapering. The brain dysfunction that inevitably accompanies withdrawal makes it impossible for the patient to adequately participate in insight oriented or depth therapy. Patients can be told that there will be time to explore such issues when they have regained their emotional equilibrium after the withdrawal is complete. At that time, in some cases, they may find that it is worthwhile to look for predisposing factors that influenced their emotions during withdrawal, but often, the painful emotions will disappear, removing any need to think about them further.
As a psychiatrist who offers psychotherapy, I often work with couples and families because I find that loved ones can empower each other to grow. During the tapering process, I especially like to see family members, or at the least to give them ready access to me, in order to have them help in monitoring the withdrawal process. Always remember that patients become spellbound by withdrawal and are likely to be the last to recognize that they are suffering from withdrawal symptoms.
When patients begin to recover from being medication spellbound, many issues may require attention from the health care provider. A man may realize that he rejected his beloved wife during a Zoloft-induced mania that lasted weeks or months, or a woman may realize that she neglected her children during a Xanax haze that lasted for years. These individuals may want help going through a period of mourning. During and after drug withdrawal, some people will begin to confront the horrific nature of their actions while spellbound by antidepressants, tranquilizers, or stimulants, including violent and criminal acts. Overcome with remorse as well as guilt and shame, they will need help in understanding the role played by medication spellbinding.
Soon after successfully withdrawing from all psychiatric medication, many patients experience an enormous period of personal growth. In the case of children, they may literally undergo a physical growth spurt, and many adults may have a return of energy. But most important for children and adults, when drug-free, they will find themselves with more fully functioning brains and minds. Memory may become sharper, thinking may become more nimble, and emotions may grow more full. Their passion for life will be unleashed from its pharmacological chains. It can be an especially productive time for therapy or counseling, especially with health care providers who welcome spontaneous feeling and creative change in their patients.
I have been focusing on what might be called technical issues. It is important for the therapist to have a good grasp of adverse withdrawal effects, but the two main points are sim pie and basic: Go slow and pay attention to the patient's feelings. Regardless of how you view psychiatric medications, the decision to withdraw from drugs must be made by your patient. Except in emergencies, I avoid encouraging patients to stop taking their drugs. I may explain that I will not prescribe medications indefinitely but that they can easily find other doctors to continue their drugs.
Once the patient has made the decision to withdraw from psychiatric medication, the health care provider can offer encouragement. But patients should not feel that they are stopping their medication because the doctor wants it. Patients should not feel guilty if they decide to continue or resume taking their medications. They should not feel that they have failed themselves or their doctors. Withdrawing from psychiatric drugs can become an overwhelmingly difficult experience, and in such cases, the patient's desire to remain on medication should be respected. In a few cases, when patients of mine have been unable to stop their medications, I have continued to prescribe for them. Although I never start my patients on psychiatric drugs, I respect that some of them may not be able to go through the process of withdrawing from them.
In addition to knowledge and experience, the health care provider offers what I have called a healing presence. Healing presence is the ability to be present, caring, and involved with patients while maintaining an ethical perspective that completely respects their autonomy and separateness. In The Heart of Being Helpful (Breggin, 1997b [199]), I described the active process involved in developing a healing presence: To create a healing presence, we fine-tune oue inner experience to the inner state of the other person. We transform ourselves in response to the basic needs of the person we are trying to heal and help. Ultimately, we find within ourselves the psychological and spiritual resources required to nourish and empower the other human being.
The final chapter continues the discussion of therapy and proposes 20 guidelines for working with very disturbed people without resort to psychiatric drugs, electroshock, or involuntary treatment.