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You may feel in a rush to stop taking psychiatric drugs. Perhaps you are experiencing distressing side effects or feel "fed up" with being sluggish and emotionally numb. Beware! It's not a good idea to abruptly stop taking drugs without first making sure that there's no danger involved in doing so. In our opinion, it is almost always better to err in the direction of going too slowly rather than too quickly. Sometimes, the development of a severe adverse reaction may require an immediate withdrawal, but if you are having a serious drug reaction, you should seek help from an experienced clinician.
Once you have begun to withdraw from psychiatric drugs, don't let anyone - not even your doctor - rush you. Especially if there's a chance that you are going too fast, pay careful attention to how you feel physically and emotionally. At the same time, however, you should take into account the warnings of professionals, family members, or friends who believe that withdrawal is causing you more problems than you realize. You may not be the best judge of your emotional condition as you come off drugs, so you should take into consideration the concerns of people you trust.
When people take psychiatric drugs, their decision-making faculties may function less effectively. Their feelings are numbed. At these times, if their thinking were expressed in words, it would likely communicate indecision, apathy or confusion. Or they may experience different feelings in rapid succession, almost as if they were out of control. Because people generally want to think more clearly to "feel fully" again, and to be more in control of themselves, they are motivated to stop taking psychiatric drugs.
Coming off drugs gradually helps to "contain" the emotional and intellectual roller coaster that sometimes accompanies withdrawal. Indeed, a slow, gradual tapering imposes a discipline upon the withdrawal process. Because of the neglect of the topic of withdrawal, there still are no clearly validated tapering procedures. Almost every clinician writing on the topic today however, as well as newer recommendations that drug manufacturers are beginning to insert on official drug labels, state that gradual discontinuation is the preferred route. In the absence of a trusted friend or ally to provide feedback on your progress, in the absence of a support network, gradual withdrawal is likely to be the wisest strategy - especially if you are unsure as to how quickly you should proceed. Even if a medical doctor or other health professional is assisting you or monitoring your withdrawal, a gradual taper is usually the safest strategy.
The minute a psychiatric drug enters your bloodstream, your brain activates mechanisms to compensate for the drug's impact118. These compensatory mechanisms become entrenched after operating continuously in response to the drug. If the drug is rapidly removed, they do not suddenly disappear. On the contrary, they have free rein for some time. Typically these compensatory mechanisms cause physical, cognitive, and emotional disturbances - which are collectively referred to as the withdrawal syndrome.
The simplest way to reduce the intensity of withdrawal reactions is to taper doses gradually in small increments. This way, you are giving your brain appropriate "time" and "space" to regain normal functioning. Unless it is clearly established that you are suffering an acute, dangerous drug-induced toxic reaction, you should proceed with a slow, gradual withdrawal. The longer the withdrawal period, the more chances you have to minimize the intensity of the expected withdrawal reactions.
Interestingly there is some evidence that "gradual discontinuation tends to shorten the course of any withdrawal syndrome" (Noyes et al., 1991 [294], p. 1621). In other words, the actual duration of all expected symptoms from drug withdrawal is likely to be shorter if you withdraw slowly than if you withdraw abruptly. There is also, however, evidence, mostly from personal accounts posted on the Internet by users of antidepressants, that gradual withdrawal sometimes does not lessen the distress of withdrawal reactions. David Taylor, chief pharmacist of Maudsley Hospital in London, described his own SSRI antidepressant withdrawal, stating:
"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" (Taylor, 1999 [361]).
However, slow withdrawal does tend to reduce the risk of severe physical reactions such as seizures or dangerous blood pressure fluctuations. One study surveyed 66 patients who recently discontinued an SSRI antidepressant. One fifth of these people abruptly discontinued the drug, and they experienced exactly twice as many withdrawal symptoms as those who tapered gradually (van Geffen et al., 2005 [377]).
In one early study of withdrawal from tricyclic antidepressants, 62 percent of those who withdrew in less than two weeks experienced withdrawal reactions, compared to only 17 percent of those who withdrew over a longer period (Kramer et al., 1961 [236]). Because unpleasant withdrawal reactions are one of the main reasons you might be tempted to abort your withdrawal, a gradual taper increases your chances of succeeding and remaining drug-free.
In addition, it appears that people who gradually reduce their drug intake find a renewed vigor and energy that they now can learn to reinvest. In contrast to a sudden, unplanned cessation, a gradual withdrawal allows them to find constructive ways to use this energy to appreciate the new confidence in their abilities that they will develop, and to consolidate the new emotional and behavioral patterns that will be learned in the process.
One published account describes the case of a woman who wanted to stop Paxil after taking 20 mg daily for six months. Her doctor abruptly cut this dose in half, to 10 mg daily and gave her the new dose for one month. Then, during the following two weeks, he gave her 10 mg every other day. On alternate, nondrug days, the woman experienced severe headaches, severe nausea, dizziness and vertigo, dry mouth, and lethargy. The dose was reduced to 5 mg daily but, convinced that this only prolonged her agony she stopped abruptly. She is reported to have experienced two weeks of various withdrawal symptoms and then to have fully recovered (Koopowitz and Berk, 1995 [235]).
A more gradual taper, rather than an abrupt 50 percent reduction at the start, might have reduced the severity of this woman's overall withdrawal reactions. Also, as we discuss ahead, taking a drug every other day during withdrawal should be done only toward the very end of the taper. Granted, many users of psychiatric drugs do cease them suddenly, without experiencing any significant withdrawal pains. Our experience, however, suggests to us that abrupt withdrawal is chosen by people who are not properly informed or supervised, who cannot tolerate their drug-induced dysfunctions any longer, or who act impulsively because they perceive that no one is listening to them or understanding their suffering.
Many people, perhaps yourself among them, take several psychiatric drugs simultaneously. Today polypharmacy - the practice of prescribing more than one or two drugs to the same patient at the same time - is quite common and encouraged, especially by physicians presenting in drug company-sponsored symposium. Frequently patients receive an antidepressant and a tranquilizer, a stimulant and a tranquilizer, or an antipsychotic and an anticonvulsant. It is no longer unusual to find children and adults simultaneously prescribed at least one drug from every single major drug class discussed in this book. Such cocktails, if combined with a physicians failure to recognize withdrawal reactions and to monitor patients carefully leave patients vulnerable to experiencing severe distress. Such cocktails vastly increase the toxicity of each drug and produce dangerous, unpredictable adverse reactions and complicated withdrawal reactions. Patients taking multiple drugs often endure a chronic state of mental confusion, dulled and unstable emotions, and cognitive problems, including memory deficits.
You can withdraw from several drugs simultaneously but this is a risky strategy. It should be reserved for cases of acute, serious toxicity. In addition, since drugs taken together (such as neuroleptics and antiparkinsonians) often have some similar effects, withdrawing them together can make withdrawal reactions worse. Also, because some drugs suppress or increase blood levels of other drugs, your health care professional should be well informed before making recommendations concerning simultaneous decrements for more than one drug. If you intend to withdraw simultaneously from two or more drugs, you should do so under the active supervision of an experienced physician or pharmacist.
When you take two drugs, your brain tries to compensate not only for the effects of each one separately but also for the effects of their interaction. The physical picture gets even more complicated with each additional drug. The increasing complexity goes far beyond our actual understanding, creating unknown and unpredictable risks during both drug use and withdrawal. In cases of multidrug use, withdrawal is like trying to unravel a thick knot composed of many different strings - without cutting or damaging any of the strings. In this analogous situation, you would have to proceed quite carefully indeed, gradually disentangling one string and continually adjusting the others in response to the ongoing progress.
It is usually best to reduce one drug while continuing to take the others. The process begins anew once you've eliminated the first drug completely and have gotten used to doing without it.
If you want to get off more than one drug, there are some considerations in deciding which drug to stop first. Lets say you're taking drug "A" to counteract the side effects of drug "B"; in this case, you should probably start withdrawal with drug "B". For example, if you're taking a sleeping pill for insomnia caused by Prozac or Ritalin, you may want to delay withdrawal from the sleeping pill until you have begun to reduce the Prozac or Ritalin. Similarly if you're taking Cogentin or Artane or some other drug to suppress movement disorders caused by neuroleptics, you should probably first reduce your neuroleptic before you attempt to withdraw from the Cogentin or Artane.
There are no hard and fast rules about which doses to reduce first. In general, however, you should consider initially reducing the dose that's causing the most side effects, such as the afternoon dose that makes you too sleepy or the evening dose that over-stimulates you and causes insomnia. Conversely, you may want to wait until last to reduce or stop the dose that seems to be helping you the most, such as the evening dose of a tranquilizer if you have insomnia. Many people are concerned about difficulty sleeping if they stop the evening dose of a tranquilizer that they are taking several times a day and in that case, they would be wise to begin reducing a dose that is given earlier in the day.
Sometimes there will be other obvious reasons to choose the morning or evening dose as the first one to reduce. When taking tranquilizers such as Xanax or Klonopin, for example, many people find that they awaken in the morning in a state of anxiety or agitation due to withdrawal from the previous dose. Therefore, they may feel more comfortable beginning with a reduction of the evening dose. Others may find that they become excessively sleepy in the afternoon. They might want to begin reducing that dose.
Nowadays patients are often treated with multiple drugs at once. In the extreme they may receive one or more from each of the main categories; stimulants, antidepressants, tranquilizers and sleeping pills, mood stabilizers, and antipsychotic agents. If possible, try to address the antipsychotic agents first because they pose severe risks including tardive dyskinesia, potentially lethal neuroleptic malignant syndrome, diabetes, and pancreatitis. However, if the antipsychotic exposure has lasted for several years, it may take many months to withdraw, and therefore it becomes more practical to start with another drug that's easier to stop. But keep in mind that your risk of getting tardive dyskinesia from antipsychotic drugs is high and that the risk increases over time, so it's a good idea to withdraw from these drugs as soon as possible. Also keep in mind that you will probably need a strong support system when withdrawing from antipsychotic drugs.
Because benzodiazepine tranquilizers often provoke unpleasant, lengthy and potentially dangerous withdrawal reactions, some people choose to withdraw from their use last, after they've experienced withdrawal from other drugs, strengthened their resolve, and gained confidence.
If dangerous drug interactions are present, such as two or more drugs that stimulate serotonin, it may be important to withdraw from one of them at the onset. And of course, if the individual is already suffering from a potentially severe adverse reaction such as abnormal movements caused by an antipsychotic drug or over-stimulation and other mental abnormalities caused by a stimulant or antidepressant, it is necessary to consider as rapid withdrawal as safe and feasible.
In general, withdrawing from multiple psychiatric drugs requires supervision by an especially experienced clinician.
How rapidly to stop medication is one of the most critical and difficult questions to address and the process must be tailored to individual needs. In complicated cases, the patient and the health professional should anticipate spending sufficient time to share their views and to outline a general plan. They must also be prepared to re-evaluate the plan on a regular basis. Under no circumstance should the bar be set too high, so that the individual fails and becomes demoralized during the withdrawal.
It is important to withdraw gradually enough to avoid potentially life-threatening physical withdrawal reactions such as seizures and blood pressure spike. If you take one month to gradually withdraw from any psychoactive drug, you will probably avoid the most severe physical withdrawal reactions, such as seizures coming off benzodiazepines or dangerous spikes in blood pressure coming off clonidine (Catapres). In the case of large, prolonged doses of tranquilizers, more than one month should usually be required. By contrast, in the case of Catapres the withdrawal may be limited to a one-week period when withdrawing from routine doses.
In carrying out a one-month taper, the simplest procedure is to reduce the dose by one-quarter (25 percent) every week. However, the plan must not be rigid. At the end of a week, if withdrawal symptoms remain uncomfortable, then the dose can be slightly increased again, or the time on the dose can be extended as needed. A planned one-month taper may end up taking several months.
If an individual has been taking a drug for more than a year, it would not be unusual to plan a month of withdrawal for every year that the drug has been taken. By this method, an individual who has been exposed to antidepressants or tranquilizers for five years could require at least five months to withdraw. If the individual has been taking both kinds of drugs for five years, it may require two separate five-month withdrawals to stop both drugs; but hopefully the process may be shorter.
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. If, however, even a small reduction is difficult, then don't push any harder. The whole point is to make sure that the taper does not go too fast and remains within the individual's comfort zone.
Unfortunately, there is no way to determine in advance how gradually you need to taper, or how long you need to take, in order to avoid the array of potentially distressing emotional and neurological reactions, such as headaches, irritability, fatigue, and mood swings while withdrawing from SSRI antidepressants; or anxiety insomnia, emotional instability and muscles aches while tapering benzodiazepine tranquilizers. Some people experience only mild reactions throughout their taper and complete it in a few weeks. Others will experience distressing reactions that will force them to proceed much more slowly, in excess of several months, as their body takes time to adjust to each reduction before beginning their next dose reduction (Glenmullen, 2005 [180]). Usually you will know within the first few weeks if the withdrawal is going well at your current pace.
If you have been taking the medications for a long time or if you are worried about withdrawal for any reason, you can test your withdrawal reaction sensitivity by starting with a relatively small and convenient dose reduction. For example, if you're taking four pills a day break one of them in half. That's a convenient reduction of roughly 12.5 percent. If that feels good after a week or more, then break another pill in half. Now you've reduced the dose by 25 percent. You may want to ask your doctor or pharmacist for the smallest pill size so that you can more conveniently make small reductions.
In regard to the newer antidepressants like Paxil and the tranquilizers like Xanax, some people discover that they must proceed extremely slowly, taking tiny fractions of a pill at the very end of the taper. If the drug comes in a liquid form, such as Paxil, some people end up using a dropper to measure small reductions of the liquid form of the drug toward the end of the taper (Pacheco, 2002 [299]).
The most important rule is to respect your own feelings and to avoid tapering faster than you find bearable. 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. Once again, it's not unusual to require a month of withdrawal for every year of drug exposure.
If you have been taking a drug with recognized abuse potential such as the stimulants or benzodiazepines, in severe cases you may be able to get help from an outpatient or inpatient rehabilitation program.
If at any time the withdrawal symptoms become intolerable, the simplest approach is to return to the previous dose you were taking. Then, if you decide to continue the withdrawal process, you can do so more gradually. Whenever possible, make use of skilled clinical supervision and a strong family and social support network. Overall, most people are able to carefully and safely withdraw from psychiatric drugs.
Again, keep in mind that these withdrawal methods are only guidelines and not absolute rules. Applying them depends on how fast you feel comfortable to proceed and on how much discomfort you experience and can bear between dose reductions.
To follow the above steps, you may have to use smaller doses than those available in individual pills. Drugs usually come in pills of varying doses. As already mentioned, your doctor or pharmacist can provide you with the smallest available pill in order to facilitate your dose adjustments. However, the smallest available pill might not be small enough to ease the discomfort of withdrawal. For example, Lexapro comes in tablets of 5, 10, and 20 mg but some people may require 2.5 mg for their last series of doses.
Most pills have a slit that allows them to be divided in half easily; you can also purchase a small inexpensive device from most pharmacies for cutting pills and tablets. Pills that are slow-release (long-acting) typically cannot be safely divided. Consult your pharmacist or healthcare professional about the safety of dividing the pills you are using.
It is also possible to take most drugs every other day during the withdrawal. However, this should not be done early in the withdrawal. Taking psychiatric drugs every other day in routinely prescribed dose sizes can be very stressful on the brain. Taking the drug every other day should be done only toward the very end of the taper when you have reached the smallest available pill. You can then try withdrawing from the smallest pill by taking it every other day, and then every third day; until you feel comfortable stopping. In addition, as already described, some drugs like Paxil come in liquid form and can be dispensed with an eyedropper at the end stages of withdrawal.
To sum up, in withdrawing from many psychiatric drugs, it is not uncommon to have difficulty stopping the smallest available dose. In these cases, it is possible to break the pill into halves or even roughly into quarters. Toward the end of your withdrawal, it is also possible to take the smallest available pill every other day and then every third day before stopping completely. In regard to antidepressants and tranquilizers, some people find it very difficult to withdraw from these last little doses and may require weeks or months to finish the process.
This chapter has focused on the mechanics of drug withdrawal. But the most difficult aspects of withdrawal often have to do with fears about giving up drugs, as well as the resurfacing of painful emotions and psychological issues that have been submerged under a drug-induced mental flattening. Before undertaking drug withdrawal, always assess your need for counseling as well as your need for a safe home situation and a supportive social network. When these basic steps are taken before starting drug withdrawal, the vast majority of people can safely taper off their psychiatric drugs.