How to Help Patients Withdraw From Psychiatric Drugs

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					  Safely Withdrawing
From Psychiatric Drugs

     Dr. Mark Foster, DO
     GOBHI Conference
        Bend, Oregon
         17 May 2012
                Five Case Studies
• Mr. G: “Something’s wrong with my brain!”
       (5 drugs: Celexa, Remeron, Wellbutrin, Xanax, Ambien)
• Mrs. B: “I started it two years ago for post-
  partum depressed, but I’ve gained 50 lbs and
  I’m still depressed.” (1 drug: Zoloft)
• Ms. A: “My psychiatrist says I’m schizophrenic.
  She says I’ll have to stay on these pills for life.”
       (7 drugs: Geodon, Lithium, Cymbalta, Lexapro, Ambien, Valium, Concerta)
• Mr. W: “I’ve been withdrawing from Paxil for 59
  months.” (1 drug: Paxil)
• Ms. S: “I stopped 13 medicines at once!”
   (Too many to count!)
    It can and must be done . . .
• Many patients do well on psychiatric drugs
  and suffer from no harmful effects.
• Many patients do poorly on these drugs
  and become increasingly ill over time, with
  compounding mental and physical harm,
  poly-pharmacy and poly-diagnosing.
     It can and must be done . . .
• Assessing the need to
  withdraw from harmful and
  ineffective drugs prescribed
  by other doctors falls under
  the purview of a primary
  care physician.
• The primary care physician
  may be the only doctor
  looking out for the patient’s
  whole health.
            But it’s difficult . . .
• It is far too easy to
  get on the
  medication highway.
• It is far too difficult to
  get off.
• Inertia conspires to
  keep patients and
  doctors there.
    Begin with the end in mind
• Use caution when starting the meds.
• Set expectations early.
• At the moment of prescribing these drugs,
  verbalize an exit strategy.
  – “This medicine is for short term stabilization.
    We’re going to come off of it within the year,
    and when we come off it, we have to do it
    slowly to minimize the withdrawal effects. In
    the long run, you’ll do better off the meds than
Begin with the end in mind . . .
              Barriers: Patients
• Patients:
  –   May be unprepared or unwilling to make a change.
  –   May not be in a life position to make a change.
  –   May be “addicted” to both drugs and diagnoses.
  –   May have had prior bad experiences withdrawing.
  –   May lack financial, social and intellectual resources.
  –   May have been convinced by other doctors,
      counselors and family members that they need to
      remain on the drugs for life, and that to come off of
      them is irresponsible.
             Barriers: Providers
• Primary care physicians:
   – May be unaware of side effects
   – May assume somebody else will address withdrawal from drugs
   – May have inherent bias about the effectiveness of their
   – May receive biased information exclusively from drug reps
   – May not be informed about alternatives
   – May not be informed about appropriate withdrawal techniques
   – May underestimate the level of distress, the resolve and the
     resilience of their patients
   – May be wary of backlash from psychiatrists and the mental
     health community
   – May be wary of malpractice suits
   – May be embedded in the medical model
       Scaling the barricades!
Providers must first educate themselves.
• “Anatomy of an Epidemic”
  – by Robert Whitaker
• “Your Drug May Be Your Problem”
  – by Dr. Peter Breggin and Richard Cohen
• “Mental Health Naturally”
  – by Dr. Kathi Kemper
Ask drugs reps to show you unbiased long-term
  efficacy studies of their psychotropic wares.
      Scaling the barricades!
• Physicians must pass on vital information
  to their patients.
  – True informed consent.
  – What do the medicines actually do?
  – What evidence is there for long-term
  – What evidence is there for long-term harm?
      Scaling the barricades!
• Providers must first attain, then convey to
  patients these traits:
  – Wisdom
  – Patience
  – Empathy
  – Optimism
Untangling the knot
         Start with a careful history:
         • What medications?
         • What diagnoses?
         • What order?
         • How long?
         • What effects?
         • What side effects?
         • Level of preparedness to quit?
         • Level of education?
         • Current life situation?
         • Current social support?
         • Current financial and time
         • Current capacity for change?
           Untangling the knot
              (Uh-oh. That list was intimidating.
     I don’t think my patient will ever be ready to quit.
               I’ll just refill their Effexor again.)

“Hold on, good doctor!
Have you considered the cost and risk of doing nothing, of
  just refilling their meds again?
• What is the risk of slowly tapering the meds under
  supervision versus the risk of staying on them
• Do not underestimate the resilience and humanity of
  your patients!”
            Untangling the knot
• . . . because not everybody
  has a hard time!
• Don’t forget all the patients
  who told you they just
  stopped the meds and didn’t
  notice a difference, or
  stopped the meds cold
  turkey, felt a little sick for a
  few days, and then were fine.
• Spontaneously healing
  applies to overcoming
  withdrawal effects, too.
• Most people do just fine off
  the meds.
          Untangling the knot
• Many patients are currently unable, unprepared,
  frightened or unwilling to withdraw from meds.
• That’s okay. Don’t cut them off.
• Plant seeds for the future.
  – “The time may come that you develop unwanted side-
    effects like weight gain, sexual dysfunction, or
    stomach problems, or that other doctors label you
    with multiple conditions and start treating side-effects
    of drugs with other drugs. If that happens, you may
    want to reconsider the need for the drugs in the first
    place, and consider slowly tapering off of them. Don’t
    stop all at once. Just think about it, and we can talk
    again sometime. At a minimum, I like to follow-up
    with my patients every six months and ask them if the
    cost and side-effects of the medicine are still worth
    the benefits.”
            Untangling the knot
• It is unknown, but likely to be true, that some people
  suffer from permanent physiologic brain dysfunction after
  being on psychotropic medications.
• Sadly, some people will be unable to come of the drugs
  completely or safely.
• This must be acknowledged, and the patient and doctor
  should not feel defeated if this is the case. At least we
  tried. However, this is the rare exception.
• The ultimate goal is not to just “get ‘em off drugs.” The
  goal is to have them thrive in their life at minimal harmful
  effect to their brains, bodies, and wallets. For most, this
  will be off drugs. But for some, drugs will continue to be
         Untangling the knot
• Questions to ask at every follow-up:
  – How is the medicine working for you?
  – Are you having any side effects?
  – Research shows that many people develop
    problems with the medicines the longer they
    are on them. Have you considered stopping
  – What are you doing besides medication to
    address your mental or emotional distress?
  General Principles of Withdrawal

• SSRIs:
     • Serotonin reuptake inhibition down-regulates, meaning more
       reuptake occurs, leading to less serotonin in the synapse.
• Benzos:
     • Decreased natural GABA when meds are withdrawn.
       Without GABA, the synapse goes into excitatory state.
• Antipsychotics:
     • Dopamine blockade is lifted. Synapse floods with dopamine,
       leading to possible withdrawal psychosis.
  General Principles of Withdrawal
• The patient must be in the
  driver’s seat.
• Both patients and doctors must
  have a strong level of
  commitment to withdrawing.
• Patients should have a strong
  support system in place.
• Patients should be at a place of
  relative calm in their lives.
• Patients should replace the
  drug’s effects with new healthy
  habits and interventions:
  exercise, counseling,
  supplements, acupuncture, etc.
  General Principles of Withdrawal:
          Before you start
The patient must be aware
  – the reasons for quitting
  – normal withdrawal effects
    and time-frame
  – possible stumbling blocks
  – the necessity of alternative
  – what life will be like off
     • It will be better! If not, then
       why are we doing this?
  General Principles of Withdrawal:
          Before you start

• Timing is critical.
• I rarely start a withdrawal on the first visit.
“This is a big life change. You need to think about it, read
  about it, and make sure you want to go through with it.”
• I have my patients purchase and read:
   – “The Depression Cure”
   – “Your Drug May Be Your Problem”
   – “Mental Health Naturally”
   General Principles of Withdrawal:
           Before you start
• See them back in 1 month, if
  possible with their spouse or closest
• Ask them to draft a “withdrawal
  contract” that states their:
   –   reasons for quitting
   –   expectations of quitting
   –   support system for quitting
   –   aspirations after quitting.
• To be co-signed by:
   –   Their spouse or closest supporter.
   –   Their counselor (must have chosen one)
   –   Their doctor (you)
   –   Themselves
    General Principles of Withdrawal
• Take it slow.
• Be flexible.
• Anticipate challenges.
• One drug at a time.
• Replace the drugs’ effect
  with healthy lifestyle
• A gradual taper will limit
  the severity of the
  General Principles of Withdrawal
• Start with a 10 to 25% dose reduction every 2-4
• The fastest time to withdraw would be 6-8
  weeks. Many people do fine with this.
• Normal time frame is 3-4 months . . . per drug.
• For higher risk patients (more fragile, longer
  history with drugs, prior bad experiences,
  multiple drugs) start slower and go slower.
• Stay flexible! Stay positive! Anticipate
  challenges! Replace drugs with healthy habits!
  General Principles of Withdrawal
• Avoid backtracking.
• If the patient is experiencing serious withdrawal
  effects, slow down or stop the taper.
• Let them catch their breath and prepare for the
  next decrement.
• Some people take years to successfully quit.
  That’s okay. As long as we’re moving in that
  direction . . .
• Stay flexible! Stay positive! Anticipate
  challenges! Replace drugs with healthy habits!
       Special Situations: Dosing
• Some medications come in very few doses,
  making gradual tapering difficult.
• Strategies:
   –   For tablets—pill cutters
   –   For capsules—counting beads
   –   Liquid dosing: Paxil, Prozac, Zoloft, Celexa.
   –   Every other day dosing
   –   Compounding pharmacy!!!
• Try not to let dosing difficulties force you to
  accelerate the taper.
    Special Situations: Polypharmacy
•    How to deal with drug cocktails?
     –   Identify the most harmful side effects.
     –   Are they diabetic? Liver damage? More depressed?
         Panicked? Sedated?
     –   In what order were the drugs started, for how long and for what
     –   Start withdrawing the most harmful drugs first.
     –   One drug at a time!
     –   Typically, I withdraw them in this order:
         1.   Antipsychotics
         2.   Stimulants
         3.   Benzos
         4.   Mood stabilizers
         5.   SSRIs
 Special Situations: Polypharmacy

• I have had some success in doing parallel
  tapering of two drugs when they seem to
  be causing simultaneous, additive
• Taper down to the lowest dose of each
  medicine prior to stopping either.
                 Special Situations:
                 The Prozac Switch
• For patients that have a hard time
  withdrawing from other SSRIs (such
  as Effexor or Paxil), switching to
  Prozac can be effective bridging.
• Prozac has the longest half-life and
  therefore the most gradual withdrawal
• Start the patient on a low dose of
  Prozac when severe withdrawal
  symptoms occur.
• Wait two to four weeks, and then
  resume the prior tapering schedule.
• Once the first SSRI has been
  stopped, then taper the low dose of
  Prozac over another 4-8 weeks.
 Special Situations: The Final Pill
• Slow is good, but at some point, you’re
  going to have to pull off the band-aid.
• If the patient is prepared, committed, and
  engaged in a healthy lifestyle with a strong
  support system, this final step can be
  decisive, minimally painful, and extremely
• “I can be okay—better than okay--off of
  medications! I can feel well again!”
• Celebrate with them when they succeed!
  Special Situations: The Final Pill
• Ultra-slow tapering methods: I am wary of methods that
  last greater than one year per medication. (Benzo
  withdrawals may need to last longer.)
• Ultra-slow tapering may be necessary in special cases,
  but I favor this as an exception after you’ve tried and
  failed a more expeditious taper.
• Online support groups can be helpful, but there can also
  be a lot of fear-mongering and extreme opinions.
  Proceed with caution.
• A support system of significant other, counselor, and
  physician is usually sufficient. Empowering peer
  counselors can be useful additions to this team.
     Special Situations: Crisis
• Stay calm. Stay positive. Be wise. Be patient.
• Back track, but only if absolutely necessary.
• Try not to re-centralize yourself in the patient’s
  care. You are there to help, but not be a savior.
• If the patient is suicidal or in severe crisis, they
  may have to re-engage with the current mental
  health care system, which will certainly mean
  renewed poly-pharmacy.
• Unfortunately, we do not yet have a non-drug
  safety net for patients in crisis. Maybe someday.
     Special Situations: Crisis
• A more rational system would have:
  – Tolerance for rare tragic events from withdrawing
    from medications.
  – Intolerance for common tragic events of people being
    kept on medications in spite of severe harmful effects
    and early death or suicide.
• Primary care physicians should consider how
  psychiatric drugs impact their patients’ whole
• They should feel empowered to recommend
  withdrawing patients from psychiatric drugs that
  are causing net harm. No one else is likely to do
• Patients must take responsibility for their
  withdrawal, replacing drugs with healthy habits.
• Slow, steady, supervised tapering wins the race.
• Stay flexible! Stay positive! Anticipate
  challenges! Replace drugs with healthy habits!
• You can do it! Your patients can do it!
• Good luck, and may the force be with you.

• Additional resources
     • Harm Reduction Guide to Coming Off Psychiatric Drugs
     •   “The Ashton Manual” for coming off benzos

  – “Your Drug May Be Your Problem” by Dr. Peter Breggin and
    Richard Cohen
  – “The Antidepressant Solution” by Joseph Glenmullen

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