Drug Dosage Reduction: Getting Off of Your Anti-Depressant Safely, with Amit Dhingra, PharmD.
March 22, 2024
BY MATT DHINGRA, PHARM.D
Antidepressant prescription drug use is on the rise in North America, Europe, Australia, and many other industrialized nations. Many factors can be attributed to this including social factors such as societal discrepancies among rich and poor, lack of education, housing instability, and lower income. It can also be attributed to lifestyle and biological factors including post covid trauma, long covid syndrome, ultra-processed foods, endocrine disruptors, hormonal changes, increased toxic burden, chronic illness, sedentary lifestyle, social media distractions, traumatic world events, financial pressures, occupational pressures, familial stressors, gastrointestinal health deficiencies, genetic factors, ruminating thoughts, familial trauma, lack of spiritual anchors, exposure to electromagnetic interference, limited outdoor exposure, and uncertainty of life’s purpose. It does not discriminate by race or social status.
Depression is a condition that can affect people from all walks of life and from various socio-economic statuses. Over 65 mm people in the U.S. are prescribed psychiatric medication and women are two times as likely to be on an antidepressant as men. Suicide deaths reached an all-time high in 2022. Psychiatric medications may include antidepressants, antipsychotics, sleeping pills, minor tranquilizers, lithium, and others. Current clinical practice guidelines (CPGs) on depression generally recommend treatment with an antidepressant for moderate to severe episodes of depression. As the clinical situation improves, however, patients may consider discontinuing their medication. Discontinuation of the drug, however, can cause side effects in a percentage of patients. Abrupt stoppage or a large dose reduction of psychiatric medications often leads to discontinuation symptoms.
What are discontinuation symptoms?
Antidepressant discontinuation syndrome (ADDS) is a new entity in the DSM-5 in the category of medication-induced movement disorders and other adverse effects of medication. The first step to understand discontinuation symptoms is to acknowledge its reality for a significant percentage of patients prescribed antidepressant medication. Not all psychiatrists have yet to fully embrace and acknowledge the scope of symptoms. The condition can easily be misdiagnosed as an exacerbation of the clinical disease rather than symptoms of the drug itself. Irrelevant old clichés, such as, “It’s all in your head,” may often supersede a good faith effort to make an accurate diagnosis based on a proper understanding of the syndrome. Together patients and clinicians must develop a strategy to curb symptoms and improve quality of life. The action plan to reduce drug dosage or discontinue the drug completely must conform to the patient’s specific needs and should never be rushed. In this blog, we’ll discuss the symptoms many undergo during a psychiatric drug taper and the potential strategies to restore balance and vibrancy! We will review:
∙ SSRI tolerance
∙ Over-rapid withdrawal
∙ Withdrawal syndromes
∙ SSRI induced symptomology
About 20% of patients develop antidepressant discontinuation syndrome following an abrupt stoppage or marked reduction in the dose of an antidepressant taken continuously for one month. If the patient has been on the antidepressant for six months or more, the percentage of patients experiencing discontinuation syndrome may be much higher. Symptoms are believed to be caused by down regulation of serotonin receptor sites (gradual decline of receptor sensitivity) leading to unwanted side effects over time. Symptoms may include brain fog, brain zaps, diarrhea, bloating, dizziness/vertigo, insomnia, akathisia, mood instability, severe depression, and dark, ruminating thoughts. Over-rapid withdrawal can have debilitating consequences including lost work hours, hopelessness, social isolation, and diminished quality of life. The mnemonic FINISH summarizes the symptoms of antidepressant discontinuation syndrome: Flu-like symptoms (lethargy, fatigue, headache, achiness, sweating), Insomnia (with vivid dreams or nightmares), Nausea (sometimes vomiting), Imbalance (dizziness, vertigo, light-headedness), Sensory disturbances (“burning,” “tingling,” “electric-like” or “shock-like” sensations) and Hyperarousal (anxiety, irritability, agitation, aggression, mania, jerkiness).
When circumstances have changed, and the initial stressor has resolved, patients may consider discontinuing the medication for various reasons including:
∙ Initial stressor has resolved or subsided
∙ Lack of clinical efficacy of the drug
∙ Debilitating side effects
Current major clinical practice guidelines provide little support for clinicians wishing to help patients discontinue or taper antidepressants. In a recent clinical review published in Therapeutic Advances in Psychopharmacology, of the 21 included clinical practice guidelines, 15 (71%) recommended that antidepressants are tapered gradually or slowly, but none provided guidance on dose reductions, how to distinguish withdrawal symptoms from relapse or how to manage withdrawal symptoms. Physical symptoms can persist for weeks, months, and even years. Beyond the physiological effects related to drug withdrawal, discontinuing antidepressants can be difficult for psychological reasons. These include worry of relapse, a perceived biochemical cause of depression, insufficient emotion regulation skills and coping strategies, need for social support, psychological dependence, and experience of previous unsuccessful discontinuation attempts. Ironically, discontinuation symptoms have an uncanny similarity to clinical patterns of depression making it often difficult to diagnose.
Symptoms and patterns of depression that may mimic discontinuation symptoms may include:
Sad, hopeless, irritable feeling
Poor concentration
Low self-worth
Thoughts about dying and suicide
Tired, low energy
Excessive sleeping or poor sleep
Other symptoms of discontinuation syndrome may include crippling anxiety, gastrointestinal symptoms including nausea & vomiting, electric shock sensations, physical tremors, panic attacks, gait issues, restless legs, flu-like symptoms, bouts of crying, and restlessness (akathisia).
With the help of your prescribing practitioner, reducing the drug’s dosage gradually, rather than abruptly is the best strategy. For twenty percent of the population who are susceptible to protracted withdrawal syndrome, tapering should be no greater than a 10% reduction every 2-4 weeks. Implementation should never be a cookie-cutter approach, but rather highly customized based on the patient’s current situation. In addition to a prescribing practitioner, working with an integrative pharmacist or Naturopath may help provide strategies for tapering support such as addressing nutritional deficiencies and hormonal imbalances, stress relief practices, therapy recommendation, access to compounding pharmacies and assistance with water titration methods.
What are best practices for tapering off SSRI’s?
Clinicians should first determine which risk category their patient is in. A lower risk category may include someone younger than 40 and on less than two psychiatric medications. For example, this patient may be someone on a benzodiazepine who is on a low dose and only been on the medication for less than two years. A higher risk category may include someone older and on more than two psychiatric medications. In this example, the patient may be someone on a benzodiazepine for longer than 2 years and on a higher dose. Younger age may play a factor in a more rapid taper as the brain may be significantly more adaptive than someone older. This is highly variable, however, as many younger patients can be extremely sensitive to medication. Higher risk patients are better served by tapering more slowly.
All tapering strategies should be coordinated with the help of your prescribing practitioner. There are several strategies to tapering: What has been tried…
Dry cuts with a scale. In this technique, the user weighs the tablet on a digital scale and then may use a razor to shave off 5% every 2-4 weeks. If you are low risk person, you could maybe do a 10% cut. Reassess for one month and then decide if you are ready for another cut.
Water titration method. In this technique, the tablet is dissolved into 100ml of distilled or purified water. The solution is then mixed until the tablet is completely dissolved. We can then throw away 10% of the solution and then drink the rest. Be sure to rinse the bottom of the cup or cylinder so that all the residual powder stuck to the surface can be consumed. This technique can allow for a slow percentage taper without having to cut tablets or use a digital scale.
Use a compounding pharmacy. Your doctor can write a prescription for the exact dose they wish to order for you. This method allows the actual dose to be measured out for you in the form of a capsule or trochee. Although this may be the most expensive of the various techniques, it may be the most useful option, especially at lower doses where cutting tablets can become more difficult. Keefer’s Pharmacy compounds specific doses for the purposes of tapering and can help you with this option. Log on to keeferspharmacy.com to learn more.
Most experienced practitioners agree it is best practice to slow down towards the end of the taper. The smaller the dose, the slower the taper. For example, at a dose of 5mg of your antidepressant, the taper should be slowed. Let’s use an example dosage of 75mg Effexor. Reducing the dosage by 10% per taper all the way down to 20mg may occur relatively quickly. Once the dosage has been decreased to 20mg, the taper may need to be slowed dramatically. It is at these last few doses where things can get more difficult in terms of discontinuation symptoms. An example of a tapering schedule might present as the following: 20mg to 18mg to 16mg to 14mg to 12mg to 10mg to 9mg to 8.5mg to 8mg to 7.5mg. It is important to note that even smaller percentage reductions may be warranted going forward from there until discontinuation has occurred.
During discontinuation, if you are experiencing high levels of anxiety or insomnia, it is important to take a look at your daily habits. Are you taking caffeine? If so, you may have to remove caffeine from your regimen. What supplements are you taking? Your integrative practitioner may suggest magnesium glycinate, lemon balm, cognitive aminos or specific nutrients you are deficient in. What are your hormone levels? Are you perimenopausal or in full blown menopause? If so, working with your integrative practitioner to confirm progesterone levels and seeing if it is running low may be supportive, as progesterone levels within normal limits support GABA production. Are you keeping a journal? Are you getting enough access to fresh air and sunshine? Are you going for walks in nature? Are you listening to mantras or praying the rosary? Are you reading books about the plight of others? Sometimes helping others in need when you are suffering is a great way to keep things in perspective.
For some, tapering can be a quick and easy transition from one dose to the next. For others, tapering off antidepressants can be hell. By working with an integrative pharmacist or Naturopathic Doctor, you will gain support for minimizing these side effects. This may include adding the right dietary supplements such as St. John’s Wort, Gingko Biloba, L-theanine, Vitamin D, 5-HTP, Tryptophan, Melatonin, and others. We believe in a patient led, flexible approach to tapering. The Doctor-patient relationship should be co-creative.
Here are some initial questions that would help strategize the taper approach.
1) How many years have you been on the drug? A person who has been on the drug for 10 years will receive a taper plan that may look different than a patient who has been on the same drug.
2) Are you currently symptomatic? Are you currently affected by symptoms of withdrawal from the medication? If the patient is currently having severe discontinuation symptoms, then we will have to taper much slower so as not to upset the balance even further. Discontinuation symptoms include insomnia, depression, akathisia, brain zaps, gastrointestinal symptoms, joint pain, irritability, paranoia, tremors, and more.
This is not a sprint, it’s a marathon. If functionality is being impaired, we slow the taper down. Part of the tapering journey may include taking a pause. Pauses are quite common in a taper, and can last anywhere from days, months, to even over one year. Your body really does have a natural capacity to heal. Stick to a healthy diet if possible. Avoid caffeine, nicotine, and alcohol. Generally, being healthy will put your body in the best position to heal from discontinuation symptoms. There are no real shortcuts out of this. Make friends online who are undergoing a similar experience. It can really help. Read books and watch movies of real people from the past who have had to undergo their own plights only to come out stronger on the other side. Write, journal, read poetry, do art projects, or anything to keep your mind going and not ruminating on your present symptoms. The body needs time. Although this can be depressing at first, it teaches us lessons about life. A comprehensive plan to curb depression would include nutrition, psychotherapy, energy medicine, and lifestyle changes. Visit www.wholeheartednaturopathic.com to learn more.
*This blog is dedicated to Mental Health Awareness month.
FDA: Disclaimer: These statements have been evaluated by the Food and Drug Administration. These statements are not intended to diagnose, treat, cure, or prevent any disease.
