Withdrawing from anti-depressants
I was recently contacted by the following American site, which I found very informative. http://survivingantidepressants.org/
It’s a peer support site and they are trying to collect a list of psychiatrist that would be willing to help users withdraw from antidepressants. Should we be considering that here?
There’s various UK information sites available for instance on Duncan’s site – http://www.uea.ac.uk/~wp276/antidepressant.htm
as well as David Healey’s guidelines – http://www.april.org.uk/pages/antidepressant_withdrawal.html and many others but professional help is not routinely available within services.
2. I agree we should take this up. “Relapse” after withdrawal from medication is a compelling argument for continuing medication, and for the view that the condition is usefully viewed as a form of “medication deficiency”, but my guess is that when it happens it is commonly associated with abrupt and clumsily managed withdrawal.
3. I think the biggest barrier to withdrawal of antidepressants is
psychological. Some people have been lead to believe that the medication got them better and they feel anxious about stopping it, and very vulnerable. So to my mind, increasing people’s confidence is important. Others of course just chuck it down the toilet without a problem!
4. I think the concerns about abrupt and clumsily managed withdrawal can’t be emphasised enough, and I’ve personally bumped my head quite a bit, in this area. I think, though, that I’ve also seen a great deal of benefit from rationalising or phasing out psychotropics. The immediate areas of priority that crop up for me are: Ongoing ‘primary prevention’ i.e. ongoing advocacy for conservatism in initiating psychotropics – perhaps particularly in primary care; perhaps particularly with young people; advocacy for lowest possible dosages when initiating medications (especially conventional antipsychotics); Client choice when initiating medication (or not) – providing information not only about the so-called evidence base for efficacy, effectiveness, and well-known risks – but also providing information about what is not known/ not researched/ difficult to research. College info leaflets and more mainstream guidelines on the use of SSRI’s may be lacking in depth and scope. The emphasis seems to be on re-assuring clients that SSRI’s are not habituating in the manner that benzo’s/ alcohol etc would be. The extent to which the use of SSRI’s and other ‘antidepressants’ could predispose to a future return of symptoms of anxiety and depression may go beyond the well described, dramatic, but relatively time limited discontinuation syndromes as is recorded with eg Venlafaxine and Paroxetine withdrawal. The whole issue of ‘recurrent depressive disorder’ and related guidance around duration of ‘treatment’ is a real problem. There seems to be a small but growing body of critical literature in this area. I guess there may be ongoing work wrt compiling, maintaining and developing reputable guidelines around initiating and withdrawing antidepressants. I think that more critical information leaflets will need to be worded quite carefully, though; Individual variability – mapping range of individual experiences of withdrawing drug treatment. On the whole, I seem to be drifting towards much more gradual withdrawal of Rx than is usually recommended; Unanswered questions around the manner in which pharmacological approaches may facilitate or disadvantage psychological approaches. Possible ill effects of medication changes while someone is attending for structured time limited therapy; Medicolegal peer support, supervision – also in the face of potential threats of defamation from drug companies.
5. I have supported quite a few people to come of antidepressants when they have recovered or are not getting any benefit (and the drug was just continued due to poor practice) or they benefitted but suffer unacceptable side effects. In my practice, when you are open to listening to people, withdrawal symptoms appear to be the rule rather than an exception contrary to previously held ‘truth’ perpetuated by the manufacturers ‘spin’. Many patients simply grin and bear it as they come of the drug whilst others I’m sure get misdiagnosed with a relapse of the depression. Therefore I am honest with patients and say that the drugs are addictive when I prescribe them. Having said this I should balance things by saying many people do find relief with these drugs through whatever mechanism. I have developed a pragmatic approach to deciding whether to withdrawing antidepressants (and all other psychotropics for that matter) which involves 2 straightforward questions;
What has changed in the person’s life since the drug was introduced? e.g. can we expect the person to be better protected from developing the depressive syndrome/reaction because circumstances, alcohol/substance use, relationships, health etc have improved?
What can take the drugs place? e.g. has the person developed effective ways of coping as an alternative to medication? Have they understood the roots of their unhappiness (e.g. trauma) and can respond differently to triggers? Do they have ongoing therapeutic interventions in place or a trusting relationship to use?
If a person comes to me and says they want to stop the drug but have very little in the way of positive responses to the above questions then I am less optimistic of a good outcome. However when people are genuinely motivated they usually feel better about themselves because they value not having to ‘rely on tablets’.
6. The administrator of Surviving Antidepressants has left a note on the website forum that would be of interest.
The practise in the US seems to be first converting the antidepressant to fluoxetine, due to its long half life, and then a gradual reduction.
Surviving Antidepressants is based in the US ( California ) but has an international membership, including many from the UK .
Patients post their own case histories here.
Reading these case histories can be very informative for clinicians.
A few things stand out: Many people have been drastically mis-medicated for excessive periods of time; Doctors are ignoring even obvious signs of severe withdrawal; Left unchecked, severe withdrawal can progress to a protracted condition lasting months or years.
It is painfully obvious that clinical guidelines for withdrawal produced in the mid-2000s under the sponsorship of drug companies need to be revisited and clarified to counteract complacency among physicians who have been lulled into believing withdrawal syndrome is invariably mild, self-limiting, and lasts only a few weeks.Peer support Web sites advocate a 10% taper per month to reduce the risk of severe withdrawal. As many patients can tolerate a faster taper, I would specify further:An initial 10% reduction in dosage for a trial taper; Monitor daily for a month. If withdrawal symptoms occur, immediately reinstate full dosage and plan a taper at 5% rate; If withdrawal symptoms are nonexistent, an additional 10% reduction in dosage (based on the current, reduced amount) for a second month; Monitor daily for a month. If withdrawal symptoms occur, immediately reinstate full dosage and plan a taper at 5% rate; If withdrawal symptoms are nonexistent, an additional 10% reduction in dosage (based on the current, reduced amount) for 3 weeks; Monitor daily for 3 weeks. If withdrawal symptoms are nonexistent, an additional 10% reduction in dosage (based on the current, reduced amount) for two weeks; If the patient is tolerating the faster taper well, continue with 10% reduction every two weeks until the patient is taking less than 1mg, then discontinue completely.
The above harm reduction approach protects those susceptible to severe withdrawal syndrome while expediting tapering for those who have the more typical mild withdrawal. For most people, the withdrawal schedule would be 10% per month for 2 months, then 10% for 3 weeks, then 10% for 2 weeks (times 8), completing the taper in about 27 weeks.
We would like to list helpful physicians here. If you read the case histories, you will see that having a nearby doctor to see for assistance in withdrawing will save lives.
We have a fairly large library of scientific papers here. Critical Psychiatry members are welcome to peruse them as guests if they wish.
7. In my limited experience, I have found that about half of patients will experience significant withdrawal symptoms, and these can last for months. Of course, it depends on many factors, including how long they’ve been on the drug or similar ones, the dose, the actual drug (paroxetine and venlafaxine seem to be particularly bad offenders), how fast you get them off, other drugs that may be interacting pharmacodynamically and pharmacokinetically. Unless urgently necessary, I tend to be quite conservative in that I taper the drugs very gradually, typically over months, depending on the particulars of the case. I sometimes convert to fluoxetine during the process. Another option is resorting to compounding pharmacies, which can provide you with doses not otherwise available. For example, venlafaxine capsules contain beads, and by removing some of these, you can get virtually any dose increments you want. Above all, this should be a collaborative process, and in the context of a strong therapeutic relationship.
8. I was prescribed paroxeteine for depression/anxiety by a GP who insisted I stop fighting and become a ‘patient’. I took trhe tablets and It made me feel more shit initially at least, and I never felt really good on it though perhaps slightly more numb. Sexual side effects were the worst and my girlfriend said I sweaty and clammy in an untypical way as well as more ‘zombie’ like then usual. About 2 months into taking it I read a very worrying article in the Gauardian about withdrawl effects and decided to take myself of it. Paroxeteine is possibly the worst offender for these effects. I thought I’d try and withdraw it by going down to every other day and so on. What I found is even after a day of not having the medication these very odd and disturnbing ‘electric shock’ and flulike like feelings would begin running through my body. In the end I obtained a script for liquid paroxeteine and then reduced it very very very slowly over a number of months. It helped but at 2-5mg and below I was experiencing these ‘shocks’ and they continued for a while after stopping altogether. I never tried another antidepressant and thankfully I am now quite well. The shocks have completely disappeared though once or twice I have had a sort of flashback to them.