Clinicians share information about slow tapering

[Altostrata]

ADMIN NOTE 17 March 2019 The pages on Dr. Phelps's Web site have changed. The information in this post has been updated (with many references to SurvivingAntidepressants.org) and now appears on

 

Avoid withdrawal: taper slowly

 

Stopping Antidepressants in Bipolar Disorder

 

About Prozac bridging

 

I have left the text for the original post below as it contains information that is not in the revised pages, and struck out the outdated information.

---

 

Doctors who have seen withdrawal syndrome in their patients are developing and sharing information about tapering. It is unfortunate that this is word-of-mouth folk wisdom among doctors and negligent of the medical profession as a whole that it hasn't studied this and issued guidelines.

 

But it is a good sign that some clinicians are paying attention. Maybe this will trickle up to the attention of psychiatry's leadership.

 

According to psycheducation.org, the author, Jim Phelps (Oregon), and a colleague, Tammas Kelly (Colorado), are concerned with very gradual tapering off antidepressants (see method below). (Both psychiatrists appear to specialize in bipolar disorder, hence the references to it.)

 

(See http://survivingantidepressants.org/index.php?/topic/988-recommended-doctors-therapists-or-clinics/page__view__findpost__p__11058 for the doctors' contact information.)

 

Drs. Phelps and Kelly agree on this technique (from Dr. Phelps's Web site) Stopping Antidepressants in Bipolar Disorder:

 

Summary: go slow, much slower than you would have thought necessary; and of course, not without your prescriber's direct involvement.

 

B. Guidelines on how to get off antidepressants

 

1. Educate/prepare the patient well ahead of time and repeatedly.

 

2. Chart GAF scores [a psychiatric standard, Global Assessment of Function, a single number summarizing how you're doing] over time. Sometimes getting off anti-depressants isn’t the right thing to do and can be used to identify “Sweet Spot” for dosing. For example, I recently had a patient who was doing poorly on 300 Effexor XR started when she was still “unipolar”. Took two years to wean off. Retrospectively I was able to see that she was doing best around 75mg. Charting the GAF at appointments and the Lowest in between is best.

 

3. If the patient stops them AMA [against medical advice] abruptly and they are doing well then leave them off. Watch for manic symptoms. (Sometimes patients get better despite our best efforts.)

 

4. If the patient stops them AMA abruptly and they are doing worse don’t jump back up to the whole dose. The longer they were at the lower without feeling bad before felling worse, the lower dose you can return to. You can sometimes use half-lives to calculate this. Calculate the dose based on when they started feeling bad. Watch patients very closely during this time, even daily by phone or at the office.

 

5. Warn patients that they will have mood swings if they do this. Warn patients that they will have mood swings if they don’t do this, probably worse. Warn them of this over and over again. The point is to try and stop them from major panic when they do have a down.

 

6. Slowly is best. The slower the better. I usually wait ... at least 6 – 8 weeks between dosage decreases. Prozac/fluoxetine can be an exception to this.

 

7. Longer if anxiety is a major feature.

 

8. Faster if they feel better as they decrease dose.

 

9. Longer if they have difficulty with dosage decreases.

 

10. Longer if they are doing relatively well.

 

11. Never decrease before a major event or holiday.

 

12. Avoid decreasing during times of major stress.

 

13. The pt can take longer if they want to take longer for any reason.

 

14. Reduce in the smallest possible increments. As you approach zero then take the dose changes smaller or longer. Get out that pill cutter. If you can’t get dosage changes in small enough changes do every other day between the smaller dose and the larger dose. You would be surprised how often this works even on very short half-life drugs like Effexor XR.

 

15. You can go faster if they feel better as they decrease dose, but not too fast. Look for signs and symptoms of mania as well as depression. I have seen both hypomania and even mania in a [patient with Bipolar II] who stopped their antidepressant without taper. This has been reported in the literature as well. Going down slowly also avoids manic reactions

 

C. Special Rules:

 

1. Effexor XR. If the pt can tolerate doing this then this is by far the best way to do this. Open up the capsule and take one more bead out each day. Rules 11 – 13 of how to get off antidepressants apply. Pour the beads out on a creased piece of paper and count out the correct amount of beads. Then using the crease of the paper to get the beads back in the capsule. [in my town I have the advantage of a compounding pharmacist who can make small doses from the patient's large doses and allow us to decrease

 

2. If pts can’t count beads or don’t want to do this then take out about ¼ capsule for 6 – 8 weeks and repeat.

 

3. For any anti-depressant you can add in 20 mg of Prozac, get them off the anti-depressant, then taper the Prozac.

 

4. Prozac is a special case because of its long half-life. I generally will drop of one day at a time when reducing dose, e.g. decrease to 6/7 days a week for 6- 8 weeks then decrease to 5/7 days a week. Prozac is also a good candidate for every other day decreases, e.g. from a dose of 40mg a day go to 20 alternating with 40 mgs a day [to make a 30 mg-equivalent dose].

(ADMIN NOTE I have since informed Dr. Phelps of ways to titrate Prozac that do not depend on the capsule dosages supplied by the manufacturer. DO NOT SKIP DOSAGES TO TAPER FLUOXETINE. We have plenty of people here who have triggered severe withdrawal syndrome by skipping doses, even of Prozac. See Tips for tapering off Prozac (fluoxetine)  )

 

Note: I disagree with the info on Dr. Phelps's site describing the biologic basis of mood disorders; please don't send me outraged pms and e-mails.

Edited March 17, 2019 by Altostrata
Added admin note

[alexjuice]

This makes me think of PSSD.

 

Heard of any shop talk going round the doc circuit on this one? Are there serious people working on prolonged sexual dysfunction? Maybe someone will come up with something. If some, even episodically, useful intervention is uncovered it should buzz virally through all the channels that inform shrinks.

 

Hey Doctors: I can measure my erection or lack thereof with more precision and reliability than you can measure my functioning by way of a freaking GAF score. (Honestly, I thought GAF scores were for disability claims and nothing else, but maybe no. I looked at the scoring criteria just now and, listen, if I scored myself I'd move +/- 10 GAF points depending on the hour. My sexual problems are more static.)

 

Anyway, not to digress, the big news (docs talking sensibly) is good news. Good on Drs. Phelps and Kelly.

 

Alex

[Rhiannon]

Sounds like they've been reading Internet forums.

[Altostrata]

They say they've made observations in their own practices.

 

Alex, other than Bahrick, Csoka, etc., I haven't heard of any new info about PSSD.

[Altostrata]

This paper, 2011 Tapering antidepressants: Is 3 months slow enough? is the outcome of the above discussion between Drs. Phelps and Kelly.

[Brandy]

Glad they're starting to catch on, but unfortunate that they recommend every other day dosing/alternating doses.

[Altostrata]

Glad they're starting to catch on, but unfortunate that they recommend every other day dosing/alternating doses.

 

Only at the very end, when it may not be practical to cut pills anymore and some people just hop off anyway.

 

Alternating dosages at the beginning of the taper, when doses are larger, really does seem to be very dangerous.

[Barbarannamated]

Getting off Antidepressants

#5 Warn people that they will have mood swings …if they do this …if they don't do this …

 

Excellent point for Antidepressants in any case -

[Nikki]

6. Slowly is best. The slower the better. I usually wait ... at least 6 – 8 weeks between dosage decreases. Prozac/fluoxetine can be an exception to this.

 

7. Longer if anxiety is a major feature.

 

8. Faster if they feel better as they decrease dose.

 

9. Longer if they have difficulty with dosage decreases.

 

10. Longer if they are doing relatively well.

 

11. Never decrease before a major event or holiday.

 

12. Avoid decreasing during times of major stress.

 

13. The pt can take longer if they want to take longer for any reason.

 

Can I ask about #8...If someone is taking too much of a medication, and they decrease, is there WD symptoms or do they just feel a little better?

 

When I was up to 30mgs. of Celexa and down to 12.50 mgs. of Imipramine for the crossover I felt the best I felt in a long time.

 

Now I am off Imipramine, on 40mgs. of Celexa and I went thru a hellacious time, which is starting to abate. I don't know if it was finishing Imiprammine - or - if i am on too much Celexa....

 

Any ideas?

 

Hugs

[bubbles]

I don't know, Nikki, but I'm feeling better as I decrease. I had a few minor w/d (parasthesia, craving for the drug) in the first couple of drops, but nothing since then.

 

Bye

Bubbles

[Nikki]

Bubbles you are dropping 1mg. at a time and you are doing well. Was Lexapro the only AD yoy have used?

 

I am seriously wondering if the 40mgs. may be too much. I have alot of anxiety producing issues going on, so I am not sure what I should do.

 

While withdrawing from Lexapro I remember feeling better for some reason when I got down to 15mgs, so I stayed there for a few months.

 

I can't distinguish between the stressors vs. the medications.

 

Hugs

[Altostrata]

....

8. Faster if they feel better as they decrease dose.

....

Can I ask about #8...If someone is taking too much of a medication, and they decrease, is there WD symptoms or do they just feel a little better?

 

When I was up to 30mgs. of Celexa and down to 12.50 mgs. of Imipramine for the crossover I felt the best I felt in a long time.

 

Now I am off Imipramine, on 40mgs. of Celexa and I went thru a hellacious time, which is starting to abate. I don't know if it was finishing Imiprammine - or - if i am on too much Celexa....

 

Any ideas?

 

Hugs

 

Nikki, if the dosage is too high and producing an adverse reaction, people need to decrease. It's possible to have an adverse reaction and withdrawal symptoms as you decrease, but you need to do it

 

....

I am seriously wondering if the 40mgs. may be too much. I have alot of anxiety producing issues going on, so I am not sure what I should do.

 

While withdrawing from Lexapro I remember feeling better for some reason when I got down to 15mgs, so I stayed there for a few months.

 

I can't distinguish between the stressors vs. the medications.

 

Hugs

 

40mg Celexa is the maximum dosage. It is entirely possible it is too high.

 

Tricyclics such as imipramine are weaker than SSRIs. Substituting 40mg Celexa for 200mg imipramine may be overshooting the equivalence.

 

If I were you, I would try a very slow, careful reduction of the Celexa.

[Nikki]

Thank you Alto....In other words 40mgs.is so much more than 200mgs. Imipramine.I get what you are saying about over shooting.

 

40 may just be too much. To get down to 30 I would have to begin a very slow, very tiny drop taper?

 

I actually know a Chemo Infuion Nurse who has Lupus and takes 70mgs. Celexa. I can't even imagine how a physician could prescribe 70mgs.

 

Hugs

[Altostrata]

The FDA has just issued a warning about high-dose Celexa and heart problems. It is not to be prescribed in doses higher than 40mg.

 

Nikki, see Tips for tapering off Celexa (citalopram) It comes in a liquid form for tapering.

[bubbles]

Nikki,

 

Yes, I am dropping 1mg at a time at present. The first drop was 2mg, but now 1mg more often. In fact, I'm considering changing that to 1/2 mg more often as I can do this easily with the liquid. As I get down further that will need to be smaller drops less often, but for now I'm still on a pretty high dose so 1/2-1mg drop seems to be a good way to go. Lexapro was the only AD I've tried.

 

I don't know what it means, feeling better with every drop. I feel as though my mood rises with each drop - a bit of a "high" I guess (though just a normal high, if you kwim) and then settles back to just feeling well. I don't know if it is real, or just a bit of elation - "huh! take that! I'm taking even less".

 

Best wishes

Bubbles

[bubbles]

Sorry, forgot, I took St John's Wort for a year before starting the Lexapro.

Bubbles

[dalsaan]

Hi

 

Does the Prozac switch only work if you are on another drug in it's same class with a shared mode of action? I have been contemplating this but am worried if I switch and it doesn't work I will be in a worse place than I am now and Mirtazapine is not an ssri It's a NASA (sends you into outer space with no way back. Huston we've got a problem)

 

Dalsaan

[Barbarannamated]

Hi

 

Does the Prozac switch only work if you are on another drug in it's same class with a shared mode of action? I have been contemplating this but am worried if I switch and it doesn't work I will be in a worse place than I am now and Mirtazapine is not an ssri It's a NASA (sends you into outer space with no way back. Huston we've got a problem)

 

LOL!!!

[Altostrata]

Sorry, I don't know, Dalsaan.

[dalsaan]

Thanks Alto. I'll see if I can find anything out and post if I do

[Nikki]

Nikki,

 

Yes, I am dropping 1mg at a time at present. The first drop was 2mg, but now 1mg more often. In fact, I'm considering changing that to 1/2 mg more often as I can do this easily with the liquid. As I get down further that will need to be smaller drops less often, but for now I'm still on a pretty high dose so 1/2-1mg drop seems to be a good way to go. Lexapro was the only AD I've tried.

 

I don't know what it means, feeling better with every drop. I feel as though my mood rises with each drop - a bit of a "high" I guess (though just a normal high, if you kwim) and then settles back to just feeling well. I don't know if it is real, or just a bit of elation - "huh! take that! I'm taking even less".

 

Best wishes

Bubbles

 

 

Bubbles this happens to me. A bit of a "high" for lack of a better word and then it settles down after a day or so. When this happens I know I will have insomnia.

It's almost like drinking too much coffee.

 

I 'think' I may be able to take slightly larger cuts in dose @ this time.

 

Thanks Bubbles

[jr1985]

 

Nikki,

 

Yes, I am dropping 1mg at a time at present. The first drop was 2mg, but now 1mg more often. In fact, I'm considering changing that to 1/2 mg more often as I can do this easily with the liquid. As I get down further that will need to be smaller drops less often, but for now I'm still on a pretty high dose so 1/2-1mg drop seems to be a good way to go. Lexapro was the only AD I've tried.

 

I don't know what it means, feeling better with every drop. I feel as though my mood rises with each drop - a bit of a "high" I guess (though just a normal high, if you kwim) and then settles back to just feeling well. I don't know if it is real, or just a bit of elation - "huh! take that! I'm taking even less".

 

Best wishes

Bubbles

 

 

Bubbles this happens to me. A bit of a "high" for lack of a better word and then it settles down after a day or so. When this happens I know I will have insomnia.

It's almost like drinking too much coffee.

 

I 'think' I may be able to take slightly larger cuts in dose @ this time.

 

Thanks Bubbles

 

Maybe it's dopamine rebound? SSRI are known to suppress dopamine, so as you drop the dose there could be a surge in dopamine, which causes this "high"?

 

I had it when I fast tapered the first time, and during my first 5% cut.

[Barbarannamated]

Defintely part of the neurotransmitter 'soup', IMHO. Death of pleasure courtesy of serotonin. I remember when my tastebuds seemed to wake up. I realized I hadn't enjoyed the taste of food for years. Every aspect of existence has been blunted, dulled.

 

Dopamine fluctuation could THEORETICALLY account for movement disorders, bruxism, RLS.

[jr1985]

I found this - "Citalopram-induced jaw tremor"

 

"citalopram-induced jaw tremor can be explained by an indirect inhibitory effect on central dopaminergic activity."

 

http://www.clineu-journal.com/article/S0303-8467(04)00015-0/abstract

 

It makes sense, as my "high" seemed to correlate with a decrease in jaw tremors.

 

I suspect, in my case, the dopamine inhibition causes the dopamine receptors to unregulate, so when you make a cut and dopamine is "less inhibited" there is a spike in dopamine activity, which causes the high and improved tremors. Then the dopamine receptors downregulate in response to the surge in activity, so the high disappears and the tremors return. It's all speculation, of course, but it makes sense to me. I'm hoping once I get to lower doses/off completely that the tremors will disappear.

[Altostrata]

Remember, there are dozens of neurotransmitters in the brain, and many of them haven't been identified yet.

[hermitical]

On Dr Phelps page there was a final special rule not quoted on this thread:

 

5. Every other day dosing of a medicine often work when reducing doses even when the pharmacology ("half life") suggests it shouldn't work. [i asked: Dr. Kelly has indeed used this technique for both duloxetine/Cymbalta and venlafaxine/Effexor, two of the trickier ones to taper. He says it works there too. ]

This seems to go against many people's stories? Can anyone comment?

[Altostrata]

You have to ask how they chose their sample of subjects to try this on. There may have been people with rubber brains in the group, who would have done okay with any kind of tapering schedule.

 

Why dose every other day when you can dose every day and not risk destabilizing the nervous system?

[hermitical]

thanks for clearing that up...

 

I'm going to be trying to come off Duloxetine (Cymbalta) soon so I'm trying to scour the forums for advice. I desperately want a quick way of doing it but looks like there isn't one...