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A Method for Tapering Antipsychotic Treatment That May Minimize the Risk of Relapse Mark Abie Horowitz, Schizophrenia Bulletin, Volume 47, Issue 4, July 2021, Pages 1116–1129, https://doi.o


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A Method for Tapering Antipsychotic Treatment That May Minimize the Risk of Relapse 

Schizophrenia Bulletin, Volume 47, Issue 4, July 2021, Pages 1116–1129, https://doi.org/10.1093/schbul/sbab017
23 March 2021


Hi I found this article while searching google scholar! It highlights some important stuff that many on here learned the hard way (including me). There are some info graphs that are interesting about dose occupancy and what types of symptoms of withdrawal correspond to the parts of the brain which I thought was helpful. There's some good nuggets in here so just ignore the bits of psychiatrist jargon that's in there.


Here's the abstract:


The process of stopping antipsychotics may be causally related to relapse, potentially linked to neuroadaptations that persist after cessation, including dopaminergic hypersensitivity. Therefore, the risk of relapse on cessation of antipsychotics may be minimized by more gradual tapering. There is converging evidence that suggests that adaptations to antipsychotic exposure can persist for months or years after stopping the medication—from animal studies, observation of tardive dyskinesia in patients, and the clustering of relapses in this time period after the cessation of antipsychotics. Furthermore, PET imaging demonstrates a hyperbolic relationship between doses of antipsychotic and D2 receptor blockade. We, therefore, suggest that when antipsychotics are reduced, it should be done gradually (over months or years) and in a hyperbolic manner (to reduce D2 blockade “evenly”): ie, reducing by one quarter (or one half) of the most recent dose of antipsychotic, equivalent approximately to a reduction of 5 (or 10) percentage points of its D2 blockade, sequentially (so that reductions become smaller and smaller in size as total dose decreases), at intervals of 3–6 months, titrated to individual tolerance. Some patients may prefer to taper at 10% or less of their most recent dose each month. This process might allow underlying adaptations time to resolve, possibly reducing the risk of relapse on discontinuation. Final doses before complete cessation may need to be as small as 1/40th a therapeutic dose to prevent a large decrease in D2 blockade when stopped. This proposal should be tested in randomized controlled trials.



Link to full article: https://academic.oup.com/schizophreniabulletin/article/47/4/1116/6178746


Excerpts (bold type mine):


"Standard guidelines do not mention antipsychotic deprescribing,70 or tapering,71although some current guidelines encourage reduction to minimum effective doses without specifying how to do so.72,73 The principal means to mitigate withdrawal symptoms is to reduce the rate at which the equilibrium is disturbed, so allowing time for the reversal of underlying neuroadaptations to return to baseline.16,70,74Gradual tapering of antipsychotics, when cessation is the goal, is sometimes advised on this principle.56,70,74 Tapering may reduce the likelihood and intensity of withdrawal symptoms, including, potentially, the risk of withdrawal psychosis.70,74

The persistence of TD, the most visible manifestation of dopaminergic hypersensitivity,75 for a considerable time following cessation of antipsychotics, provides evidence that neuro-adaptations to antipsychotics persist for many years and supports the need for long tapering. An early review of studies found that it took 2–5 years for 60%–90% of symptoms of TD to resolve following antipsychotic cessation (supplementary table S1).76 Another study found that 92.8% of patients achieved a 50% reduction in TD symptoms 46 weeks after discontinuing on average 10 years of antipsychotic treatment.77 "


"Indeed, even reductions from 0.5 mg of haloperidol (the smallest available tablet) to 0 mg will produce a reduction in D2 antagonism of 40.0 percentage points, and reduction from 0.25 mg (half the smallest tablet) to 0 mg will produce a 25.5 percentage point reduction (larger than the change from 20 to 2 mg [19.6 percentage points]); this may account for the relative ease of reductions at higher doses of antipsychotic and the difficulties in tapering at lower doses.45,51,74 


"Given that reduced antagonism of D2 dopaminergic receptors has been implicated in many of the withdrawal phenomena attributed to antipsychotics, including psychotic symptoms,17,20,23 we suggest that tapering regimes should aim to reduce D2receptor antagonism in a linear fashion with adequate time provided in between dose reductions to allow adaptation to lower doses of the drug, as this may produce more “evenly spread” perturbations to the system, which may minimize withdrawal-associated effects (figure 3).16,99 "




2006 - 13 years old: put on Lamictal (had previously been exposed to Lexapro but taken off)

sometime around 2007 or 2008 put on Wellbutrin  and Seroquel

2011 December put on Zipraisidone (Geodon)  at mental institution (voluntarily there for depression)

sometime later 2012 maybe? put on small dose of Lithium

2018 had long psychotic episode but no hospitalization. Old psych put on Vraylar and took off Geodon not taking Seroquel anymore for a while, then saw new psych Dr. B. Took off Lithium and Seroquel, dosed Wellbutrin down to 300 mg from 450 mg

2019 then taking Lamictal 300 mg, Wellbutrin 300 mg, tapered off 6mg Vraylar (on my own) too fast! 

June 2019 hospitalized for psychosis put on Haldol 5 mg and Seroquel 400 mg. Saw psych Dr. B after hospital, took off of Wellbutrin 300 mg and put back up on Lamictal 300 mg(hospital took down to 50 mg) 400 mg to 300 mg Seroquel and Haldol tapered to 2 mg. By end of year on 0.5 mg Haldol.

December 2019-July 2020 tapered too fast no symptoms except...

July 2020 hospitalized while on vacation at the beach. Put on 900 mg Lithium and 30 mg Olanzapine and (?mg) Propanolol. Told the Propanolol was for anxiety, (once home) wasn't anxious so stopped Propanolol and started getting akathisia. Tapered down from 20 to 10 or 15 (not sure...) mg Olanzapine and...

November 2020 starting seeing new psychiatrist Dr. D. He took me down to 10 mg Olanzapine and over two years down to 7.5 mg then 5 mg. And reduced Lithium to 600 mg a day.

Currently: taking a divided dose of Lithium 300 mg a.m. and 300 mg p.m. along with 5 mg Olanzapine p.m. Doing well.


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Previous publication, and topic here:

This one is dated March 23, 2021

(I need to study them a bit more to see if there are differences between the 2, ??)

Late 2023- gone to emeritus status, inactive, don't @ me, I can check who I've posted on, and I'm not really here like I used to be......thanks.

Started with psycho meds/psychiatric care circa 1988.  In retrospect, and on contemplation, situational overwhelm.

Rounding up to 30 years of medications(30 medication trials, poly-pharmacy maximum was 3 at one time).

5/28/2015-off Adderal salts 2.5mg. (I had been on that since hospital 10/2014)

12/2015---just holding, holding, holding, with trileptal/oxcarb at 75 mg. 1/2 tab at hs.  My last psycho med ever!  Tapered @ 10% every 4 weeks, sometimes 2 weeks to

2016 Dec 16 medication free!!

Longer signature post here, with current supplements.

Herb and alcohol free since 5/15/2016.  And.....I quit smoking 11/2021. Lapsed.  Redo of quit smoking 9/28/2022.  Can you say Hallelujah?(took me long enough)💜

None of my posts are intended as medical advice.  Please discuss any decisions about your medical care with a knowledgeable medical provider.  My success story:  Blue skies ahead, clear sailing


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