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Groot, 2018 Antidepressant tapering strips to help people come off medication more safely

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Addax
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ADMIN NOTE Also see

 

Netherlands organization is producing tapering kits

 

Petition calling for tapering kits in the UK

 

Daily Mail: Tens of millions of Americans are struggling to get off antidepressants - and going to extreme lengths to quit

 


 

Antidepressant tapering strips to help people come off medication more safely

Peter C. Groot & Jim van Os

Received 30 Mar 2018, Accepted 22 Apr 2018, Published online: 24 May 2018

 

Abstract and full text at https://www.tandfonline.com/doi/full/10.1080/17522439.2018.1469163

 

Antidepressants are commonly prescribed for many mental disorders, including psychosis. Withdrawal effects, resulting from inappropriately short duration of tapering or lack of flexibility in prescribing gradual reduction, are common. An observational study was conducted of the use of “tapering strips”, which allow gradual dosage reduction and minimise the potential for withdrawal effects. A tapering strip consists of antidepressant medication, packaged in a roll of small daily pouches, each with the same or slightly lower dose than the one before it. Strips come in series covering 28 days. Of 1194 users of tapering strips, 895 (75%) wished to discontinue their antidepressant medication. In these 895, median length of antidepressant use was 2–5 years (IQR: 1–2 years– > 10 years). Nearly two-thirds (62%) had unsuccessfully attempted withdrawal before (median = 2 times before, IQR 1–3). Almost all of these (97%) had experienced some degree of withdrawal, with 49% experiencing severe withdrawal (7 on a scale of 1–7, IQR 6–7). The most common medications were paroxetine (n = 423, 47%) and venlafaxine (n = 386, 43%). Of the 895 wishing to discontinue, 636 (71%) succeeded in tapering their antidepressant medication completely, using a median of 2 tapering strips (IQR 1–3) over a median of 56 days (IQR = 28–84). Tapering strips represent a simple and effective method of achieving a gradual dosage reduction.

 

 

Edited by Altostrata
put in Journals format, added admin note

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Barbarannamated
2 hours ago, Addax said:

"Antidepressants are commonly prescribed for many mental disorders, including psychosis."

 

I apologise for this tangent up front...

 

This opening statement by the study author (not Addax!) is disturbing on a few levels.  

 

1) the term "mental" has become ubiquitous.  When did "emotion", "mood", and even "depression" become *mental* ?  Is everyone taking an antidepressant or going to therapy "mentally ill"??   People refer to their own depressive or anxious feelings as "mental illness" quite frequently.  I'm not sure, but I believe "mental illness" used to refer only to psychosis / loss of touch with reality. 

 

2) when are antidepressants RX'd for psychosis??  I worked with psychiatrists /pharmacology for many years and have never seen this, unless it is part of a cocktail.  If anything, they are known to CAUSE psychosis.  

 

I'm sure this reactive comment belongs elsewhere.  Mods, please relocate at your discretion.  

 

Thank you for the article, Addax. 

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Altostrata

From the paper:


 

Quote

 

Methods

....

A tapering strip consists of antidepressant medication, packaged in a roll or strip of small daily pouches. Each pouch is numbered and has the same or slightly lower dose than the one before it. Strips come in series covering 28 days and patients can use one or more strips to regulate the rate of dose reduction over time. Dose and day information printed on each pouch allow patients to precisely record and monitor the progress of their reduction (Groot, 2013 Groot, P. C. (2013). Tapering striptapering strips for paroxetine and venlafaxine. Tijdschrift voor Psychiatrie, 55(10), 789–794 (article in Dutch, English version retrieved from http://bit.ly/729PaY787F[PubMed], [Google Scholar]). Here, we report on the experience of 1194 users of psychotropic tapering strips in the Netherlands, who responded to routine and anonymous quality assessment follow-up questionnaires which, at the request of Cinderella, were sent by the Rainbow Pharmacy to patients who had used tapering strips (n = 1750, response rate 68%). Participants who had previously tried to stop taking their antidepressants were asked to respond to the question ‘Did you experience withdrawal symptoms?’ on a seven point scale with anchor points of 1 = ‘not at all’ and 7 = ‘very much’.. Patients were given information about the purpose of the questionnaire and were considered to provide consent by sending back a completed questionnaire.

....

Results

Of the 1194 users of tapering strips, 1121 had used the strips for tapering antidepressant medications, whereas 73 had used them for other medications. Of the 1121 who used the strips for reducing antidepressant medications, 895 (80%) indicated they had specifically wished to discontinue their antidepressant medication, 118 (11%) wanted to reduce the dose of their antidepressant medication, 18 (2%) used the strip for other reasons and 90 (8%) had missing values. Of the 1121, 692 (62%, 97 with missing data) had unsuccessfully attempted withdrawal before. Of these 692 almost all (97%) had experienced some degree of withdrawal (2–7 on the seven point scale), with 339 (49%) reporting the most extreme of the six levels of withdrawal (7 = ‘very much’). In the 895 who had used the strips specifically to discontinue their antidepressant medication, median length of antidepressant use was 2–5 years (Interquartile range [IQR]: 1–2 years - >10 years). Two-thirds (66%) had unsuccessfully attempted withdrawal before (median=2 times before, IQR 1–3), with 51% reporting the most extreme of the six levels of withdrawal (7 = ‘very much’). The most common medications were paroxetine (n = 423, 47%) and venlafaxine (n = 386, 43%). Of the 895 wishing to discontinue, 636 (71%) succeeded in stopping their antidepressant medication entirely, using a median of 2 tapering strips (IQR 1–3) over a median of 56 days (IQR = 28–84). A total of 67 (8%) said they were still trying to stop their medication using further tapering strips. They had used a median of 2.5 tapering strips (IQR 1–4) over a median of 70 days (IQR 28–112).

 

Of the 192 (21%) who had not succeeded in stopping their antidepressant medication and were not attempting further tapering, 39 (4%) indicated this was because of severe withdrawal symptoms and 53 (6%) because of re-emergence of symptoms associated with the mental disorder. The 192 had used a median of 3 tapering strips (IQR 2–4) over a median of 84 days (IQR 56–112).

....

Discussion

In conclusion, this is the first study shedding light on the likelihood of being able to discontinue antidepressant medication in those who previously failed because of severe withdrawal symptoms. The results indicate that a very large proportion of these individuals can be successfully withdrawn from antidepressants using tapering strips.

....

 

I have been communicating with Dr. Groot for several years. I've asked him for clarification of the tapering schedule embedded in the graduated dosages in the tapering strips.

 

I am particularly interested in the 21% who found tapering with the strips to be intolerable. It could be they need a more gradual tapering schedule. (I am wondering how many of those who thought they had a reemergence of a prior psychiatric conditions actually had withdrawal symptoms, as the two are easily confused.)

 

Also see our prior discussions Dutch organization is producing tapering kits

 

Petition calling for tapering kits in the UK

 

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bubbles

I am also interested in that 21% - especially that 6% that interpreted effects as the return of their illness. It may have been, but there is no way to tell that, so at the very least I think it is necessary to have a high level of suspicion that it was simply withdrawal. That 4%, as far as I can see, at least accurately identified their symptoms as to do with withdrawal from the drug.

 

My other reservation is to do with follow up. Unless they've followed up at one or two years and found people to be well, I'm not very convinced about the success *or otherwise* of the taper. I don't see evidence of that in the paper.

 

I've seen an awful lot of youtube videos with people who've done a rapid taper of an SSRI like that (admittedly often not a proper taper), declared themselves well, then you fast forward a year or so into their videos and find that they're on another drug - they've crashed a few months out. Or worse, they have a shiny new diagnosis. Unless there is something specific about this taper that compensates for the rapidity of the taper that we don't know, I am not yet convinced.

 

Still, the strips are probably a great idea. Could it be possible to use those tapering strips to do a more appropriate taper? You could get, say ten or twenty strips and use them all - pill one in turn from each of the ten or twenty strips, then pill two in turn from each of the ten or twenty strips. Or thirty strips... Etc. It could save all that compounding, making liquids, measuring, calculating...

 

So, I think this is one step forward, but I'm not convinced *yet*. I do think that, once an appropriate tapering speed is identified, it should be compulsory for all manufacturers of all psychoactive drugs to produce these tapering kits. I wonder how expensive they'd be.

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Altostrata

I have been corresponding with Dr. Groot for years. I asked him for clarification of the tapering schedule in the strips. His response:

 

Quote

We have tried to make this clear in our 'treatment guidelins or the use of tapering strips' (Figure 2). [pdf]

 

As I understand the treatment guidelines, the physician and patient are to decide how long the taper will take, and the graduated strips will be composed accordingly. (I believe this can be changed month to month, which is reasonable.) Rather than a 10% or 5% (or other) decrease once a month, within a month, doses more or less decline slightly every day -- which corresponds to a laudable microtaper.

 

Here is Figure 2

 

17_groot_Guideline_Tapering_Strip_figure2_schedule.png

 

Dr. Groot also told me:

 

Quote

I am aware of the discussions on [SurvivingAntidepressants]. In fact, one of the comments on your website has been extremely helpful for us and has changed my way of thinking. After we presented the first tapering strip I got the comment that what I was doing was great but that tapering paroxetine from a dose of 20 mg in 1 month was way too fast. After my initial disappointment about this comment (I had been working so hard to work out this scheme) I realized that the schedule we proposed could work for some patients (as it turns out probably only for a very small minority), but not for others. As a result, I started thinking about a more flexible solution, beginning with the addition of a very limited number of extra strips, and finally resulting in the very flexible system that is now in place.

 

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bubbles

Wonderful!

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bubbles
Quote

I am aware of the discussions on [SurvivingAntidepressants]. In fact, one of the comments on your website has been extremely helpful for us and has changed my way of thinking. After we presented the first tapering strip I got the comment that what I was doing was great but that tapering paroxetine from a dose of 20 mg in 1 month was way too fast. After my initial disappointment about this comment (I had been working so hard to work out this scheme) I realized that the schedule we proposed could work for some patients (as it turns out probably only for a very small minority), but not for others. As a result, I started thinking about a more flexible solution, beginning with the addition of a very limited number of extra strips, and finally resulting in the very flexible system that is now in place.

 

Actually, this is more than wonderful. Someone is (a) listening to us and (b) trying to help us. I'd like to give these people medals/knighthoods/sainthoods.

 

 

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bthate

Taperingstrips made by psychiatrist to get people of the drugs they put them on might sound like they are 1) finally listening to their patients and 2) are finally trying to help them, the fact is that they are not informing their patients properly. They forget to mention the "damaging character" of their product namely 1) they are toxic 2) the are addictive (something all patients find out sooner or later).

 

Not informing a buyer the damaging character of the product is a crime that can get you 15 years here in the Netherlands (30 is someone dies from it).

 

Doctors should inform you the medicine i a toxic substance.

Doctors should inform you that their medicine are addictive. Not in the sense that you want more and more of it, but in the sense of addictive that you get sick if you don't use them

Doctors should inform you that they commit a crime if they prescribe these substances and therefor won't

fluoxetine.jpg

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Altostrata

This tapering strips are for people already taking the drugs for quite a while. The time to inform them the drugs are harmful is long past. It should have been done with the initial prescriptions.

 

Perhaps in the Netherlands, rules about informed consent are stricter, but in the US, the responsibility for informing patients falls to the inserts in the drug packages. Patients are supposed to read and understand those warnings in tiny print before they take the drugs.

 

It would be an extraordinary US doctor who tells patients in advance of the worst adverse effects of a psychiatric drug. As best, most would say serious side effects are very rare, the usual side effects are mild and go away quickly -- then they would ignore any problems.

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RealMe
On 6/1/2018 at 8:51 PM, Altostrata said:

As best, most would say serious side effects are very rare, the usual side effects are mild and go away quickly -- then they would ignore any problems.

The only side effects I was ever warned of were "dry mouth and a little weight gain which could be controlled by diet and exercise."  If I had known the serious side effects of the medications I took, I would have refused to take them.  That is why the doctors minimized or failed to mention the serious side effects.

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Altostrata

Whenever you hear a psychiatrist talk about "access," what is meant is "we cannot let information about adverse effects discourage people from taking these so very beneficial drugs."

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Terry
4 hours ago, RealMe said:

The only side effects I was ever warned of were "dry mouth and a little weight gain which could be controlled by diet and exercise."  If I had known the serious side effects of the medications I took, I would have refused to take them.  That is why the doctors minimized or failed to mention the serious side effects.

 

It looks like you are doing a quicker taper than some.  How is that working for you?  I did that for a while, but started experiencing more WD symptoms, so have started slowing down my taper.  Wishing you well!

 

 

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RealMe

Hi Terry,

 I started withdrawing from psychiatric medications in August of 2017 before I found this forum.  By the time I found SA, I was down to prozac 10mg .  So far I am doing ok.  My tapering reductions are 10%, and I hold for two weeks or more.  If my symptoms worsen or feel intolerable, I hold till I feel stable again.   I am definitely experiencing windows and waves, but my overall picture is one of improvement.  From what I have read here, WD symptoms are not the same for everyone or for every medication.

Best wishes for healing,

RM

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