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JimH

Calculators to help you create your own taper plan

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JimH

Hi,

 

You need a taper plan for your antidepressant(s) or benzodiazepine(s) and you don't know how to start? How about create by yourself your own taper plan? If you want to see how your possible taper plan may look like, have a look to the following online planners:

- For antidepressants users: http://antdep.alwaysdata.net/

- For benzodiazepines users: http://benzo.alwaysdata.net/ and the related video: 

 

Have a look to the Help section first.

 

Hope it can help.

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Altostrata

Thanks, Jim. This looks very full-featured.

 

Observations:

  • Use slower music without prominent percussion, like meditation music. People whose nervous systems are sensitized will have a hard time with peppy music.
  • Don't understand what "Daily Dose(s) in Taper Order" means. Label needs clarification. "Daily Dosage Schedule" might work. Adding a field for time of day might be even more helpful in the pdf version.
  • Thanks for including calculations for making your own liquid.
  • The graph is nice, but you'll want as flat a curve as practical. Our guess is 10% is the default.
  • We recommend a basic taper schedule of 10% per month, calculated on the last dosage. Most people can tolerate this. Some need smaller percentage reductions, and an even smaller number need micro-tapering on personalized schedules.
  • If you are dosing more than once a day, side effects determine which dose you'll want to eliminate first. For example, if you're getting paradoxical reactions from a benzo dose, you may want to reduce all of the daily doses at the same rate.

 

We have a couple of people here who are interested in calculator development, @DoctorMussyWasHere @DanS

 

@Shep @brassmonkey what do you think?

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JimH
38 minutes ago, Altostrata said:
  • Use slower music without prominent percussion, like meditation music. People whose nervous systems are sensitized will have a hard time with peppy music.

No comment.

 

39 minutes ago, Altostrata said:
  • Don't understand what "Daily Dose(s) in Taper Order" means. Label needs clarification. "Daily Dosage Schedule" might work. Adding a field for time of day might be even more helpful in the pdf version.

This goes together with the option Taper Order: First dose first / Across doses. When First dose first is selected the first dose in the  "Daily Dose(s) in Taper Order" will be tapered first. When it extinguishes then the second dose in this list will start and so on. As taperer can decide to taper whatever dose of the day in the order he/she wishes (Ex: midday, morning, night), the app asks for the desired taper order . When Across doses is selected all doses are tapered together and will extinguish together. 

 

47 minutes ago, Altostrata said:
  • ...but you'll want as flat a curve as practical....

Could you please better explain?

 

48 minutes ago, Altostrata said:
  • We recommend a basic taper schedule of 10% per month, calculated on the last dosage. Most people can tolerate this. Some need smaller percentage reductions, and an even smaller number need micro-tapering on personalized schedules.

This seems to be what has been implemented as default approach for this site. As a matter of fact, the curve is a hyperbole and not a straight line when a percent is used. But perhaps you intended something else? For information the default approach used in benzobuddies.org is fixed quantity reduction that leads to a straight line.

 

55 minutes ago, Altostrata said:
  • If you are dosing more than once a day, side effects determine which dose you'll want to eliminate first. For example, if you're getting paradoxical reactions from a benzo dose, you may want to reduce all of the daily doses at the same rate.

See point 2.

 

56 minutes ago, Altostrata said:

We have a couple of people here who are interested in calculator development, @DoctorMussyWasHere @DanS

 

@Shep @brassmonkey what do you think?

Good.

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Altostrata

Correct, the 10% curve is hyperbolic, the amount of decrease gets smaller and smaller at time goes on.

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ChessieCat
14 minutes ago, JimH said:

Could you please better explain?

 

This is what a 10% reduction of current dose every 4 weeks looks like:

 

post-5985-0-07114400-1496291012_thumb.jp

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JimH

How about this?

 

image.thumb.png.c17fd50e6fd77503bd26f90ee7ec005e.png

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Cleerity

The two graphs/methods above appear to be accomplishing the same thing.  While I am not certain, I make the assumption that in the first graph, the user makes a full 10% cut (?) and maintains that dose for four weeks before repeating the cut and hold.  In using the method in the second graph, the user is spreading the 10% cut over the 28 day period and just keeps moving along making the more minuscule cuts.

 

Is one method more preferable to another?  

 

 

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JimH

Hi Cleerity,

 

1 hour ago, Cleerity said:

... I make the assumption that in the first graph, the user makes a full 10% cut (?) and maintains that dose for four weeks before repeating the cut and hold.  In using the method in the second graph, the user is spreading the 10% cut over the 28 day period and just keeps moving along making the more minuscule cuts.

This is my understanding too when I saw the graph from ChessieCat . That strongly reminds me of what I know as "Cut & Hold" method where the quantity of drug  planned to be reduced during 4 weeks suddenly get cut away from one day to another. As the cut is abrupt, symptoms might kick in. Amid symptoms taperer holds waiting for the storm to pass. When after 4 weeks user get stabilized then hop! another sudden cut again and the  'hiccup' pattern starts again.

 

The reduction as shown in the second graph is a daily taper. That means the quantity of drug  planned to be reduced during 4 weeks will be equally spread to each of the 28 days and the dose of each day is always lower then the previous day. The jump between each dose will be limited to 1/28 cut compared to the previous method where there is an important initial cut followed by 27 days of zero-cut to give time to the body to catch up with the initial cut.

 

1 hour ago, Cleerity said:

Is one method more preferable to another?

In my humble opinion, the method that consistently lowers your dose with manageable symptoms is the preferred one.

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Altostrata

You can make a mini-taper reduction every day, but some people will find the calculations and measuring to be too onerous to do every day, or get confused. So a monthly schedule will suit them better, if their nervous systems adapt well to a 10% increase all at once.

 

A tiny decrease every day will give you a smoother curve, which is desirable for those whose nervous systems are sensitive to 10% monthly decreases.

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Shep

Jim, thank you for the work and care you've put into this. 

 

I noticed at the lower right hand corner of the app itself, as well as in several places in the video, the narrative states, "The recommendations are to reduce the daily doses between 5-10% every 10-14 days to minimize withdrawal symptoms."   That could mean going as fast as 10% every 10 days, which is 30% in a month. 

 

This is far faster than the 10% per month recommended here on SA. 

 

Of course, the app will display whatever the user enters for the taper rate and time period, but I did want to point this out for members and guests who may view the video and set their taper up using the information noted as being "recommended". 

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JimH
48 minutes ago, Altostrata said:

You can make a mini-taper reduction every day, but some people will find the calculations and measuring to be too onerous to do every day, or get confused.

Not if they have a printout to follow. No onerous work nor confusion more than the mere act to take the dose following the listing.

image.png.2d60f9bdf3ce4cd42e7ef7d938177418.png

 

53 minutes ago, Altostrata said:

if their nervous systems adapt well to a 10% increase all at once.

If not what would be until now your suggestions to alleviate their suffering?

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Altostrata

Yes, although they may have a printed schedule, some people find the measuring difficult, because of cognitive issues or difficulty using their hands (tremor, arthritis, poor vision, etc.).

 

We suggest smaller decreases, possibly more often, if someone can't tolerate a 10% decrease.

 

The daily micro-taper is always an option for those so inclined, we don't condemn it. In fact, Cinderella tapering strips incorporate this into their rather arbitrary tapering schedule -- you (or rather, your doctor) take a guess when you want to finish. (Who has the experience or knowledge to estimate this??) They very much need a more sophisticated calculator, maybe a phone app, for their doctor and patient customers.

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JimH

Hi Shep,

 

The idea of an application to taper Antidepressant arrived recently following a request from a buddie in benzobuddies.org . In that forum the application for benzodiazepines taper has been put in place some time ago. Actually a number of members from this forum have indirectly participated in the effort. In this forum the general recommendations are to reduce between 5%-10% every 10-14 days (I will come back to this). The video made together with a member of this group relates to this version of the app.

 

When it came to adapt the code to taper Antidepressant, as some buddies mentioned www.survivingantidepressants.org, I started to make a few research. I read posts in here and made sure the code somehow reflects the philosophy to taper Antidepressant as opposed to taper Benzodiazepines. This is why for the recommendations part, for http://antdep.alwaysdata.net , the original statement has been changed to "Recommendations: Reduce the daily dose 10% every 4 weeks with the percent calculated on the LAST dosage.". The code has adhered to this idea to set the default values for the app.

 

Although the app has been designed by using information gathered in the Internet, it is by no mean made to serve any specific site or group. It is open for anybody, who do not wish to deal with math and spreadsheet, to create their own taper plan with as little guidance as possible. The way it is designed, it leaves large space for users to adapt to most of their needs but it cannot satisfy all requirements from all users. No app can.

 

As you gave me the opportunity to talk about, I must say that finding two distinct taper approaches for Benzodiazepines and Antidepressants, both known as affecting somehow the same neurotransmitters, left me baffled. While both claim that a correct taper must be symptoms-driven by listening to one's own body, that there is no one-for-all taper pace and it can greatly vary between individuals, that there are no two individuals who react the same way under the same treatment...I read about formula seemingly carved on stone like "10% every 4 weeks with the percent calculated on the last dosage". Where is for instance the margin left for taperers who have just taken AD for just a few weeks? Should they need to go through the long taper time (Ex: total 797 days or 2 years 2 months 5 days) the same way a 20-years-AD user would for their taper? And for those who are luckily less sensitive to cut, are they not penalized by keeping their dependency going when not "allowed" to taper 10% every 10 days? After all, are we or are we not all different and the way our CNS deals with benzo/AD can greatly differ from one person to another?

 

While I was developing the initial application, I wondered what users might think about the number of months, years it would take them to taper with the percent method. In this precise instant when I write these lines, I wonder if all concerned people are fully aware of its impact. As it takes easily 2, 3 years to taper one AD, someone with 3 drugs to taper one after the another will have spent 10 years of his life to taper. Had I used this method for my taper then instead of having stopped benzo 14 months ago, I would still have 3 months to go from today (total 797 days or 2 years 2 months 5 days). From a pure psychological viewpoint, I would have had suicidal thoughts knowing about that enormous (for me!) time required from me to get rid of 0.5 mg of drug. How about people learning they would need 5-7 years to taper off their ADs? Would they be motivated enough to start the taper process or they just drop the project?

 

Furthermore with this method should one decide to jump at zero mg/day then the time it takes will not be in years but INFINITE!. The reason is that being the reduction proportional to the daily dose, it lowers as the daily dose decreases. As the reduction lowers, so does the daily dose that turns the reduction smaller that turns the daily dose smaller that turns.... For those users with the psychological need to feel "healed" only if they lower to zero their daily dose, unless they quit anyway before, they have no chance as the daily dose never goes to zero.

 

The recommendations from benzobuddies.org, over fast for SA standards, can be in reality slower that what we can read in the Ashton's manual, kind of bible for benzodiazepines taperers. Nevertheless one can scratch his head for long time, not sure he can understand why that much difference of approach between 2 groups both dealing with psychotropic meds. Both will say that "experiences from (our) healed users showed that..., many users (in here) reported no symptoms while healing, the success stories (in here) confirmed that..." to confirm their excellent approach. If we think that taperers are frequently poly-drugged with benzos and ADs taken together then this difference can be a hassle to grab with their drug-induced diminished brain capability. While I recognize each method has its own strength and weakness, as they are far apart I wonder if the approach from each site has not rather reflected the position due to personal experiences of the site master. Adventurous in BB and conservative in SA. I might be wrong.

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Shep
1 hour ago, JimH said:

When it came to adapt the code to taper Antidepressant, as some buddies mentioned www.survivingantidepressants.org, I started to make a few research. I read posts in here and made sure the code somehow reflects the philosophy to taper Antidepressant as opposed to taper Benzodiazepines. This is why for the recommendations part, for http://antdep.alwaysdata.net , the original statement has been changed to "Recommendations: Reduce the daily dose 10% every 4 weeks with the percent calculated on the LAST dosage.". The code has adhered to this idea to set the default values for the app.

 

Jim, thank you for taking the time to write out a thorough reply to my post.

 

Please note that although Surviving Antidepressants was started to help people withdraw from antidepressants, the forum has grown to include many other drugs, including benzodiazepines, antipsychotics, PPIs, mood stabilizers, and others. Please see the section of the below thread titled "Tapering Off Specific Psychiatric Drugs": 

 

Important topics in the Tapering forum and FAQ

 

So we are dealing with many drugs, especially those who are caught in the polypharmacy trap, so we really don't have a separate taper recommendation rate for antidepressants as opposed to benzos or any other drugs. 

 

We also are very aware that the order of coming off these drugs is important - and sometimes even more important - than the taper rate. Please see:

 

Taking multiple psych drugs? Which drug to taper first?

 

1 hour ago, JimH said:

Where is for instance the margin left for taperers who have just taken AD for just a few weeks? Should they need to go through the long taper time (Ex: total 797 days or 2 years 2 months 5 days) the same way a 20-years-AD user would for their taper? And for those who are luckily less sensitive to cut, are they not penalized by keeping their dependency going when not "allowed" to taper 10% every 10 days? After all, are we or are we not all different and the way our CNS deals with benzo/AD can greatly differ from one person to another?

 

This is where Surviving Antidepressants differs greatly from BenzoBuddies (I was a senior moderator over on BB before coming to SA, so I'm very familiar with BB).  BenzoBuddies is a social support site where members give tapering advice that can wildly vary, especially since members only are required to disclose their benzo use, not their other drugs. Surviving Antidepressant is much more research-oriented and only allows moderators to give tapering advice. We work with each member to provide a customized taper plan based on the individual's experience, ALL of the drugs they are taking, and the latest research (please see Journals and Scientific Sources). 

 

So if someone comes into the forum with only a few weeks use, their taper plan will be different than someone who comes into the forum with 30 years of use. The 10% per month is a guideline. Since most of the people who come into this forum have been on psychiatric drugs for far longer than a few weeks and since most of our members are dealing with polypharmacy, the 10% rule is one that is most used as a guideline, although many members prefer various forms of micro-tapers. Please see:

 

Micro-taper instead of 10% or 5% decreases

 

The Brassmonkey Slide Method of Micro-tapering

 

1 hour ago, JimH said:

From a pure psychological viewpoint, I would have had suicidal thoughts knowing about that enormous (for me!) time required from me to get rid of 0.5 mg of drug. How about people learning they would need 5-7 years to taper off their ADs? Would they be motivated enough to start the taper process or they just drop the project?

 

Yes, the psychological viewpoint is important. You may want to have a read of Brassmonkey's brilliant series of essays that tackle this very subject: 

 

Are We There Yet? How Long is Withdrawal Going to Take?

 

We encourage members to grasp the enormity of the situation, but not to let it take them into dark spaces. 

 

Dealing With Emotional Spirals

 

Handling Neuro-Emotions

 

Also, keep in mind that 16.7%  of 242 million US adults reported filling 1 or more prescriptions for psychiatric drugs in 2013 (Adult Utilization of Psychiatric Drugs and Differences by Sex, Age, and Race) and meanwhile, according to the World Health Organization, depression is the number one reason for disability WHO - Fact Sheet - Depression). So clearly there are problems with staying on psychiatric drugs. If they worked, disability would go down, not up. 

 

Because antidepressants have been linked to tardive dysphoria, and there's the possibility that benzos are linked to Alzheimer's, as well as many other unwanted results of continuing on psych drugs, the motivation to get off safely can outweigh the thought of staying on them indefinitely. 

 

Our goal here isn't to motivate people to come off their drug(s). This is a personal choice. All we can do is give people information and resources from the latest research once they have made that decision. 

 

 

1 hour ago, JimH said:

Furthermore with this method should one decide to jump at zero mg/day then the time it takes will not be in years but INFINITE!. The reason is that being the reduction proportional to the daily dose, it lowers as the daily dose decreases. As the reduction lowers, so does the daily dose that turns the reduction smaller that turns the daily dose smaller that turns.... For those users with the psychological need to feel "healed" only if they lower to zero their daily dose, unless they quit anyway before, they have no chance as the daily dose never goes to zero.

 

This is explored here:

 

When to end the taper and jump to zero?

 

With a slow taper and bringing in a lot of non-drug coping skills, people are able to build up emotional resiliency along the way and come out the other side with a little bit of the Buddha in them. 

 

Some people do heal and feel better on the way off the drugs, some people don't heal until a number of years later. And some people have lingering legacy effects that can be made worse by age and / or by the collateral damage such as broken marriages and job losses. None of us have a map or a guidebook. We are dealing with an epidemic of massive polypharmacy in the first world countries. To have an escape, to be able to dig ourselves out of this, leaves us with the most precious and valuable gifts of psychological strength. This is an example of what mythologist Joseph Campbell described as a Hero's Journey. 

 

 

1 hour ago, JimH said:

The recommendations from benzobuddies.org, over fast for SA standards, can be in reality slower that what we can read in the Ashton's manual, kind of bible for benzodiazepines taperers.

 

 

The Ashton Manual is out-dated and has a lot of misleading information. While it is cited as a "kind of bible" in the benzodiazepine forums such as BenzoBuddies, it is not here. Please see:

 

Ashton and beyond in benzo tapering

 

1 hour ago, JimH said:

If we think that taperers are frequently poly-drugged with benzos and ADs taken together then this difference can be a hassle to grab with their drug-induced diminished brain capability. While I recognize each method has its own strength and weakness, as they are far apart I wonder if the approach from each site has not rather reflected the position due to personal experiences of the site master. Adventurous in BB and conservative in SA. I might be wrong.

 

It's not two methods at all. Please read over the links I posted and feel free to explore. We also have a members-only benzo forum:

 

Benzo tapering and recovery

 

Since you weren't a member yet when you were researching your app, you would not have had access to the benzo forum (it's only available to members). Please have a read of the various links, especially those pinned to the top. 

 

The major difference between BenzoBuddies and Surviving Antidepressants isn't just in the differences in tapering rates so much as in the fact that BB is a peer-led social support site and SA is a moderator-led research oriented site that is gathering case studies and being used in academic research by Dr. G. Fava,  Dr. E Tomba, and others (you can find these papers in the Journals section). 

 

Both kinds of sites are very valuable. BB is able to provide social support far more than SA. And SA is bringing in the latest in research for ALL forms of psychiatric drugs far more than BB. So they are both important, but very different. 

 

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JimH

Hi Shep,

 

Thanks for the information.

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Altostrata

Hi, Jim. Please don't take our comments for a lack of appreciation! You've done an excellent job with the calculators.

 

The rate of taper is always debatable. Nobody knows what an ideal rate of taper for any type of drug might be. Peter Groot and the team of concerned physicians who developed the Cinderella tapering strips takes an agnostic approach to taper rate: They suggest the patient work it out in consultation with the physician, taking their best guess. We all know where that leads!

 

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

 

We put it at 10% per month based on the last dosage because we've seen tapers of 25% at a time, often recommended by doctors are too fast -- we've seen a lot of withdrawal syndrome from this. Many peer support sites have adopted the 10% taper, which results in tapers much longer than anyone expects or wants, but many people seem to need in order to get off drugs with minimal withdrawal symptoms.

 

The monthly interval is an observation period to see if withdrawal symptom emerge. See Why taper by 10% of my dosage?

 

From our experience, the 10% taper seems safe for almost everyone. We err on the conservative side -- towards slower tapers -- because we don't have the authority to jump in with additional rescue prescriptions or hospitalizations. We assume our folks are doing this on their own (we'd be happy to refer them to physicians who would guide a taper, if we could find them) and we want to minimize risk.

 

(However, Dr. Sandra Steingart, a psychiatrist who deals mostly with antipsychotics, tries an initial decrease of 25%, and smaller decrements after that, which seems to work for her patients. This may be because many drugs are dosed at levels much higher than needed for receptor occupancy )

 

Coincidentally, it appears the 10% asymptotic taper approximates the obverse of SERT transporter occupancy curves, see Why taper? SERT transporter occupancy studies show importance of gradual change in plasma concentration

 

Ashton did the world a great service by laying the groundwork for benzo tapering. We don't take her work as gospel, just a starting place. Please see Ashton and beyond in benzo tapering

 

I believe we've synthesized good approaches to both benzo and non-benzo psychiatric drug tapering.

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JimH

Hi Altostrata,

 

Thanks for taking the time to reply. I will reserve some time next week to read the resources Shep and you have kindly put in evidence.

 

PS: Is there any specific section for technical support (Eg: HTML link to an article, reference to a member...)? Thanks.

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Shep
3 hours ago, JimH said:

PS: Is there any specific section for technical support (Eg: HTML link to an article, reference to a member...)? Thanks.

 

Here is the technical support thread:

 

Technical support and bug reports

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JimH

Hi @Shep

 

I read with a lot of interest Taking multiple psych drugs? Which drug to taper first? . Found it very useful and really enjoyed the reading. Thanks @Altostrata for the good work.

 

I'm recently more and more interested in understanding what lies behind statement like this found in the web: "...I have had a headache now for 3 weeks non stop. Nothing is working. 5:30 this morning it is the worst it has ever been. If I lay down pain intensifies especially depending how ie. If lay on back the back of my head with hurt more than the rest. If lay on side that side of head will hurt worse. If I sit up everything still hurts but feel like brain is going to explode out my ears. The pain is worse even when I talk. On escitoplam so can't take migraine meds ...". This is only one example. I have seen many others where people suffer headache (migraine) in many forms as a consequence of benzo/AD withdrawal. For some of them headache is so debilitating that it prevents them to be functional forcing them to be confined to bed. I googled a large amount of time to look for information that can convincingly explain the reasons behind this symptom but not always came out satisfied. If you have a source you can drive me to, I would be very grateful. I apologize if this is not the good thread to ask this question. In that case please feel free to redirect it to the right section. Many thanks.

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Shep
42 minutes ago, JimH said:

I have seen many others where people suffer headache (migraine) in many forms as a consequence of benzo/AD withdrawal.

 

You may find some answers here:

 

Migraines, headaches, neck ache / pain and head pressure

 

This thread is about a related symptom, brain zaps. Some people find them painful, while others just find them annoying.

 

Brain zaps

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JimH

Hi @Shep

 

Thanks. I forgot to mention that I asked that question after having read about everything I can find in here including those 2 links about migraine and brain zap. I would be more interested in the why of this headache symptom and less in the symptom itself. Thanks anyway.

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Altostrata

We don't know how any particular withdrawal symptom develops. The autonomic nervous system is very complex and manages everything -- muscle tension, blood pressure, heart rate, even the behavior of blood vessels and hormone release patterns. Medicine doesn't know very much about dysautonomia.

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