Guides to tapering off psychiatric medications

[dalsaan]

Hi Alto

 

Did you get a response to your follow up email?

 

Cheers

 

Dalsaan

[Altostrata]

Nope. After a while, I sent them this.

 

 

From: Altostrata

Subject: Re: The Maudsley Prescribing Guidelines in Psychiatry

Date: November 20, 2012 5:46:42 PM PST

To: David Taylor <David.Taylor at slam.nhs.uk>

Cc: carol.paton at oxleas.nhs.uk, Shitij Kapur <shitij.kapur at kcl.ac.uk>

 

Dr. Taylor, you and your colleagues may be interested in the following paper, which suggests reactions to abrupt discontinuation may be more severe and longer lasting than only two weeks:

 

J Psychiatry Neurosci 2001;26(1):44–8.

Abrupt discontinuation of psychotropic drugs during pregnancy: fear of teratogenic risk and impact of counseling.

Einarson A, Selby P, Koren G.

 

Abstract at http://www.ncbi.nlm.nih.gov/pubmed/11212593 with free full text.

 

 

Throughout the literature, there are indications abrupt discontinuation leads to more severe and longer lasting withdrawal syndrome than tapering, as well as suggestions that, if withdrawal symptoms appear during tapering, the tapering be slowed with smaller decrements, not with abrupt discontinuation.

 

This is borne out by hundreds of thousands of posts all over the Web by patients who have discontinued too rapidly and report suffering withdrawal symptoms for months or even years.

 

Here are the results of a recent informal Web survey conducted by the Royal College of Psychiatrists http://www.rcpsych.ac.uk/expertadvice/treatments/antidepressants/comingoffantidepressants.aspx :

 

"People in our survey report that the symptoms generally lasted for up to 6 weeks. A small percentage of symptoms lasted longer than this. A quarter of our group reported anxiety lasting more than 12 weeks."

 

Please reconsider revising this section of the Maudsley, as clinicians may be injuring people by too-abrupt discontinuation.

 

Sincerely,

 

Altostrata

SurvivingAntidepressants.org

[hippopotamus]

In the [Icarus Harm Reduction Guide to Coming off Psychiatric Drugs & Withdrawal] guide, it says: 'Some people may go slower or faster, but a good guideline is 10% or less

of their original dose, every 2-3 weeks or longer.'

 

Shouldnt it say 10 % of every last dose someone is taking?

Edited May 31, 2018 by Altostrata
added clarification and link

[GiaK]

yes...it should...is that the updated manual (2nd edition) or the first one?

 

I'll let Will know if it's the new edition

[hippopotamus]

It's in the second edition, that I got from his own website.

[GiaK]

ok thanks

[John]

I know that what I learned on this site, everyone says that while tapering, if you get withdrawal symptoms, pushing back up the dosage doesnt always work.  I read Glenmullen's book, and he never mentions that. He also says that your original disorder would come back between 1-2 months after stopping the pill, and withdrawals come within days?  When I went cold turkey, I started the Effexor back 2 months after, and it took 6 months for me to start feeling better.

[Altostrata]

Read the insert in your package of Effexor XR. What does it say about discontinuation?

[John]

I see nothing there that says reinstating may not work, nor does it mention how to determine if your original disorder returns.

[Altostrata]

This is the limit of what medicine knows, and most doctors don't even know this:

 

From FDA advice about discontinuation

Discontinuation of Treatment With Venlafaxine Hydrochloride Tablets

Discontinuation symptoms have been systematically evaluated in patients taking Venlafaxine, to include prospective analyses of clinical trials in Generalized Anxiety Disorder and retrospective surveys of trials in major depressive disorder. Abrupt discontinuation or dose reduction of Venlafaxine at various doses has been found to be associated with the appearance of new symptoms, the frequency of which increased with increased dose level and with longer duration of treatment. Reported symptoms include agitation, anorexia, anxiety, confusion, impaired coordination and balance, diarrhea, dizziness, dry mouth, dysphoric mood, fasciculation, fatigue, flu-like symptoms, headaches, hypomania, insomnia, nausea, nervousness, nightmares, sensory disturbances (including shock-like electrical sensations), somnolence, sweating, tremor, vertigo, and vomiting.

During marketing of Venlafaxine, other SNRIs (Serotonin and Norepinephrine Reuptake Inhibitors), and SSRIs (Selective Serotonin Reuptake Inhibitors), there have been spontaneous reports of adverse events occurring upon discontinuation of these drugs, particularly when abrupt, including the following: dysphoric mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesias such as electric shock sensations), anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania, tinnitus, and seizures. While these events are generally self-limiting, there have been reports of serious discontinuation symptoms.

Patients should be monitored for these symptoms when discontinuing treatment with Venlafaxine. A gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose but at a more gradual rate....

 

We know reinstatement doesn't always work because we see people here who have tried it and not had good results.

 

There are many studies in the scientific literature that show doctors cannot recognize withdrawal syndrome and almost always misdiagnose it as "relapse." This contaminates every study of antidepressant efficacy where patients have been taken off the drugs and said to have "relapsed," thereby demonstrating a need for continuing to treat the psychiatric condition with antidepressants.

 

There is a giant question mark about how often relapse actually does happen after going off drugs.

 

John, this site exists because of a vacuum of knowledge among doctors. I would be happy to close it tomorrow if doctors took the responsibility for tapering people off drugs and monitoring for withdrawal symptoms.

 

I suggest you read 10 of the Introductions topics and decide for yourself if people are being well-served by their doctors.

 

If you don't want to believe what you see here about reinstatement, you are free to reinstate or not as you wish.

 

The basic premises of this site are explained in the Read this First forum and in pinned topics at the top of the Tapering and Symptoms forums. If these premises doesn't fit your understanding of your reality, you are welcome to go elsewhere.

[Lilu]

If skipping doses by following a tapering schedule of taking medication every other day, then every two days, then every three days... is not written in any of the guides given to doctors, WHY ARE THEY ALL STILL DOING IT?   Given where I live, I had access to the top psychiatrists in both Rutgers and Princeton University.  The Rutgers psychiatrist told me to skip doses, defending his method with "that's exactly how we taper Heroin!"  And the Princeton psychiatrist told me to just quit cold turkey after being on Effexor/Pristiq for SEVEN years!  When I mentioned bridging to Prozac she had never heard of it, thought it was ridiculous, and got angry at me for even suggesting that quitting cold turkey was dangeous, saying, "lots of my patients do it."   These are not some shrinks in private practice, these are doctors who are heading entire inpatient and outpatient units at major research universities.  How is it that they do not know?!!  

 

(Ugh, I'm so mad, because they same thing is happening to my cousin who is under the care of Neurologists at a prominent hospital in Philadelphia, and they are having him skip doses and rapidly withdraw from 3 psychotropic drugs at once, following brain surgery.  For 5 years he's been on an antidepressant, a mood stabilizer, and an opioid for severe migraines that were caused by a pituitary tumor than no one detected.  Arrggghhh! And he's one of those types that religiously does what doctors tell him.)

 

I just don't know why most psychiatrists and neurologists still instruct patients to taper their medications by skipping doses.  Would a doctor ever tell you to lose weight by only eating every other day?  Everyone knows that this would make your body go into alarm mode, thinking that there's a famine going on, and it would only start holding on to it's fat stores. You know what else it does? It starts feeding on it's own muscle tissue, and breaking it down for energy.  And the less muscle you have, the less fat your burn.  It's completely counterproductive.

[bubbles]

Hi everyone

 

(I searched for a similar topic but didn't find one - the search timed out. Sorry if there is already one.)

 

I saw this article one from rxisk.org: https://rxisk.org/guide-stopping-antidepressants/#How_to_withdraw

 

It looks like a useful site. This concerns me, however : "Convert to a liquid form of the drug you are on. Reduce by a comfortable amount in weekly steps. This may mean reducing as little as 1 mg per week and being prepared to stop and stabilize if things get too difficult. Another approach is to reduce by 10% each week. For some people depending on the drug and their own physiology, there may be a need to go very slowly, others may be able to go faster."

 

I wonder if anyone has been in contact with David Healy about the speed recommended?

 

Cheers

B

 

 

 

[Altostrata]

If you're taking 150mg of a drug,  a reduction of 1mg per week is indeed quite slow (until you get down to 10mg).

 

Reductions of 10% a week is a lot slower than what doctors are currently recommending and may work for some people. Our reductions of 10% per month are deliberately very conservative to avoid injury to a wider range of people.

 

He is correct in cautioning to taper slower if withdrawal symptoms appear. However, we see that withdrawal symptoms sometimes don't show up right away and a wait of a month is prudent.

 

Dr. Healy's instructions are accurate, but not specific enough. There's too much room for misunderstanding.

[bubbles]

I'd love a resource to give to my providers from someone like Dr Healy (ie, a psychiatrist), but I agree about the possibility for misunderstanding. Rxisk.org isn't that one, or at least not yet. He's so close though!!!

 

(Thank you for merging the topics.)

[Altostrata]

Thank you for sharing what you've found.

[bubbles]

(Hmm, I've just noticed an editing artefact in my original post. Sorry, it's too late to edit it.)

[Altostrata]

We're fine with imperfection.

[summitbound]

I've been tapering my benzo, and the Aston Mannual serves as the premier authoritative resource for that drug.  Is there a similar book / reference I should know about before I start tapering my antidepressants?  Thought I'd check before I start asking a million questions here. Thanks!

[Altostrata]

No, there is no such central guide. See Official guides to tapering off psychiatric medications

[bubbles]

 

[bubbles]

Hi Alto - this is a really old post, but did they ever respond and/or revise their recommendations?
 

[Altostrata]

The only response I received was to my November 10, 2012 note at 

The response was:

 

Quote

This advice is based on clinical and personal experience.  I know of no studies which support abrupt withdrawal but we have observed that symptoms persist only for a week or two after sudden stopping.
 
The reason it is not recommended to all is that the symptoms can be disabling and necessitate absence form work, etc.  Symptoms are better tolerated in slow withdrawal.
 
D
 
Professor David Taylor
Director of Pharmacy and Pathology

 

[bubbles]

Thanks Alto.