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Important topics in the Tapering forum and FAQ

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--------HOW FAST SHOULD YOU TAPER?--------

Why taper by 10% of my dosage?
The general philosophy of gradual tapering

The slowness of slow tapers
Some people can tolerate tapering only by very small amounts over a long time.

Why taper? SERT transporter occupancy studies show importance of gradual change in plasma concentration
Discussion of a scientific journal article with data supporting a very gradual taper. If your doctor is a scientific type, print the journal article out and give it to him or her.

--------PREPARING TO TAPER--------
Taking multiple psych drugs? Which drug to taper first?
If you're not having an adverse reaction from the other medications, taper the most activating drug first. This is usually an antidepressant or stimulant (ADHD drug).

Preparing to taper
Taking care of yourself so you are prepared to taper.


Dose Equivalents for Antidepressants and Second-Generation Antipsychotics
If you have to make a switch.
Taper more than one drug at a time?
Try this only if you know your withdrawal symptom pattern and know how to control your taper with various tapering techniques.
Drug Interactions Checker -- use it to reduce your drug burden
If you are suffering adverse effects from a combination of drugs, this can help determine which drug is the key culprit to reduce first.


DrugBank.ca - drug database website

User-friendly website to look up your drug to find what size doses it comes in, market availability (i.e. which country it's available in), mechanism of action, water solubility, and other useful information.  

Rate symptoms daily to track patterns and progress
Keeping a record of your withdrawal symptom pattern so you can manage it.

Dr. Joseph Glenmullen's withdrawal symptom checklist
Use this to track symptoms.


Benzo-wise doctors who will assist in benzodiazepine tapering
How do you talk to a doctor about tapering and withdrawal?
What should I expect from my doctor about withdrawal symptoms?
--------METHODS OF TAPERING--------
How to calculate dosages? 
How to cut up tablets or pills
Using a pill cutter -- flat, round tablets easier to cut accurately

Which tablets or pills may be split or crushed?
Most tablets that are not extended-release may be split or crushed
Did I go wrong with my nailfile?
Filing a tablet is popular but inexact. Taking a liquid is more consistent and reliable.
Using an oral syringe and other tapering techniques
How to use oral syringes, gelatin capsules, powdered tablets, and do-it-yourself liquid solutions
How to make a liquid from tablets or capsules
General instructions on making a homemade liquid suspension
Making a citalopram solution yourself
This is about citalopram (Celexa) but can be applied to most tablets that are not extended-release or sustained-release

Pharmacy liquids to make suspensions
Liquid bases for medication


Questions and answers about liquid medications

How to calculate dosages of liquids and other tips

Compounding pharmacies (US, UK, and elsewhere)
These pharmacies can make up custom dosages and liquid medications

Using a digital scale to measure doses
Digital scales can measure less than 1mg by weight


Combining tablets or capsules with liquid to taper


How to calculate dosages and dilutions? Spreadsheets and calculators

Counting beads in a capsule versus weighing

The Prozac switch or "bridging" with Prozac
Substituting one medication for another for easier tapering

Micro-taper instead of 10% or 5% decreases
Decreasing your dosage by very tiny amounts more often might be more tolerable than 5% or 10% decreases. Know your symptom pattern first so you can estimate how often you can reduce.


The Brassmonkey Slide Method of Micro-tapering

One way you can micro-taper.

--------AT THE END OF A TAPER--------
When to end the taper and jump to zero?
How do you determine a good stopping point?

Experiences after tapering to zero
How do people feel after finishing a taper?

Tips for tapering off amitriptyline
Tips for tapering off amphetamine/dextroamphetamine (Adderall)
Tips for tapering off aripiprazole (Abilify)


Tips for tapering off asenapine (Saphris)

Tips for tapering off busipirone (Buspar)

About going off mirtazapine plus venlafaxine (Effexor) aka "California rocket fuel"


Tips for tapering off Celexa (citalopram)


Tips for tapering off clomipramine (Anafranil)

Tips for tapering off Cymbalta (duloxetine)
Aka Ariclaim, Xeristar, Yentreve
Tips for tapering doxepin (Sinequan, Zonalon)
Tips for tapering off Effexor (venlafaxine)
Aka Efexor, Elafax, Venlafaxina, Venlor, Ventab, Alenthus
Tips for tapering off ziprasidone (Geodon, Zeldox)
Tips for tapering off Invega (paliperidone)
Tablets and injectable Invega Sustenna
Tips for tapering off Lamictal (lamotrigine)

Tips for tapering off Lexapro (escitalopram)
Aka Cipralex, Seroplex, Lexamil, Lexam
Tips for tapering off lithium
Tips for tapering off lurasidone (Latuda)
Tips for tapering off Luvox (fluvoxamine)
Tips for tapering off Lyrica (pregabalin)
Tips for tapering off Neurontin (gabapentin)
Tips for tapering off nortriptyline 
Tips for tapering off olanzapine (Zyprexa)
Tips for tapering off oxcarbazepine (Trileptal)

Tips for tapering off Paxil (paroxetine)

Tips for tapering off Pristiq (desvenlafaxine)

Tips for tapering off Prozac (fluoxetine)
Aka Rapiflux, Sarafem, Selfemra, Fontex
Tips for tapering off Remeron (mirtazapine)
Tips for tapering off Risperdal (risperidone)

Tips for tapering off Savella (milnacipran)
Tips for tapering off Seroquel (quetiapine)

Tips for tapering off sodium valproate and valproic acid (divalproex sodium, Depakote, Depakene)

Tips for tapering off Tramadol
Tips for tapering off trazodone (Desyrel)
Aka Oleptro, Beneficat, Deprax, Desirel, Molipaxin, Thombran, Trazorel, Trialodine, Trittico, and Mesyrel

Tips for tapering off Trintellix (vortioxetine), previously called Brintellix

Tips for tapering off Viibryd (vilazodone)
Tips for tapering off Vyvanse (lisdexamfetamine dimesylate)

Tips for tapering off Wellbutrin, SR, XR, XL (buproprion)

Tips for tapering off Zoloft (sertraline)
Aka Lustral

Tips for tapering off Z drugs for sleep (Ambien, Imovane, Sonata, Lunesta, Intermezzo, etc.)
These drugs commonly prescribed and can cause drug-drug interactions with psychiatric drugs or other health problems.
Tips for tapering off stomach acid blockers or PPIs...


Tapering Alpha Blockers or Beta Blockers


Antihypertensive Clonidine Withdrawal: Psych Meds not the only drugs to cause PAWS


Tips for tapering off propranolol


SAM-e (S-adenosyl-L-methionine)
Guides to tapering off psychiatric medications
From medical societies and other organizations, including the American Psychiatric Association and UK National Health System
What is withdrawal syndrome?
About reinstating and stabilizing to reduce withdrawal symptoms
The Windows and Waves Pattern of Stabilization

Edited by Altostrata

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How about taking my medication every other day to reduce my dosage?



(See this comparison graph:  Skipping Days vs Every Day Dosing Graph)

If your medication is not designed to take every other day (very few are), don't try to taper by alternating doses. The half-lives of almost all psychiatric drugs are too short for this to make sense. It causes the amount of the medication in your bloodstream to go up and down, battering your nervous system, and makes withdrawal worse.

Your brain likes stability, to be treated gently. The object is to gradually accommodate it to lower and lower dosages. Don't throw it off a cliff every day. Move it slowly down a ramp by gradually decreasing dosage by an amount it may hardly notice. A 10% reduction in dosage may be appropriate. Stay at that dosage for 3-4 weeks, then decrease again -- by 10% of your last dosage. Your decreases will be progressively smaller the lower you go in dosage.

Some people can quit cold turkey and not notice. Some people can alternate dosages and not notice. If you are having withdrawal symptoms, you are not among those people.

We don't know why some doctors, pharmacists, and alternative practitioners recommend tapering by alternating dosages. It's terrible advice. Don't do it.

Why do I need to taper? Why can't I just quit?

Withdrawal syndrome may occur after you stop taking a psychiatric medication and can last weeks, months, or years. Symptoms can be distressing, debilitating, or even disabling.

While some people may be able to quickly stop taking these medications without serious symptoms, severe and prolonged withdrawal syndrome can happen to anyone.

You don't know in advance if you'll be one of the unlucky ones.

Tapering off the medication is the only known way to reduce the risk of withdrawal syndrome. Don't risk the integrity of your nervous system -- do not suddenly stop taking any psychiatric medication.

Your nervous system has become dependent on the medication. Gradual tapering enables your nervous system to return to its original state.

A 10% reduction in dosage every 3-4 weeks is a good harm reduction plan.

Edited by Shep
Alto updated and expanded/CC added graph link, Shep fixed link

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I'm not sure I have withdrawal symptoms. What are they?


When you withdraw from a neurologically active medication, your nervous system has to adjust back to a normal state. While it is adjusting, you experience withdrawal symptoms.


The autonomic nervous system, which controls the "automatic" functions of the body, is strongly affected. This is one reason withdrawal symptoms are so various.


Withdrawal symptoms can include:

- Electrical feelings in the head or "brain zaps"

- Surges of anxiety, agitation, or excitation

- Hypomania or mania

- Inability to concentrate

- Disorientation

- Dizziness

- Diarrhea

- Sensitivity to light or sound

- Nausea

- Waves of fear or weepy melancholia

- Sleep problems


For scientific papers about withdrawal symptoms, see Diagnosis of antidepressant withdrawal syndrome

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What is antidepressant withdrawal syndrome?

Although medicine avoids recognizing it, there are about 200-300 scientific papers and many anecdotal patient reports that indicate antidepressant withdrawal syndrome:

-- In most cases, is autonomic instability, with probable disinhibition of the locus coeruleus, generating unprecedented symptoms of anxiety, fear, and panic, contributing to a very common unrelenting insomnia
-- Develops in the context of the serotonergic desensitization caused by all antidepressants
-- Is not degenerative or progressive
-- Has a set of symptoms that are fairly common
-- Very gradual, halting recovery pattern

Withdrawal syndrome often causes hypersensitivity to subsequent psychiatric medications, which are usually unhelpful and often exacerbate symptoms.

Tapering off a psychiatric medication too quickly or stopping suddenly ("cold turkey") can lead to prolonged withdrawal syndrome. Recovery can take months or years.


Read more in these topics What is withdrawal syndrome?

(For scientific papers about withdrawal symptoms, see Diagnosis of antidepressant withdrawal syndrome)

Edited by Altostrata

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What does half-life mean? Why is it important?

"Half-life" means the amount of time it takes for the level of the drug in your bloodstream to be reduced by half, as measured by scientific tests.

For example, Cymbalta has an extraordinarily short half-life of about 12 hours.

Over the next 12 hours, your body will continue to metabolize the medication, but some may still be in your bloodstream after 24 hours, due to individual variation and uneven rates of clearance. Researchers believe "washout" requires 5-7 half-lives; to be safe, psychiatrists are advised to wait 2 to 6 weeks between drugs to avoid drug-drug interactions (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215520/). (The longer period is for drugs with very long half-lives, such as fluoxetine or Prozac, or MAOIs, which are notorious for interactions.)

It is thought the short half-life antidepressants, such as Paxil and Effexor, have the worst withdrawal symptoms and subsequent withdrawal syndrome because a reduction in dosage happens so quickly the nervous system doesn't have time to adapt to it.

In medical studies, Paxil, Effexor, Zoloft, and Luvox -- all with short half-lives -- have been reported to have the worst withdrawal issues, hence the conclusion that half-life is key to withdrawal syndrome. However, since statistics on antidepressant withdrawal are so poor, half-life may or may not be a determining factor.

One thing is clear, if you are inconsistent in taking any medication with a short half-life, you will feel withdrawal effects very quickly, as so many people who have forgotten to take their medication have found.

Edited by Altostrata

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What is the difference between withdrawal symptoms and withdrawal syndrome?


While you are tapering, or if you quit suddenly, you may soon experience what are known as acute withdrawal symptoms. These symptoms indicate you may need to taper more gradually. If your taper is too fast, they may persist beyond the few weeks or months that medicine expects.


If withdrawal symptoms persist for a long time after you stop taking the medication -- sometimes they do not become obvious for weeks -- they are called post-acute withdrawal symptoms or, collectively, withdrawal syndrome.


It is called a syndrome because it is a symptom pattern seen in many people but is not a disease.

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From the Icarus Project http://theicarusproject.net/alternative-treatments/mind-uk-coping-with-coming-off-psych-drugs-guide


Am I addicted?


Addiction means being physically dependent on the drug, with a need to increase the doses to get the same effect, and having a compulsive psychological need to take it. Many people who experience unpleasant symptoms when they withdraw, consider themselves to be 'addicted' to the drug. Many doctors and pharmaceutical companies prefer to call it 'dependence', or even 'withdrawal symptoms' or 'discontinuation symptoms'. The language used, however, doesn't alter the fact that some people have extreme difficulty when coming of psychiatric medication and only achieve it with great determination.

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Why should I taper by 10% of my dosage? I know people who just quit with no problem.


The very conservative approach of a 10% taper every 3-4 weeks protects people who are sensitive to fluctuations in dosage. You can't know you are one of these people until you try a reduction in medication. We recommend trying a 10% initial reduction to see how you do with a small decrease. If you have no problems, you may be able to taper faster.


A more complete explanation is here.

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Can I go any faster than 10% reduction per month?


It's best to go slowly to find out how you tolerate a reduction. Once you damage your nervous system with withdrawal symptoms, it can take a very long time to feel good again.


But -- many people do fine with a faster taper. Are you one of them? You can't tell. We advocate a harm reduction approach to tapering:


  • Initially, make a 10% reduction and hold there for a MONTH. It can take several weeks for withdrawal symptoms to emerge. Do that again the second month.
  • If you have very minor or no symptoms from these 2 reductions, you can try reducing by 10% every 3 weeks. Do that twice. If no problems, reduce by 10% every 2 weeks. Do that twice.
  • If no problems after 4.5 months of very gradual reduction, you may be able to reduce by 10% every week.
  • If significant withdrawal symptoms appear, make smaller cuts or go slower. Listen to your body.

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What is a micro-taper?


There is a lot of discussion on this site about a technique we call micro-tapering, in which tiny dosage reductions, as small as .01mg (or even less), are made more frequently than in a regular taper.


Often, this isn't any faster in total than a 10% or 5% reduction, but for people whose nervous systems are exceptionally sensitive, it may be more tolerable than the relatively larger reductions.


Only people who already understand their withdrawal symptom pattern and nervous system tolerance for dosage changes should try this. As with any tapering schedule, if withdrawal symptoms appear, the patient is advised to slow tapering or hold on the current dosage until the nervous system stabilizes.


Liquid solutions are helpful for micro-tapers because they enable very gradual, controlled tapering. Many drugs are available in liquid solution form, or they can be made into a liquid by a compounding pharmacy. Some drugs, such as Prozac, can be made into a solution with water at home. Use the Search box in the upper right for more information about this.

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Why do so many people have such a difficult time at the end of the taper?


There may be several reasons: Because the level of the drug has gotten so low:

  • the nervous system notices even small changes
  • due to half-lives, the drug is no longer distributed among affected receptors equally
  • some drugs, such as Paxil, inhibit their own metabolism and as you get to a lower dose, are metabolized faster, giving the effect of a larger proportional decrease
  • if the person is taking other medications, the drug ecology changes, producing symptoms that may have been masked by the lowered dosage of the drug being tapered

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How long do you need to be taking an antidepressant to require tapering?


According to scientific papers on withdrawal, use of an antidepressant for more than a month increases the risk of withdrawal symptoms.


We suggest a 10% taper in those situations.


If you've been taking an antidepressant for a month, a faster taper may be tolerable, such as a 25% reduction per week.


If you've been taking an antidepressant for less than a month, you might be able to make more frequent dosage reductions to discontinue in a week.


Slow down and make smaller decreases if you get any withdrawal symptoms.


Unless you are having an adverse reaction, do not cold turkey.

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