Tapering and Discontinuing Psychotropic Medication
More and more calls and e-mails are filtering into my office these days from folks who are interested in tapering and possibly even discontinuing their psychotropics.
Uniformly, my first two questions to them are why and, why now? Answers to these questions typically align with three themes: 1) I can’t determine whether the drug is helping me anymore, 2) I’d like to try going it alone without medication, and 3) I don’t want to run the risk of long-term dependence on medication.
All three of these responses are reasonable and valid, so then I press a bit more with this question: how equipped are you for doing this, specifically, have you thought about or do you have a plan for managing the tough moments that will inevitably occur once you get started? This question either renders people speechless or delivers answers that indicate potential pitfalls haven’t been adequately considered.
Then there’s the even bigger picture as to which psychotropic medication classes can be successfully tapered or discontinued. Credible literature is sparse when it comes to tapering mood stabilizers for bipolar disorder and antipsychotics for the psychotic spectrum. And there is virtually no mention of discontinuing these medications for long periods, as these disorders are associated with lifetime prevalence. This leaves the antidepressants and the anxiolytics – think benzodiazepines here.
With regard to the antidepressants, the literature supports a trial off these medications after a year of full recovery from moderate depression, and consideration of long-term use after a second relapse. What about after years of antidepressant use though? This question hasn’t been studied in any measurable detail, thus tapering and discontinuation remain quite the conundrum for the person using antidepressants for a decade or longer.
As for the benzodiazepines, operatively these drugs should be used for no longer than a few weeks, and in rare instances for up to six months, (although these time frames are routinely violated) at which point a gradual discontinuation strategy should ensue.
Antidepressants and benzodiazepines can be tapered and eventually discontinued for sure, but at what price? What to do when the user experiences symptom reemergence or uncomfortable withdrawal symptoms? Has the user matured sufficiently through the employment of proven behavioral therapies and positive self-talk to carry the load when the road to becoming medication-free gets rocky?
If you’re working with someone who floats the idea of tapering their medications, first have a discussion with them about BSOS – bright shiny object syndrome. You know, that hope springs eternal thinking that starts up because it’s new, breaks a current rhythm and is filled with possibility – until the novelty wears off. And remind the person that discontinuing medication is a “long haul” decision, so retreating to the safety and comfort of resuming drug treatment is not part of this new equation.
Change is always risky because it takes us from what we know to what we don’t know. A desire to be chemical-free is not enough; to be successful at shedding medication, one must have a strong support system, an attitude that fosters trust in a skill set to keep moving forward and belief in the ability to apply such skills – during and after – drug discontinuation.
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.