For most of us I believe, once we’ve made a firm decision to do something, we want results swiftly with as little pain and effort as possible. So it never surprises me when a patient of mine who has decided to distance himself from sleep agents or antidepressants asks how long it will take and how difficult the withdrawal process will be.
Fair questions yes, but the wrong questions. Every one of us is wired differently and our tolerance for discomfort is quite variable. What follows are guidelines for withdrawing from hypnotics (sleeping pills) and anxiolytics (benzodiazepines in particular, used for sleep purposes) as well as contemporary antidepressants. I’ll start with the sleep agents.
- Sleep agents encompass the commonly prescribed non-benzodiazepines such as Ambien, Sonata and Lunesta along with the traditional benzodiazepines such as Xanax, Ativan, Valium and Klonopin. All of these are controlled substances.
- Begin by halving the dose on one of the nights that the medication is taken. Choose a night that is associated with fewer obligations the succeeding day and less pressure to have to perform.
- Once sleeping “reasonably” well on this night at half the customary dose, move on to doing the same on a second night. Don’t attempt to do this two nights in a row just yet, space the reduction nights apart.
- Continue along these lines until the nightly dose has been reduced by 50 percent on all the nights on which the medication is taken. Obviously this will mean cutting the dose in half on successive nights at some point, but by then reassurance that this exercise is doable will have taken hold. Keep in mind: the essence of commitment means not reverting to the original dosing pattern.
- After reducing the dose by half on every night the drug is taken, eliminate the other half according to the same regimen — one night a week, then two nights a week etc., until medication-free.
- Don’t be concerned about how long this process will take because the intensity and arc of the withdrawal is dependent upon length of use and how high the dose has become. For some people, decreasing the dose by half in this sequential manner may mean not sleeping well on any given night(s) for days or even weeks. So proceed at a tolerable pace without backsliding.
- Other variables which will influence the ease or difficulty with which this will unfold include: diet, exercise regimen if any, overall sleep hygiene (preparing for sleep, establishing regular sleep and wake times), physical issues such as sleep apnea and restless legs, multiple medications and ability to relax.
Withdrawing from Antidepressants
Antidepressants have long been prescribed for depressed and non-depressed individuals as sleep agents. Many of them — particularly the older cyclic drugs such as trazodone and Elavil — produce sedation and drowsiness as a result of their antihistaminic side effects. And of course antidepressants are the mainstay pharmacological option for major depressive disorder.
Same as the sleep agents, antidepressant discontinuation is dependent upon how long the drug has been used and at what dose. These two factors again will drive the degree of intensity of the common withdrawal symptoms of these drugs — such as flu-like symptoms, and electric shock sensations in the hands and feet accompanied by brain “zapping.”
At sub-therapeutic or suboptimal dosing, practically anyone should be able to safely proceed toward complete discontinuation within a two month period assuming the use of a single agent. For those using more than one antidepressant or a single agent for a year or longer, I routinely recommend reducing the total weekly milligram dose by 5 percent. The half-life of antidepressants is much longer than that of the traditional sleeping pills. This means that the length and arc of withdrawal phenomena is going to be longer — not necessarily more intense, but longer for sure. Safe and relatively comfortable withdrawal therefore can be achieved in 20 weeks or approximately 5 months. Calibrating this dosing is very difficult or all but impossible for the average layman using antidepressants. As such, use of a compounding pharmacy is warranted to get this right. It comes at a price, but worth it I think to avoid antidepressant withdrawal “hell.” Liquid antidepressant formulations are another possibility for safe withdrawal as they provide a path for dosage “fine-tuning.”
There’s no ONE right way for discontinuing sleep agents or antidepressants, no algorithm or formula guaranteeing success and there are more opinions and recommendations on how to proceed than I could shake a stick at. The most important considerations are:
- No one should go this alone. The physician or prescriber of these medications has a stake in this, and should be consulted every step of the way.
- Commit and don’t retreat. Keep pressing forward in spite of discomfort.
- Keep a watchful eye on the prize — saying goodbye to drugs that once served some purpose but now have outlived their usefulness.
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Attribution Statement:
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.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.