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THIRD PLACE WINNER!
Best of Naturopathic Medicine 2013
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Permission has been granted from Integrated Healthcare Practitioners for publication of this article. The contents of this article have been considerably expanded upon since its original publication in: Integrated Healthcare Practitioners. 2012;5(1):56–59.
Abstract
The author's private clinical practice focuses on the evaluation and treatment of mental disorders. One of the most common requests from patients involves their desire to reduce or discontinue one or more psychotropic medications. It is entirely appropriate for patients to request this. Their psychotropic drugs might be doing more harm than good by creating objectionable side effects, which may limit rather than enhance their quality of life. Issues related to pharmacological dependence and discontinuation reactions are described. Since there is a scarcity of clinical research pertaining to tapering patients off psychotropic drugs, there are no clearly defined standards to inform clinicians about the most appropriate method of tapering. The author recommends an integrative approach (when possible) involving communication between the prescribing clinician (i.e., the patient's psychiatrist or family doctor) and the clinician proposing the tapering plan. The tapering plan should involve one drug at a time and reduce the drug with the longest elimination half-life first. Overall, the tapering plan needs to be very slow and gradual in order to reduce the potential for relapse. Diet, lifestyle modifications, and specific natural health products can significantly improve a patient's chances of successfully tapering psychotropic drugs. Several examples of tapering schedules are described. Each plan was individualized to suit the patient's needs, and support mental stability. This article should assist and empower clinicians to develop effective tapering strategies on behalf of willing and mentally competent patients.
Introduction
For over a decade I have focused the majority of my clinical practice on the evaluation and treatment of mental disorders. One of the most common requests that I receive from patients stems from their desire to reduce or discontinue psychotropic medications. It is entirely appropriate for patients to request this. Their psychotropic drugs might be doing more harm than good by creating many objectionable side effects, which may limit rather than enhance their quality of life.1 Patients might want to see how they feel and function once their psychotropic drugs are reduced and/or discontinued. They might also wish to be drug free. When this request it made, I usually tell then something along the lines of: "I need to see that you are stable for at least 6 months before there is any consideration of reducing and/or discontinuing your psychotropic medication. By 'stability,' I mean getting along well with family and friends; maintaining some type of regular work or employment, such as school, a volunteer position, or a career; and having no more disabling symptoms of your psychiatric disorder."
This is usually well received, since most patients prefer to work in a slow, methodical fashion, rather than becoming destabilized should this process be rushed.
Difficulties in Overcoming Pharmacological Dependence
Pharmacological dependence is an expected and biological adaptation of the body becoming long habituated to the presence of psychotropic drugs.2 Since psychotropic drugs can induce unpredictable global reactions when used properly, there are no reliable ways to predict how patients will overcome pharmacological dependence once their psychotropic drugs are tapered and eventually withdrawn.3,4 Every patient's withdrawal process is unique, as is his or her susceptibility to develop withdrawal side effects.5
One helpful barometer of potential success is the length of time of psychotropic drug use. In one report, patients taking psychotropic drugs for less than 6 months were more successful at tapering off (81%), compared with patients on drugs for more than 5 years (44%), and patients on drugs between 6 months and 5 years (a little over 50%).5
Discontinuation Reactions Following Cessation of Psychotropic Drugs
Some patients do fine and experience little withdrawal, while others have become so habituated to and dependent on their psychotropic drugs that stopping them is paramount to disaster. While no ethical clinician would instruct a patient to abruptly stop taking his/her psychotropic drugs, it is important for clinicians to recognize discontinuation reactions connected with the common classes of psychotropic drugs.
Possible Discontinuation Reactions when Psychotropic Drugs are Stopped Abruptly6–8
Drug Type
Antidepressant Drugs |
Reactions from Abrupt Discontinuation |
Tricyclic Antidepressant drugs |
Anticholinergic discontinuation syndrome, characterized by nausea, vomiting, abdominal cramping, sweating, headache, and muscle spasms; other symptoms, such as rebound anxiety, restlessness, sweating, tremors, abdominal pain, heart palpitations, headache, hypertension, vivid dreams, and nightmares |
| Monoamine Oxidase (MAO) Inhibitor drugs |
At risk for diet (i.e., tyramine-containing foods) and drug reactions for 2 weeks; symptoms include flu-like symptoms, dysphoria, restlessness, tachycardia, hypertension, and a delirium-like state characterized by excitation or psychosis. This does not happen with transdermal selegiline |
Selective Serotonin Reuptake Inhibitor (SSRI) drugs |
Dizziness, weakness, nausea, headache, lethargy, insomnia, anxiety, poor concentration, and, rarely, paresthesias |
| Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) drugs |
Serotonergic discontinuation syndrome described previously, and norepinephrine adrenergic effects that result in urinary urgency and increased gastrointestinal motility |
| Antipsychotic Drugs |
|
First-generation antipsychotic/FGA drugs and second-generation (atypical) antipsychotic/SGA drugs |
With FGA and SGA drugs, patients will have earlier and more severe illness episodes (i.e., dopamine supersensitivity psychosis); patients can also develop withdrawal dyskinesias (similar to tardive dyskinesia) and, less commonly, parkinsonism symptoms, dystonias, and neuroleptic malignant syndrome; other symptoms include anticholinergic discontinuation syndrome (described previously), rebound anxiety, restlessness, sweating, tremors, abdominal pain, heart palpitations, headache, and hypertension |
| Mood-Stabilizing Drugs |
|
Lithium and anticonvulsant drugs |
With lithium, sudden discontinuation is associated with mood instability and increased risk of mood relapses; with anticonvulsant drugs, patients at risk for mood destabilization, increased anxiety, agitation, and sleep disturbances; with carbamazapine discontinuation, patients on other medications will be at increased risk of drug adverse effects and toxicity due to decreased liver metabolism and increased serum concentrations; with valproic acid and divalproex sodium discontinuation, patients on other medications will be at increased risk of less efficacy from their coprescribed medications due to increased liver metabolism and decreased serum concentrations; discontinuation of topiramate can lead to weight gain |
| Antianxiety Drugs |
|
SSRIs (previously described) and benzodiazepine drugs |
Insomnia, gastric problems, tremors, agitation, fearfulness, muscle spasms, and, less frequently, irritability, sweating, depersonalization, hypersensitivity to stimuli, depression, suicidal behaviour, psychosis, seizures, and delirium tremens |
Tapering Patients off their Psychotropic Drugs
When it is appropriate for this to happen, I usually communicate in writing to the patient's prescribing clinician (i.e., the general/family practitioner or psychiatrist) that our mutual patient is doing well and wants to try discontinuing one of his/her psychotropic drugs. I have made many requests to my patients' prescribing clinicians (e.g., psychiatrists), particularly about switching from a psychotropic drug with a short elimination half-life to a similar psychotropic drug with a longer elimination half-life prior to tapering.
In the majority of cases, the prescribing clinicians have cooperated with me and agreed to the proposed tapering strategy. However, if the prescribing clinician does not agree to any plan of psychotropic drug tapering, despite the patient's wishes and noted stability, it is entirely appropriate for the patient and the nonprescribing clinician to proceed with a tapering plan. In such a circumstance, it might be suitable to draft a waiver (i.e., a release) outlining all potential risks and benefits of psychotropic drug tapering and review this with the patient. This waiver would clearly delineate that this is what the patient wants, and that the patient is willing to assume all risks (e.g., destabilization and hospitalization) associated with the tapering process.
Since there is a scarcity of clinical research pertaining to tapering patients off psychotropic drugs, there are no clearly defined standards informing clinicians about the most appropriate method of tapering. Patients are just as likely to succeed in coming off their psychotropic drugs when they have support and endorsement from their prescribing clinicians as when they do not.9 The published data from one organization found that 53% of patients were successful in coming off their psychotropic drugs – even though this was either against their doctors' advice or occurred without their doctors' knowledge – compared with 44% who had their doctors' approval.5
Overall, the tapering plan needs to be very slow and gradual to reduce the potential for relapse.1 The patient should never be made to feel like a failure during this process, since coming off psychotropic drugs is very difficult due to the "physiological and psychological manifestations of the biological effects caused by the withdrawal of a regularly-administered drug."1 For patients to successfully come off psychotropic drugs they need to: (1) be well prepared and informed about the process; (2) have a positive attitude; (3) keep in mind that they will experience strong emotions throughout tapering and possibly for months after; and (4) receive some type of regular psychological support (e.g., psychotherapy, art therapy, support groups, etc.) during the tapering and perhaps beyond.9,10
A good rule of thumb is for the tapering duration to be for the same length of time of previous psychotropic use.10 For example, if a patient was taking a psychotropic drug for 6 months, the tapering process should last for 6 months. The only exception involves patients who have been on psychotropic drugs for 5 or more years. The tapering process for these patients should be approximately 18 to 24 months.10 However, each patient situation is different, so the time allotment for tapering needs to be individualized to the patient's needs and to what is possible.
The tapering plan should involve one drug at a time and reduce the drug with the longest elimination half-life first. Psychotropic drugs with longer elimination half-lives (i.e., more than 24 hours) are easier to taper, since their withdrawal reactions tend to be less severe than drugs with shorter elimination half-lives (i.e., less than 24 hours). Psychotropic drugs with short elimination half-lives can produce significant and quick withdrawal reactions. Considerations should be made to switching patients from psychotropic drugs with short elimination half-lives to drugs with longer elimination half-lives prior to tapering, as this will increase the chances of a positive experience and successful outcome. A psychotropic drug such as venlafaxine (which has an elimination half-life of around 5 hours) can cause significant withdrawal and possible destabilization. A psychotropic drug such as fluoxetine, on the other hand, can be used as a substitute for venlafaxine, allowing for a more successful tapering plan, since the elimination half-life of this drug is 4 to 6 days.9
One report suggests that for each unspecified tapering period, there should be a 10% reduction in dose, meaning that the psychotropic drug gets reduced by subsequent 10% reductions until the patient is comfortably off his/her medication.9 Another report suggests that the psychotropic drug is tapered down every 2 weeks, so that after each 2-week tapering period, the dose is further reduced by 10%.10 If a patient, for example, begins the tapering process on a drug that is 400 mg once daily, then the dose to take for 2 weeks would be 360 mg. After two weeks, the dose would be further reduced by another 10% to 320 mg and so on. This process would continue until the psychotropic drug is fully discontinued. If the patient feels that the reduction is too marked or there are troublesome withdrawal reactions such as anxiety and sleep disturbances at any time during the tapering, the patient can remain on the previous tapered dose until he/she feels well enough to proceed.
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