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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.
This stable schizophrenic patient had been on SGA drugs for 5 years prior to seeing me. She had been on olanzapine for about 1 year and then, due to objectionable side effects, was switched to 5 mg of loxapine daily. Since she had a mild form of schizophrenia, her daily dose of loxapine was well below doses typically used for more severe forms of the disorder (e.g., 30–50 mg twice daily or more). She attributed chronic stomach pain, fatigue, and dizziness to the medication and wanted to stop it. I corresponded with her psychiatrist and we agreed that the patient was stable enough to pursue my tapering plan. In addition to tapering, I further supported her mental health by adding an orthomolecular program providing daily dosages of niacin (3000 mg), vitamin C (3000 mg), omega-3 essential fatty acids (1500 mg of eicosapentaenoic acid and 500 mg of docosahexaenoic acid), and N-acetylcysteine (1000 mg). The patient is now completely off the loxapine and has not had a return of previous psychotic symptoms, which were auditory hallucinations and paranoid ideation. She has agreed to remain on the orthomolecular program for life. All of the physical symptoms that she ascribed to the loxapine ameliorated as well.
- Weeks 1–3: 5 mg loxapine every other day and 1 pill daily of Neurapas Balance.
- Weeks 4–6: 5 mg loxapine every 2 days and 1 pill daily of Neurapas Balance.
- Weeks 7–9: 5 mg loxapine every 3 days and 1 pill twice daily of Neurapas Balance.
- Weeks 10–12: 5 mg loxapine every 4 days and 1 pill twice daily of Neurapas Balance.
- Weeks 13–15: 5 mg loxapine every 5 days and 2 pills of Neurapas Balance in the a.m. each day and 1 pill in the p.m. each day.
- Weeks 16–18: 5 mg loxapine every 6 days and 2 pills of Neurapas Balance in the a.m. each day and 2 pills in the p.m. each day.
- Weeks 19–21: 5 mg loxapine every 7 days and 3 pills of Neurapas Balance in the a.m. each day and 2 pills in the p.m. each day.
- Weeks 22+: No more loxapine and 3 pills of Neurapas Balance a.m. each day and 3 pills p.m. each day for a minimum of 3 months.
Some patients may wish to taper; that is, reduce their doses to reduce side effects but retain benefits of particular medications, while other patients may wish to go off their medications altogether. Sometimes a patient needs a very low dose of a particular medication to remain stable. Thus, the tapering strategy should always consider this possibility. Patient expectations must be managed with clinical vigilance and education; otherwise, the stabilizing benefit of a very low-dose medication might be undermined by the patient's unrealistic wish to be completely free of his medication. The tapering process can teach such patients the value of continuing to take very low doses, and respect the reality that some patients will need low doses of one or more medications for the duration of their lives.
Bipolar patients who successfully go off their medications altogether are potentially at risk for cycling again into hypomania or outright mania. Schizophrenia patients who successfully go off their medications altogether are potentially at risk for a return of psychosis; therefore, in my experience, it is important for patients to understand and accept their diagnosis and know that they will need to continue taking specific combinations of natural medicines (i.e., a supervised plan of botanical medicines, nutrients such as vitamins, minerals, amino acids, and/or hormones) for life to sustain their mental stability.
Given life's uncertainties and the fact that all patients will experience periods wherein their emotional regulation and mental stability are challenged, clinicians should secure regular reassessments with their patients during the first 1 or 2 years after being off psychotropic medication. Clinicians should inform patients that they can temporarily benefit from resuming medication as needed should their circumstances warrant the immediate relief and stability afforded by medication. Clinicians should routinely check for thyroid, blood sugar, and hormone imbalances; that is, underlying medical or metabolic conditions which may have been root cause(s) or contributed to some of their patients' anxious, intense moods in the first place. This continuity between clinician and patient affords the best long-term outcome, since these particularly vulnerable patients need to have a trusting ally in their quest for improved physical and mental health.
Above all, none of the strategies outlined in this article are meant to be adopted without consulting a clinician experienced in psychotropic drug tapering. Patients should not attempt to taper from their psychotropic drugs and experience withdrawal without proper guidance and regular clinical supervision; otherwise, it is very possible to deteriorate, destabilize, and in worst cases, commit suicide.
Helping patients taper their psychotropic drugs is complicated by many factors, including their stability, support system, and the length of time they have been on psychotropic drugs. This is also controversial, since family doctors and psychiatrists often oppose tapering due to concerns of ongoing stability, and their beliefs that psychotropic drugs are required over the long term. From my perspective, mentally competent patients have the right to choose what they think is best, even if such beliefs are not held by their prescribing clinicians. This article should assist and empower clinicians to develop effective tapering strategies on behalf of their willing and mentally competent patients.
I thank Mr. Bob Sealey for his helpful editing suggestions and input on the contents of this paper. Written consent was obtained from each patient for publication of the tapering schedules in this article.
Dr. Prousky is a consultant for Pascoe Canada, the distributor of Neurapas Balance. All of the tapering schedules described in this article were developed prior to Dr. Prousky's consultancy with Pascoe Canada.
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Jonathan E. Prousky, ND, MSc
Chief Naturopathic Medical Officer, Professor Canadian College of Naturopathic Medicine
1255 Sheppard Ave. East
Toronto, Ontario, M2K 1E2 Canada
416-498-1255, ext. 235
Editor, Journal of Orthomolecular Medicine
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