“I trusted my providers so I kept taking more and more medications when they told me I should. After a few years, I couldn’t remember what each medication was for. I started having side effects, so I tried to stop taking them—but that made me feel even worse! After that, no one would give me any advice on how to stop them! I feel trapped!”
–An All-Too-Common Patient Complaint
At Benson Behavioral Health, a psychiatric practice serving Oregon, we are available for an initial evaluation within one week. Click HERE to request a free consultation.
Disclaimer: This blog post is not intended to provide medical advice. Consult an expert before making any adjustments to your psychiatric medications.
Since the discovery of Thorazine (chlorpromazine) for the treatment of schizophrenia in the 1950s, the field of psychiatry has increasingly focused on prescribing medications to manage mental health conditions. This approach has produced tremendous benefits to society: millions of people worldwide feel that psychiatric medications have literally saved their lives. However, all too often patients are prescribed medications that have limited effectiveness, may be causing harm, or may no longer be necessary. Recent research shows that one in six Americans takes at least one psychiatric medication, and many take more than one. In response to this research, a new movement in medicine known as deprescribing has developed that focuses on intentionally reducing doses of, or gradually stopping medications. This movement started among clinicians specializing in the treatment of the elderly, but it is growing in popularity with providers caring for the general public who are interested in stopping psychiatric medications.
In this blog post, we’ll discuss the process of stopping psychiatric medications.
Step One: Establish Mutual Trust
The bedrock of any successful therapeutic alliance is mutual feelings of respect and trust between the patient and the provider.
The deprescribing process can be stressful. If a patient does not trust the clinician’s judgment, they will be more likely to second guess the treatment plan which can yield feelings of anxiety, depression, or resentment toward the clinician.
In addition, many individuals will want to finish the process of tapering medications faster than is recommended. The consequences of rapidly stopping medications can vary based on the medication, dose, and past length of treatment. Possible effects of stopping medications too fast may include depression, irritability, nausea, anxiety, insomnia, or thoughts of suicide. Some medications like benzodiazepines (Xanax, (alprazolam) Ativan, (lorazepam) etc.) may even be physically dangerous to abruptly stop. Due to these hazards, the clinician must be able to trust that the client will accurately report the negative effects of dose reductions and that they will carefully follow the prescribed plan.
Step Two: Clarify the Mental Health/Psychiatric Diagnosis
Patients are at the greatest risk of being overmedicated when their diagnosis is unclear, or if they are believed to have several co-occurring mental health conditions. For example, data suggests that individuals diagnosed with bipolar disorder or post-traumatic stress disorder are likely to take as many as five psychiatric medications.
Our current psychiatric diagnostic system, known as the Diagnostic and Statistical Manual (DSM) relies mainly on symptoms to identify mental health conditions. For example, an individual is likely to be diagnosed with bipolar disorder if they report experiencing at least one period of elevated or irritable mood lasting at least four days, as this is considered the main symptom of this condition. However, the symptom of irritability is trans-diagnostic: it is frequently seen in many common conditions including substance use disorders, attention-deficit/hyperactivity disorder, autism spectrum disorder, schizoaffective disorders, schizophrenia, major depressive disorder, and personality disorders to name only a few. Clarifying the diagnosis is critical as it guides the treatment plan and most of these conditions are likely to benefit from entirely different treatments than bipolar disorder.
Instead of focusing on symptoms alone, clinicians also need to consider each possible diagnosis’ other diagnostic verifiers including the age of onset of illness, course of illness, response to treatment, and genetic history. Consider this comparison of bipolar disorder with borderline personality disorder adapted from work by noted psychiatrist Dr. Nassir Ghaemi:
| Bipolar D/O | Borderline PD | |
| Symptoms | Euphoric/irritable mood Decreased need for sleep | Euphoric/irritable mood Self-injurious behaviors |
| Genetics (Family History) | Very heritable | Non-specific |
| Course | Severe/recurrent mood episodes | Disproportionate history of childhood sexual abuse |
| Medication Response | Frequent cure | Modest effects |
Clients with many conditions including personality disorders, PTSD, and autism spectrum disorders generally benefit only modestly from pharmaceuticals. Unfortunately, they are also more likely to be prescribed multiple medications and/or high doses. If medications are used, they should be recommended only for a limited period and in conjunction with non-medicinal treatments like psychotherapy. These are clients who should consider consulting an expert to discuss stopping psychiatric medications.
Step Three: Consider Benefit vs. Risk
The more effective a medication is, the riskier it is likely to be. Pharmaceutical companies now release drugs that are less effective than the ones that came before them but are safer and better tolerated. Our most effective treatment for bipolar disorder is lithium which requires routine blood monitoring. Our most effective treatments for depression are the MAOI anti-depressants which can cause dangerously high blood pressure in some situations and can have serious interactions with many other medications.
Many common psychiatric medications can cause harm. Zyprexa (olanzapine) and Seroquel (quetiapine) can cause significant weight gain. Depakote (valproate) can cause hair loss, memory issues, fetal malformations, and polycystic ovarian syndrome. SSRIs/SNRIs like Zoloft (sertraline), Celexa/Lexapro (citalopram/escitalopram), and Effexor/Pristiq (venlafaxine/desvenlafaxine) can cause withdrawal symptoms if stopped abruptly.
All medical treatments require a careful balance of benefit and risk. However, the appropriate balance of risk/benefit is different for every individual and can only be properly assessed by an experienced provider. If a client is taking a potentially harmful medication for a condition they do not appear to have, or one that has resolved, they should consult an expert and consider gradually stopping that agent.
Step Four: Recognize That Some Medications Probably Shouldn’t Be Stopped
Many medications work better if taken for a long period of time. For example, the “mood stabilizers” Lithium, Depakote (valproate), Tegretol (carbamazepine), and Lamictal (lamotrigine) are generally used as “maintenance” treatment for bipolar disorder. Assuming an individual has a clear history of bipolar disorder, is feeling well, and is not experiencing a significant side effect or is at high risk for side effects, we generally recommend ongoing treatment. We are likely to make similar recommendations for individuals with a clear history of schizophrenia taking antipsychotics as well as those in remission from severe, recurrent cases of conditions including depression, anxiety disorders, or obsessive-compulsive disorder.
In tough situations, we may suggest optimizing your treatment rather than deprescribing. For example, if you experienced significant weight gain with Zyprexa (olanzapine) but also clearly benefit from it, we may propose a transition to a similar medication that is weight-neutral.
Step Five: Carefully Stop Psychiatric Medications
Minimal formal research exists regarding the process of stopping psychiatric medications. However, in our opinion, providers of high-quality care follow these guidelines:
- Taper or stop only one medication at a time
- Perform frequent follow-up sessions (generally every one to four weeks)
- Frequently consider slowing, stopping, or reversing the taper as appropriate
- Consider switching to a drug of the same class with a longer duration of action (e.g., from the SSRI Paxil (paroxetine) to Prozac (fluoxetine))
- Consider the short-term use of adjunctive medications to prevent withdrawal symptoms (e.g., gabapentin to control symptoms of benzodiazepine withdrawal)
- Carefully monitor for recurrence of psychiatric symptoms on every session (e.g., depression, anxiety, mania, psychosis, etc.)
Key Takeaways to Stopping Psychiatric Medications:
- Deprescribing is the process of gradually stopping medications that have limited effectiveness, may be causing harm, or may no longer be necessary.
- An expert can determine which medications are necessary only after careful consideration of your psychiatric diagnosis.
- People should take medications only when the benefits of doing so outweigh the risks.
- The risk/benefit ratio of a medication regimen can only be determined by an experienced clinician.
- Medication tapers must be performed slowly and carefully.