Discontinuing Long-Term Medication Use
When deciding whether to start using a psychotropic medication such as an anti-depressant, there is often concern over whether this choice will become a life-long sentence and what the consequences could be if you choose to discontinue the medication later on. Today we discuss the risks and benefits of psychotropic medications as well as what we know about the long-term effects of their use.
There are very real reasons to start taking psychotropic medications
Often if a person is considering using a psychotropic medication it is because they have significant symptoms that affect their day to day life and ability to function. In these cases, medications can bring quick relief and sometimes that is essential. Medications can also help someone get started with the lifestyle changes such as beginning an exercise routine or improving the diet, when they are not able to find the motivation to do self-care activities due to serious depression symptoms. So when symptoms are more severe starting medications right away can be the best option.
Yet when someone is experiencing mild to moderate depression or anxiety symptoms, I recommend taking at least three months to try alternative treatments. Other interventions include lifestyle and diet changes, psychotherapy, supplements and laboratory testing to screen for any medical issues or vitamin deficiencies that may be contributing to symptoms. If the lifestyle interventions are not sufficient for improving mood and function after three months, then we come back to the discussion about medication treatment. While psychotropic medications can provide relief from many different symptoms, they can also cause side effects of their own which reduce the overall benefit. The length of antidepressant or other medication treatment varies depending on the condition, symptoms and individual circumstances, yet in general, a typical course of treatment is six months to one year. After six months to one year, I recommend checking in and reevaluating the need for medications.
Discontinuing psychotropic medications
If symptoms are improved and it’s time to stop medications then speak to your psychiatrist about making a plan for a taper. While tapering off medications is relatively easy for most people when following a reasonable and gradual dose reduction schedule, going too fast can have negative side effects. For some, even going down slowly can cause withdrawal symptoms and so it is important to be systematic and intentional when tapering. It is also important to reduce medication dosage gradually so that you can notice the return of any underlying symptoms that were being treated by the medications.
A recent New York Times article put medication discontinuation in the spotlight by reporting that the stopping of antidepressants often results in severe withdrawal symptoms (what is called “discontinuation syndrome”) for many people. In clinical practice I rarely see severe withdrawal symptoms when we follow a slow taper schedule and address underlying mental health conditions, biological factors, and lifestyle factors and put in place nutritional supports such as detoxifying supplements. But the truth is that we don’t yet know how to predict who may have more trouble discontinuing psychiatric medications and who may not. It is reasonable to expect that individuals who used medications long term (10 years plus) may have more withdrawal symptoms when coming off and may need far longer taper schedules. The reality is that these problematic withdrawal symptoms can potentially affect anyone tapering off of medication, and unfortunately, sometimes this causes people to remain on medications longer than they would have otherwise wanted or needed to.
Effects of discontinuing psychotropic medications after long-term use
There are many different medications designed to address a range of mental health problems, everything from anxiety (which affects many people and which is often easily treatable) to schizophrenia (a chronic condition often requiring lifelong treatment). And scientific research has supported the use of these medications - at varying dosages and for different periods of time - in the treatment of mental health disorders.
As the New York Times article illustrates, the reality is that most anti-depressants were approved for short-term use in research studies that only lasted an average of two months. There is much less data available to illustrate the effects of long-term use, and yet despite this lack of evidence, some doctors and psychiatrists were still prescribing these medications for long-term use. These patients, who have now been taking antidepressant for long periods of time, and giving doctors and researchers a clearer picture of the effects of such long term use.
Unfortunately, the real-world experiences of people discontinuing long-term anti-depressant use have not been favorable. As noted, people are reporting symptoms of withdrawal and science supports the presence of a withdrawal syndrome in many individuals stopping a serotonin reuptake inhibitors (SSRIs). While the recommended approach has been to taper off such medications gradually, for long-term use there is no set of scientifically proven approache to precisely guide the process of discontinuation. This is challenging, especially for people who are at high-risk of relapse or other psychological problems if discontinuation does not go well.
Certain medications are more difficult to discontinue than others. Those that are more challenging have a shorter half-life (which means they quickly leave the body’s systems such as Paxil, Effexor and Cymbalta) and the effects of their leaving the body quickly can be more pronounced. Common withdrawal symptoms include nausea, headache, and dizziness with some people also experiencing electric shock sensations in the brain and paresthesia (tingling sensations in the body). Symptoms often last two weeks or longer and research suggests that they may be the result of a stress response in the brain caused by the chemical changes.
Working to reduce withdrawal and the effects of discontinuation
To avoid such intense withdrawal symptoms, some people are turning towards their own microtapering approaches which draw out the discontinuation process. Online resources may advise on the microtapering process which involves taking incrementally smaller amounts of compounds; however, such online resources cannot replace the advice of a trained doctor or psychiatrist who can respond to your unique needs and monitor your health throughout the process.
Even for people considering microtapering, other things need to be in place to protect them against the effects of withdrawal. Essentially, people need to prepare their body and brain for the change they are about to experience. Many people with mental health problems have blood sugar that is out of balance, immune system dysregulation, and internal inflammation that causes or at least exacerbates their symptoms. Taking these concerns into account, it is helpful to address diet and nutrition in order to properly prepare the body for tapering.
Research has also found that gut health can influence brain health. A history of eating overly processed foods can lead to problems in the gut/brain axis, which can be corrected with dietary changes, probiotics, and other gut healing methods such as elimination diets and supplements. Conditions such as adrenal fatigue can also be a factor that would need to be addressed. Essentially, the body needs a check-up and tune-up before starting the process of stopping psychotropic medications.
Beyond preparing the body, the mind must also be ready for the shift off of psychotropic medications. Often, the initial mental health problems started as a result of difficulty dealing with stressors or as a deficit in resiliency when faced with life changes, challenges, and setbacks. To prepare the mind for the discontinuation of psychotropic medications, therapy can help to strengthen a person’s ability to manage stressors and be resilient in the face of difficult life events. Also if the medication was actually treating the underlying symptoms and the underlying depression or anxiety returns in full force, you may not be dealing with withdrawal but rather with the resurfacing of the original symptoms.
Final Recommendations
The problems we face when discontinuing psychotropic medications are compounded by the fact that many people are prescribed psychotropic medications by their primary care provider. While this can be appropriate for short-term use, it is less ideal for long-term treatment. It is recommended that people interested in addressing their psychological conditions see specialists in the mental health care field. Therapists can often help clients identify the underlying problems and develop coping skills that will provide long-term benefits.
Integrative Psychiatrists are also an optimal choice if therapy is not sufficient to address the mental health symptoms. An integrative provider can take a holistic approach which may include therapy, nutrition changes, supplements, and psychotropic medications as needed. Psychiatrists have specialized training to prescribe and monitor medication use, and then assist with a healthy, safe discontinuation.
If you are currently on medications and want not to be, consider reaching out to an integrative psychiatrist. They can assess your unique situation, help determine whether discontinuation is appropriate, recommend a safe process for discontinuation, monitor any symptoms of withdrawal, and help you to maintain your mental health throughout the process.
Ultimately, each person’s situation is unique and will determine whether they may benefit from the short or long-term use of medication. What is universal is that everyone wants to live a life that is healthy and happy and there are trained providers who can offer support. It can be helpful to ask potential providers about their views and approach to medications to make sure they are in line with your own, and to ensure the greatest therapeutic benefit to you.
Our team of care providers is also here to offer support and information if you are interested in tapering off of medication. Our integrative psychiatric nurse practitioners, Kathleen Fentress Tripp and Natasha Felton, and Dr. Beata Lewis MD are experts in medication management and can work with you to establish a tapering schedule that works for you.
Whatever your situation, if you are currently taking psychotropic medications and thinking about discontinuation, do not do it alone. Speak to a healthcare provider to reduce your risk of side effects and optimize your short and long term mental health.
