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We can sum up the most prudent and sensible way to stop taking psychiatric drugs in one short sentence: Plan it well and go slowly. Regardless of the drug you are using and the problems it may have created in your life, a well-planned, gradual withdrawal has the best chance to succeed. Conversely, an unplanned, abrupt withdrawal increases the risk of undue hardship and may lead you to return, in an equally unplanned manner, to taking drugs.
In this chapter, we offer a rational, person-centered program of withdrawal from psychiatric drugs. By "rational", we mean that it rests on sound clinical principles and evidence. By "person-centered", we mean that it seeks to help individuals take charge of the withdrawal process. Anyone considering coming off psychiatric drugs, or advising a relative, a friend, a client, or a patient on this issue, should read this chapter carefully. In Chapter 8, we discuss the actual process of reducing your drug intake down to zero. Then, in Chapter 9, we review the specific withdrawal reactions associated with various types of psychiatric drugs. In Chapter 10, we discuss how to help your child come off these drugs.
The withdrawal process may be likened to a journey. Before undertaking a journey especially one with an unfamiliar destination, you would probably find it useful to plan your steps, to make an inventory of the essentials to bring along, and to anticipate potential obstacles, allies, and resources. You wouldn't be able to predict all the difficult or pleasant surprises, but you could certainly be prepared for many of the obvious ones.
Before you take the first step, though, it would be best if you know whether you really want to undergo this journey.
Choosing to come off psychiatric drugs should be your own personal decision. It would be unwise for anyone else to decide for you whether you should take drugs or stop taking them.
Opinions on the usefulness of drugs vary widely. As the reader knows by now, we believe that taking drugs to solve emotional, psychological, and social problems is at best a misleading, temporary superficial solution. But other people believe that drugs are very helpful, even life saving, and some can't quite envisage ever doing without them. We have met many individuals who deeply believe in psychiatric drugs. Some have eventually come off them and found other ways to surmount life's difficulties. We believe that until people decide for themselves what course of action to take, the best we can do is to provide accurate information and share our experience.
Taking psychiatric drugs is much more than a simple medical or technical matter. Taking drugs can seem to give meaning to a person's life; if done at the urging of an authority it may be the nearest thing to a religious ritual that you have ever experienced. Your values and ideas about human nature and personal growth, and about the sources of psychological suffering, will influence whether or not you choose to take psychiatric drugs. In turn, taking drugs will come to color your values and ideas (see Chapter 12).
As noted, the decision to take or to stop taking psychiatric drugs should be a personal one. It should not be trivialized by glib acceptance of pseudo-medical arguments from your doctor or others such as "This drug is the most effective treatment for your serious illness" or "This drug corrects biochemical imbalances in your brain" or "Never fail to take this medication; it's just like insulin for diabetes".
In the field of mental health, not a single physical explanation has been confirmed for any of the hundreds of psychiatric "disorders" listed in the DSM-IV. A recent editorial in the American Journal of Psychiatry states the case plainly: "[A]s yet, we have no identified etiological agents for psychiatric disorders" (Tucker, 1997 [374], p. 159). Even in this age of biological quick fixes, an increasing number of researchers are documenting the observation that nondrug approaches produce equivalent or better results than drugs. This is true even for problems considered extremely serious, such as "schizophrenia"109. Your doctors claims to the contrary have little or no scientific basis.
Yet even well-educated people may be deeply impressed by psychiatric , propaganda that appeals to their insecurities. Precisely because there is so little solid scientific backing for the use of psychiatric drugs, mystification and slogans are often communicated to doctors by drug advertising, and then to patients by doctors110.
Therefore, the first principle of rational psychiatric drug withdrawal is to decide for yourself that you want to do it. Even though taking psychiatric drugs has become a fad, pushed by drug companies and doctors, withdrawing from drugs should be a well-thought-out individual decision.
Deciding for yourself requires that you take responsibility for the outcome of your withdrawal. Regardless of the difficulties you might encounter, you should not blame others. By the same token, you should take pride in your own accomplishments. Coming off drugs in the most rational way possible often requires planning and preparation, strength and determination, and patience.
If others influenced you to take drugs in the first place, and if your own wishes were not respected, you may find it more difficult to decide for yourself to come off the drugs. If you depend on others for your economic or physical sustenance - as do many people who take neuroleptics, such as Risperdal, Seroquel, Zyprexa, and Haldol - the decision to withdraw from the drugs may be harder to make. If you've taken drugs for many years, you might not remember exactly when and why you started on them. Or if family members or your doctor are adamant that you remain on the drugs, you understandably may not wish to risk alienating these people. These are difficult circumstances, and there may be no easy solution.
True health emergencies only occasionally occur during a well-planned, gradual withdrawal. Our impression is that most people who come off psychiatric drugs have successfully done so on their own, without active clinical supervision. Yet it can sometimes be dangerous to try to withdraw without professional supervision. We believe that most people would benefit from the support of a qualified, experienced therapist or clinician who is sympathetic to their wishes. This person could be a psychiatrist, a general practitioner or other medical doctor, a pharmacist, a clinical social worker, a psychologist, a nurse, or a counselor with training or experience working with people who take prescription psychiatric drugs.
A therapist should feel free to communicate clearly to patients or clients, and often to their families, that withdrawing from psychiatric medications is a reasonable choice with great benefits for many people. The therapist should also communicate that the choice remains with the client or patient, that each person's case is unique, and that any withdrawal strategies should be tailored to the individual's needs, often with the involvement of friends and family. The emphasis always remains on the patients right to choose whether to stay on medications or to stop them. Some people may need encouragement to break out of a destructive cycle of using medication; others may need reassurance that they will not be pressured to stop their medication unless they are facing serious risks of toxicity (Cohen, in press).
We find that patients and clients often want to learn in detail about the health professionals experience in helping people withdraw from specific drugs. They should expect their health practitioners to provide in-depth answers about their knowledge and experience.
Most clinicians are not well versed in the techniques for helping people to withdraw from psychiatric drugs. Some are plainly hostile to the idea, especially in cases involving neuroleptics, lithium, or antidepressants. Indeed, if you are reading this book to get help in stopping psychiatric drugs, its possible that you've already discussed this intention with your doctor but were not able to "get through" to him or her.
An experienced therapist can be helpful precisely because he or she has observed withdrawal reactions and knows that most tend to subside within a few days or weeks. Hearing that you are experiencing a withdrawal reaction, rather than "losing your mind", may be enormously reassuring. In addition, the therapist may be able to identify a potentially severe withdrawal reaction.
A caring and empathic therapist can also work with you on the psychological and practical issues that are bound to arise as you reduce your drug intake, begin to experience your problems differently, and seek solutions for them other than drug use. One of the main challenges of drug withdrawal is not the withdrawal itself but, rather, how you live your life after withdrawal. A good therapist can provide you with the encouragement and advice you will probably need as you rebuild your life on more secure footing without drugs.
Having a doctor on your side may also ease the anxiety that friends or family members are feeling about your plans. And since mental health professionals are often connected to a network of colleagues who can give them advice about specific problems that arise, they are likely to have ready access to medical or psychological information and to be able to help you make sense of it.
As a first step, you may wish to inform your doctor of your intentions concerning withdrawal. You can ask for help in developing a schedule of tapered doses and a list of likely physical and emotional reactions. If you are taking benzodiazepine tranquilizers (i.e., "antianxiety" drugs such as Ativan, Klonopin, Valium, or Xanax), your request should be easily met. Chances are that your doctor will actively support your desire to stop taking sedatives, sleeping pills, or tranquilizers. These drugs are less popular, in fact, they are viewed as decidedly dangerous by many informed physicians. Even doctors who believe that your anxiety is a chronic illness requiring lifelong medication may be sympathetic to your desire to stop taking benzodiazepines. Many physicians have seen too many patients addicted to benzodiazepines; they realize that these patients are suffering from "benzo blues" (Drummond, 1997 [135]) rather than from their original anxiety or stress.
If your relationship with your doctor is not based on trust, you will probably find it awkward to broach the subject of drug withdrawal. If you are not used to being honest with your doctor or generally disclose only a limited amount of information about yourself for fear that your doctor will increase your dosage or add new drugs, then expressing your intention to come off drugs might strain the relationship.
If you are taking psychiatric drugs other than tranquilizers, and especially if you've had one or more psychiatric hospitalizations or a suicide attempt in the past, your doctor may be very hesitant to support you and might even become antagonistic. Try to remain calm, however. Displaying agitation over your doctor's negative reaction could be counterproductive in the planning of your withdrawal process. Instead, try to understand your doctors perspective.
Your doctor is probably committed to believing that pills are indispensable, especially if he or she lacks knowledge about counseling and empathic listening. Chances are that most of his or her recent training or continuing education has focused on classifying patients in diagnostic categories so as to prescribe drugs for them. Moreover, if your doctor is a general practitioner, he or she probably attends annual conferences in which doctors are urged to recognize "hidden cases of depression" and "underlying anxiety" and to quickly prescribe drugs. Shifting their problem-solving abilities toward nondrug options can pose major challenges to doctors' expertise and professional identity. Many different types of mental health professionals offer psychological services, but only medical doctors prescribe drugs. If you have come to see a physician, there is a built-in expectation that you want and need - and will very likely get - a drug111.
Precisely because many doctors express a negative or antagonistic attitude about drug withdrawal - especially withdrawal that the patient initiates, controls, and evaluates - they are not likely to accept or welcome reports of positive results. Our clinical experience indicates that when patients successfully stop taking psychiatric drugs on their own, they usually do not tell their former doctors. Patients are even less likely to tell their doctors if the relationship was superficial or centered around the prescription. Frequently patients are too angry or afraid to communicate with the doctor, or feel insufficiently cared for. Thus the doctors simply do not learn that withdrawal can be accomplished effectively and frequently results in substantial benefits.
However, if your doctor is open-minded and genuinely interested in your welfare, you should definitely discuss the issue with him or her. You will need to describe calmly the goals you are trying to reach and the nature of your withdrawal and rehabilitation program. If you detect resistance from your doctor, you might try to negotiate certain conditions under which the doctor will agree to supervise your withdrawal.
You might point out to your doctor that you have been "stable" for some time, and explain that, since drugs do not cure any problem but only help suppress some symptoms, you feel it's time for you to try to control them yourself. You could also remind your doctor that when things go well, its your drug that gets praised; but when things go wrong, it's your "illness" that gets blamed. If you insist on discussing the issue, calmly but firmly, and if you share the plans you are making to ensure that the withdrawal will be successful, there's a good chance you will be able to earn your doctor's support.
This is not to say that you should let your doctor control the withdrawal. Even if you have been given every possible reason to believe that he or she understands the withdrawal process, it has to feel like a collaboration.
And since physicians often withdraw patients too abruptly from psychiatric drugs, above all else you must feel free to slow the process down.
Sometimes, as we discuss in Chapter 9, doctors cut the dose by half from one day to the next, while still calling this a "gradual" withdrawal. Such an abrupt reduction is an imprudent strategy in most cases. Because of ignorance, lack of experience in patient-centered withdrawal, or even an unacknowledged wish to sabotage your effort, your doctor may rush ahead and create unnecessary complications. The unfortunate outcome will then be used to prove to you that withdrawal was a bad decision to begin with.
Some of the steps discussed in later chapters of this book, such as seeking replacement solutions and mastering techniques to cope with various manifestations of your problem, will help you to show your doctor that you are motivated, responsible, and capable of withdrawing successfully.
One woman who was prescribed an antidepressant and two tranquilizers for three years said to us: "I told my doctor that if she didn't help me [to withdraw], I was simply going to do it alone. She didn't misjudge my determination and turned out to be very cooperative. She looked up a few references, gave me advice to go slow, and called me once a week. She later told me that she learned a lot from me."
If attempts to enlist your doctor's cooperation or assistance fail, you should be neither surprised nor discouraged. Remember that you, and no one else, will do the actual "work" of coming off drugs. You will feel - the pain, and you will experience the rewards. You will have to deal with the objections and fears of those around you who resist the idea that at least some of your current problems are actually drug-induced. You must therefore try to be in charge of the entire process from the very beginning, from the very first moment you decide for yourself that coming off drugs is your goal.
At best, your doctor will support and even encourage your desire to live a drug-free life; provide you with factual, medical information on withdrawal effects; recommend a sensible, practical tapering schedule; prescribe, if necessary, another drug that may be less unpleasant to withdraw from than the one you're currently taking; remain available for ongoing medical supervision during the withdrawal; refer you to a psychologically minded colleague for counseling during the withdrawal process; and, if you have been taking very high doses of tranquilizers for several years, possibly hospitalize you for detoxification.
At worst, your doctor will dismiss or ridicule your desire to withdraw from drugs, encourage your dependence on drugs, undermine your confidence in yourself, provide you with incorrect information, threaten you with dire consequences, and sabotage your efforts.
If your own doctor refuses to help you, consult another doctor or therapist. Bear in mind, however, that mental health professionals are likely to help you withdraw from drugs only within the context of a sustained relationship and only if they are able to entertain for themselves the idea that nondrug solutions are realistic, desirable options for a range of problems.
Pharmacists are sometimes quite willing to provide patients with withdrawal advice, especially from tranquilizers. As a whole, prodded from within and without, the profession of pharmacy changed over the last two decades, with pharmacists increasing their visibility and competence as counselors and as evaluators of physician-prescribed treatments112. Nowadays, because prescribing physicians so often fail to inform their patients appropriately many people first learn about adverse effects at the drugstore, directly from the pharmacist, or from a printout or pamphlet about the drug received as they filled their prescription.
When pharmacists provide withdrawal advice to patients, they are not contradicting a doctor's medical prescription. When they answer patient's questions about the safest ways to withdraw, they are giving vital information needed by those patients to make intelligent decisions about their future well-being. Indeed, although pharmacists are often pressured to increase patients, compliance in taking drugs, some people find in them a much more sympathetic ear than they do in their doctors. In any case, because of their specific training in pharmacology chances are that pharmacists are more knowledgeable and sensitive about withdrawal issues than most other health professionals.
Increasingly mental health professionals without medical training are intimately involved in the prescription situation. Social workers, counselors, and psychologists are today often called upon to inform their clients about medication effects and to monitor these effects when clients are medicated, and to discuss clients' ideas about medications. They serve as educators, counselors, monitors, advocates, and researchers. These professionals sometimes pursue specialized training about psychotropic drugs. As well, many in the profession of psychology are actively lobbying state legislatures to grant psychologists some form of authority to prescribe psychotropic drugs - a move strongly opposed by organized psychiatry. While we are ambivalent about further increases in the number of individuals with the power to prescribe psychiatric drugs, we can also see some potential benefits. Over the past decade many non-medical mental health professionals have gained more specialized knowledge about psychiatric drugs. Hopefully, this may give clients more options about the type of advice they receive when trying to decide whether to take, continue taking, or stop taking medications. But as of now, most professionals exercise the power to prescribe with dangerous abandon.
More than a doctor or a therapist, your network of friends and trusted acquaintances could become your most valuable resource during the entire withdrawal process. Coming off drugs is an undertaking best done with support from others, especially if you have been taking drugs for several years and have dulled or lost some of your other coping responses.
Although family members and friends can provide invaluable help, we have found that peer counselors or members of a self-help group often offer the best support. Many self-help groups, including Alcoholics Anonymous (AA), help their members to withdraw from psychoactive substances. Although we do not personally know of any "Twelve Steps" support programs designed specifically for users of psychiatric drugs, we believe that such groups might be helpful. However, beware of self-help groups in which the principal objective is to get members to accept the idea that their emotional problem is a disease, that they should consult a medical doctor for it, and that drugs are the best remedy. When these groups discuss medication issues and adverse effects, the aim is to decrease members, resistance to taking drugs.
Less structured self-help groups, such as those found in peer-run mental health centers, are likely to put you in touch with people who have successfully given up psychiatric drugs and who remain available to discuss their experience and give advice. Whether these people have freed themselves wholly or partially from drugs, they may be extremely helpful to you.
People who have been through the process of getting off psychoactive drugs will usually be nonjudgmental and accepting of your plight. They will quickly understand why you want to stop taking drugs. They will not need to be convinced that its a sensible alternative to your treatment. Possibly, they will have a more positive outlook about your chances than other people will. Even if their motives and experiences were different from yours, talking with them might show you that coming off psychiatric drugs can be accomplished without major drawbacks, while leaving you a stronger person.
Discussing your wishes, goals, and apprehensions informally with empathic nonjudgmental people - matter how novice in counseling or lacking in professional credentials they are - can be very beneficial. One way that resource persons can help you is to agree to stay in touch with you during the duration of your withdrawal. But this is not to say that they have to be saddled with the responsibility of "seeing you through" the withdrawal. After all, you must take responsibility for your decisions. And in any case, no matter how well-meaning and well-intentioned other people are, they may break their promises. So, rather than becoming disappointed in specific individuals and feeling discouraged, seek out - and make use of - as much social support as you can.
Arrange for your resource persons to talk to you on the telephone on a regular basis - once a day or a few times a week - whether you're feeling fine or not. Perhaps they could also agree to meet you on occasion to offer reassurance and advice, or simply to lend an ear. If they've been through drug withdrawal themselves, they will know that, if you're not feeling well, there is a valid reason. They will know that painful emotions and bodily sensations are to be expected. They will know that people undergoing this potentially difficult experience often lose perspective, despairing over minor drawbacks or exaggerating small victories. They will know that a few reassuring words can do wonders at critical times. They will be able to see if you need additional help, especially if your withdrawal reaction is more serious than you realize. They will also help you avoid making rash or unwise decisions about your life.
Ideally you should be helped to come off psychiatric drugs within the context of a safe, trusting relationship with an experienced, informed helper. One principle often applied in drug addiction treatment centers is to establish a trusting relationship with an individual who has been through the same process and can provide reassurance, as well as anticipate some of the difficulties involved.
In sum, the process of coming off psychiatric drugs necessitates that you build a social support network. Seeking alliances with like-minded, supportive individuals will strengthen not only your resolve but, quite likely, your abilities in other areas as well. You will feel the beneficial effects of learning to seek support from others beyond the issue of drug withdrawal.
Countless people have been too stigmatized, isolated, scared, or confused to enlist this kind of support. Forced to rely on their own resources, they have nevertheless successfully managed to stop taking psychiatric drugs. However, in the absence of medical supervision, many of these people have incurred increased risks of experiencing unpleasant and even dangerous withdrawal reactions.
The degree to which self-help support resources have taken hold in the "online world" attests to their usefulness to many people around the world. No discussion about setting up a support network to handle difficult situations would be complete without reference to the resources available on the Internet.
In his guide to online mental health resources, psychologist and Internet pioneer John Grohol writes: "It is easy to forget that the online world offers not only the ability to `browse' but also to take part in an interactive, supportive community" (Grohol, 1997 [190], p. 244). Indeed, via the Internet, tens of thousands if not millions of people discuss issues of interest and try to support each other through difficult times.
The Internet has been particularly useful in establishing connections between current and former psychiatric patients. As Grohol points out, online support is indispensable to people who live in remote or rural areas. It is also especially useful to people who have difficulty with face-to-face interpersonal relationships. Still others may find that their emotional problems are less stigmatized in the online world. Above all, the Internet offers an immediate way to "talk" with people throughout the country and around the world, who are likely to have experienced troubles very similar to your own.
Thousands of self-help discussion groups and forums flourish on the Internet. People discuss their personal difficulties, ranging from alcoholism to weight loss, and offer advice to others. In some groups, people discuss withdrawing from psychiatric drugs.
All that is required for you to begin such a discussion is to enter a forum by getting a password and posting a message. In all likelihood, you will receive several empathic and encouraging replies within a couple of days. If you are lucky, you'll receive some well-informed replies as well. Keep in mind, of course, that most participants will be expressing their personal views and opinions, which are much like those expressed in any other context. In fact, all online comments should be taken cautiously because participants will usually remain anonymous and you will lack the feedback that face-to-face or even telephone conversation provides.
The myriad Web sites devoted to mental health issues and psychiatric drugs require caution. Obviously the quality of drug-related information on the Web varies greatly. Some of the most commonly used and highly respected sites such as WebMD are sponsored by drug companies. When it comes to the topic of drug withdrawal, we have found the following characteristics to be associated with better-quality information on the Web: (1) the owner or author of the site is clearly identified, (2) the site is easily readable, (3) exact references to the literature are provided, as well as acknowledgments that most knowledge on withdrawal rests on case reports and on first-person accounts, and that most recommendations about specific tapering strategies are the opinions of experts, (4) the site does not sell or endorse "herbal", "nutritional" or other products claimed to hasten withdrawal or to greatly reduce withdrawal effects (without inducing psychotropic effects or creating the potential for future withdrawal difficulties), and (5) the site is not sponsored by drug companies, medical centers, or other groups highly vested in the pharmaceutical and medical industry.
An ongoing dialogue often develops between two or more individuals on the Internet. The following are just a few of the hundreds of messages about antidepressant withdrawal posted during the spring of 1998 on the Health for Life Center message board ( www.lexmall.com ). They are unedited (except for spelling) and, for the most part, concern withdrawal from the antidepressant Zoloft.
"This is what I have been looking for, I feel a lot better now that I have read that other people have the same type of withdrawal that I am having. I can almost cry because like you I was told no problems, just quit ... yeah, right!! I thought that I had something worse than what this may be. Thanks for having this here. I was on 100 mg of Zoloft for 6 months, and it helped. However I quit 2 weeks ago and this withdrawal is deadly I have a steady headache, I feel like I am high but the mind is still here, my body tingles, I get twitches, I am exhausted most of the time, I can't stand this anymore. I am dizzy, I have stomach cramps, I am sick. My appetite, well, for a few days I was hungry constantly; couldn't stop eating, and now though, I am still hungry but I can't eat. I wonder when it is going to stop, hopefully soon!!" [Posted by Tanya on March 26]
"Yes ... me too. However, I think I have taken a safer approach than that recommended by your doctors. I have come down gradually ... from 200 mgs to 125, to 100, to 75, to 50, to 33.3, to 25, and now to 0. The entire process has taken me about 3 months. When I first used it, I built gradually up to the 200. I experienced TOTAL sexual dysfunction, and knew that I wanted out altogether ... if I had wanted castration I would've asked! The final part the withdrawal has been the most difficult ... 25 to 0 ... and I wonder if I should've gone to 10 or 15 first. But now that I am here, I am going for broke. I have dizziness and mood swings for the last couple days, but they do not seem nearly as severe as those I read about above. I do not believe there is any other way to reduce the withdrawal symptoms. ... Feel free to `e-mail' me about any of this. Take care and hang in there!" [Posted by Ed on April 5]
"I really want to stop taking Zoloft, but I'm so scared. Withdrawal has always caused me to experience a deeper depression. I want to stop but don't know how. Anybody got any ideas?" [Posted by Kristin on April 12]
"I've been withdrawing from 100mg/day Zoloft for three weeks now. The vertigo is worse, not better. I can practically fall down just by turning my head. I'm probably not safe behind the wheel of a car. I have constant headaches, can't think clearly can't focus my eyes, and a myriad of other symptoms. I'm tired/sleepy grouchy emotionally labile. My appetite is history. I get nothing done at work or at home. My temper is so short it's practically nonexistent."
"When my doctor and I decided I'd try life without Zoloft again, I asked about withdrawal symptoms and he said, `No problem-just quit taking it'. I don't want to take drugs every day. But to avoid feeling like this, I might revise my feelings on the subject! When will this end? Ever?" [Posted by Kate on April 13]
"I was prescribed Zoloft only 2 months ago (50mg). After the first bottle ran out, I couldn't afford to get another until 2 weeks later. What I experienced in those 2 weeks was horrible! I didn't know what was wrong with me. Now, from reading these e-mails, I know that I was experiencing Zoloft withdrawal. Had I only known! Why didn't the doctor tell me about this? Now I'm afraid I'm going to feel worse trying to kick the drug. In that 2-week period, I started feeling dizzy and sick to my stomach. The dizziness was so bad at one point when I was driving that I had to pull over and park the car for a few minutes. I thought I had the flu. Then my fingers, hands, and part of my arm started to tingle. The dizziness lasted for about 7 days. The last 4 of the 7, I had started taking the Zoloft again. I've been back on the Zoloft now for 6 days. No more dizziness and the tingles are slowly disappearing. They were almost non-existent today. I told the doctor about these symptoms. He told me I probably have a virus. He also told me to keep track of the tingling and other symptoms. He said it could be the early warning signs of a disease. Apparently, doctors are uninformed and my doctor very casually prescribed it to me. How am I ever going to get off this drug?" [Posted by Joyce on April 16]
These messages vividly illustrate, in ordinary language, the great variety and potential severity of withdrawal reactions from antidepressant drugs such as Zoloft. They also express the writers judgments that their doctors were uninformed, prescribed and withdrew drugs too easily and misinformed them about the withdrawal process. As we have noted and will further discuss, although problems with withdrawal from antidepressants are neither rare nor mild, they have received scant attention until very recently.
Of particular interest, however, are the expressions of relief from some of the writers upon discovering that their discomfort is drug-induced and that they are not alone. Clearly, they received comfort and encouragement from having their experience validated by others, even complete strangers.
To succeed in your withdrawal, you should have a good idea of the "journey" ahead of you and the events and situations you are likely to encounter. You should anticipate possible problems and understand, in advance, what concrete steps should be taken to reduce these problems.
The good news is that energy, vigor, and memory often return when people stop taking psychiatric drugs. Indeed, you may well discover that you are able to think and focus more clearly that you are able to feel a wider range of emotions, and that you are more sensitive to cues from your social and physical surroundings.
You may recall that when you first started taking psychiatric drugs, your body reacted in various ways. For instance, you may have felt more sleepy, sweated more, had bouts of dizziness or nausea, noticed a tremor in your arms or legs, lost your appetite, or experienced various sexual dysfunctions. Possibly one or two of these reactions were somewhat severe, put you out of commission for a few days, and then quickly disappeared as your body became tolerant to the drug or as the dosage was altered.
You may also have reacted emotionally to these changes. Perhaps you felt relieved that the drug was actually hating an effect and thus began to feel better about some of the difficulties in your life. Or maybe you were anxious or depressed about having to put up with the physical reactions involved, worried about taking the drug for a long time, or felt apathetic about the prospect of dealing with those people around you who seem to have contributed to your personal difficulties.
Similarly, letting go of a drug is bound to create physical and psychological reactions. Your body will begin to adjust to the absence of the substance. At the same time, the knowledge that you are giving up a drug and the physical changes you are undergoing will stir up various emotions and thoughts. These physical and psychological reactions may be quite subtle or quite obvious, or both. They will often resemble the problems that led to your taking drugs in the first place.
It will help greatly to find out what you can about the withdrawal symptoms associated with the drug you're taking. In Chapter 9, we review this information in detail.
The severity of your withdrawal reactions will depend on the type of drug you're taking. For example, drugs with a shorter half-life (the amount of time it takes for the body to eliminate half of the drug) tend to produce more intense withdrawal symptoms, even during gradual withdrawal. Their withdrawal effects are also usually felt sooner after the last dose than those of drugs with longer half-lives. Information on the half-lives of drugs is almost always included in the drugs' official labels published in the Physicians' Desk Reference113.
The intensity of your withdrawal will also depend on how long you have been taking the drug and how much you were taking on a daily basis. In general, it's more difficult to withdraw from drugs taken at high doses and for several months or years.
The withdrawal process will also be influenced by your general state of health. Advancing age and chronic medical conditions, which render people more vulnerable to adverse drug effects, may also increase the difficulty of withdrawal. Sometimes, however, younger patients report more difficulties than older ones.
In addition, various subjective factors will undoubtedly play a role. Your attitude toward withdrawal is particularly significant. As we discuss below, the psychological fear of withdrawal, unless squarely faced, may represent a powerful obstacle. Your attitude toward physical discomfort is also important. For example, the urge to relieve even minor discomforts with pills may limit your willingness to put up with withdrawal-induced discomforts. Your knowledge of withdrawal reactions will also influence the way in which you deal with these reactions. Knowing in advance that you might experience a temporary withdrawal symptom will help to reassure you that the process is predictable. Finally the support and encouragement you receive can be decisive. One study has shown that even a single encouraging letter from a doctor may help patients to significantly reduce their drug intake, even in cases involving drugs that have been taken for years and are widely considered addictive114.
Coming off drugs is often accompanied by the return of some of the original distressing feelings and behaviors that led you to take drugs in the first place. In the psychiatric literature, this phenomenon is usually referred to as a "relapse". Once a drugs effects begin to wear off, your original problems may begin to resurface if their psychological or situational roots have been neglected. Also recall our discussion (in Chapter 1) of how difficult it may be to distinguish between a recurrence of your original problems and an actual withdrawal reaction.
The return of your original problems represents a crucial test of your determination and abilities, as you will be challenged to accept and deal with these emotions and behaviors through constructive means other than drugs.
Just as withdrawal symptoms vary, so does the length of time that those symptoms last. Depending on the drug you're taking, and on other factors such as your state of health, your withdrawal process may last several weeks, even months. Renewed energy and vigor, as well as subtle, unpleasant effects, may be experienced over this period. In our clinical experience, withdrawal reactions to many drugs, including the SSRI antidepressants like Paxil and the tranquilizers like Xanax, can be quite protracted, lasting a year or more, sometimes leaving permanent adverse effects.
Unless a medication has been taken for only a few days or weeks, abrupt withdrawal is never advisable. As a general rule, it may require one month of withdrawal for every year of exposure to a drug. For example, a person who has taken antidepressants for two years may require at least a two-month gradual taper. However, there are no strict guidelines and, as emphasized in the next chapter, each individual needs to find a comfortable pace for tapering a drug. The next chapter also examines the withdrawal process in more detail with specific recommendations regarding safety.
If you have been taking drugs for a long time, your lifestyle may become profoundly disrupted as you withdraw. For a few weeks, you might have difficulty sticking to your regular routines. At times, simply knowing that you're trying something different may preoccupy your thoughts to an unusual degree and leave you unable to carry out your regular duties as effectively as before.
Coming off drugs - especially strong depressants such as tranquilizers, neuroleptics, or lithium - often involves a potentially dramatic reawakening of the senses. This reawakening can lead to feelings of panic in people who do not realize the extent to which their hearing, touch, taste, or sensations of cold and heat can become unexpectedly acute after having been desensitized or anesthetized for long periods.
Withdrawal from several psychiatric drugs - especially central nervous system (CNS) depressants such as tranquilizers, many antidepressants, lithium, and antipsychotics - often provokes bouts of severe insomnia. And withdrawal from stimulants, and from the more stimulating antidepressants such as Prozac-like drugs, can induce "crashing" with sleepiness and fatigue. Infrequently the insomnia or excessive sleepiness may last several weeks.
Sleep deprivation can be frightening and emotionally disrupting. A few nights of disrupted sleep may be sufficient to make you lose your resolve. It is important that you manage to sleep between five and eight hours every day with naps during the day if needed. The mental and physical efforts involved in drug withdrawal require that you rest and renew your energy every day.
If you have a tendency to become high or euphoric ("manic"), the inability to sleep may signal that you are on the verge of a more serious emotional crisis. In this case, you may need to temporarily resume a higher dose of the drug you are taking or to seek a consultation. Also, persistent loss of sleep can make you impatient, irritable, and quick to anger. It can bring out almost any problem that you have had difficulty controlling. In general, however, a temporary period of sleeping difficulties will not be harmful over the long term.
If you find yourself overly sleepy during withdrawal, get lots of rest and try to be cautious in your physical activities. Moderate, safe exercise may be helpful. Don't resort to excessive caffeine or stimulants to stay awake. Your brain needs a break from drugs. The fatigue and somnolence should subside with the gradual elimination of the drug from your body and your brains return to normal functioning.
Those around you may fear that any unusual feelings or withdrawal symptoms are a sign that you are deteriorating or "relapsing" without your medications and need to restart them immediately. They may even pressure each other to "do something" about whats happening to you.
Often, relatives are worried about the harmful effects of drugs on their loved ones. Many of the requests for help and information we receive about drug withdrawal come from concerned family members. However, because they are also bombarded with prodrug propaganda and have so little access to nondrug options, your relatives may believe that they should pressure you to stay on drugs. Anticipate that their choices will sometimes be more restrained than yours.
If you are living with family members, or remain dependent on or closely involved with them, they will naturally have serious concerns about your withdrawal from psychiatric drugs. The problems that led to your taking the drugs may have caused them a great deal of stress and worry giving them good reason to fear that you will lose control of your emotions or behavior. If you want their encouragement, which depends in part on allaying their fears, you need to be honest about the past consequences of your behavior.
Conflicts embedded within the family itself are often unfairly blamed entirely on the person who has received a psychiatric diagnosis and is taking drugs. Thus, when you decide not to accept your previous role as a "psychiatric patient", others in the family may feel threatened. Perhaps they have become accustomed to focusing on you instead of on their own problems, or on the ways in which they have contributed to their conflicts with you. Anything you do to upset that balance might be strongly resisted by your family. Your relatives may be especially resistant if your withdrawal seems haphazard, careless, or unplanned. In sum, family members can help or hinder your withdrawal, but either way they are bound to be quite concerned.
There is no easy recipe for turning your relatives into allies during this phase. However, sharing your detailed plans about withdrawal, and about life after withdrawal, could help. Making clear your determination to act responsibly will be important to your relatives - and to you. You should also openly acknowledge the difficulties your past behavior may have caused them as well as yourself. Asking for their support in potentially difficult times will be reassuring to them and valuable to you.
Ultimately your family's fears or apprehensions will be best allayed by seeing you function well without psychiatric drugs.
As you withdraw from drugs, you may become angry about the drug treatment that you've received, especially if you were misled or forced to take drugs. The drug effects may have estranged you from some of your most powerful emotions, including your sense of outrage, injustice, and self-preservation. Some of these emotions may resurface when you withdraw. It is very important to keep your anger under control during withdrawal.
You and you alone should decide what you can bear while undergoing withdrawal. We believe that there are no hard and fast schedules. You should not withdraw at a faster pace than you desire or feel comfortable about.
Some clinicians may be skeptical about whether tiny doses of a psychiatric medication can actually help to manage or control withdrawal reactions. Despite our own initial skepticism, we have seen patients effectively use tiny doses in the last few weeks and even months of withdrawal. A few individuals have taken as little as one-sixteenth of the smallest available pill over several weeks as a means of controlling their last remaining withdrawal symptoms from tranquilizers, antidepressants, and antipsychotics. For example, tiny doses have managed the nausea associated with Zyprexa withdrawal (see Chapter 9). For some people, a sensitization to drugs115 toward the last stage of withdrawal appears to explain the impact of minuscule doses. Our experience with these people confirms the importance for each individual to withdraw at his or her own pace.
You and you alone must choose how you will stick to your withdrawal schedule when stressful and anxiety-provoking situations arise. You must decide whether or not to take pills or to increase doses on "hard" or difficult days. You must determine when you are able to use these situations to practice your skills at living without resort to drugs. The important thing is not to push yourself to any extreme in coming off drugs.
For example, when unexpectedly severe reactions are produced by withdrawal, you could reinstitute your previous dose and then proceed with a more gradual taper (see Chapter 8). If this process is well-planned, you are not likely to become overly discouraged. On the contrary you will be practicing an appropriate, measured response to your body's signals.
A detailed action plan increases your chances of success. Here are some suggestions:
Many individuals continue to take drugs not because they find them genuinely helpful but because they are afraid to stop taking them. Our interviews with patients frequently reveal that drugs do not keep their distress under good control. Many patients actually become insensitive to or hopeless about their continued suffering.
You may become disconcerted if, immediately after you start the tapering process, you feel more anxious and nervous than before. The mere knowledge that you are stopping taking drugs, or have reduced your drug intake, can cause anxiety116. You may feel compelled to resume taking drugs even before you experience actual drug-induced withdrawal effects.
The fear of withdrawal often goes beyond the fear of experiencing unpleasant physical sensations. Drug withdrawal presents a potentially frightening challenge to live your life differently without a guarantee that you'll be up to the task. This natural, almost inevitable fear may be worsened by years of being told that you have an incurable disease caused by biochemical imbalances that must be corrected with modern medical panaceas117.
Withdrawal also requires that you face the reappearance of familiar, painful emotions from the past - emotions that are best understood as signals for you to deal with the consequences of previous conflicts, abuses, or traumas. The process of withdrawal may confront you with the realization of how much your life has been driven by painful emotions - such as guilt, shame, and anxiety - rather than by well-chosen principles and a love of other people and life.
In sum, deciding to come off psychiatric drugs "forces" you to examine your behavior and lifestyle, your morals and values, your personal history. It compels you to go beyond the veneer of the drug-for-a-disease argument. It requires that you examine the role that drugs have played in suppressing your life and subduing your emotions. These are not the sorts of issues that you might readily reflect upon, but having to think about them, and perhaps discussing them with a sympathetic counselor, can become a major unexpected benefit of withdrawal. The self-aware and passionate life is the one most worth living; withdrawing from drugs can empower you to live that richer, more fulfilling life.