Safely Stopping Antidepressants
With increasing awareness of the importance of mental and emotional wellbeing, more and more people are feeling comfortable talking about challenges they’re facing with their friends, families, coworkers and healthcare providers. They are looking for options to optimize their wellbeing and cope with challenging emotions and situations. One common treatment that people may opt for is antidepressant medication.
But once they’ve been treated with the antidepressant, how do they decide when to come off of the medication? Current Canadian guidelines recommend treatment with antidepressants for 6-9 months after symptoms improve and for 2 years for those with higher risk factors for recurrence. In general, improvement of symptoms should occur between 6-12 weeks of optimal treatment, which sometimes requires increasing the dose or switching the medication.
There are many reasons people might want to stop their antidepressant. The original event that prompted their initiation may be resolved. They may be concerned about long-term effects. They may want to become pregnant without worrying about the antidepressant’s effects on the pregnancy. They may experience unwanted side effects of the antidepressant, like weight gain, sexual dysfunction or emotional numbness. They may feel they no longer need the antidepressant or that it doesn’t seem to be doing anything. They may have learned healthy coping mechanisms and incorporated lifestyle habits that support them and they want to experience life without the antidepressant.
But when they’re exploring what it might be like to come off the medication, questions may start to arise: Is this possible? Will I relapse? Will I be in more pain than I was before? Is it safe?
These are all normal questions to be asking, and to answer them there are some considerations they need to be made aware of.
Read on to find out what you can expect and the optimal way of stopping antidepressant medications.
Note: The information provided in this article is for general informational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a qualified health provider with any questions you may have regarding a medical condition and don’t delay or disregard medical advice based on information in this article.
A background on antidepressants and conventional tapering
The number of people using antidepressants long-term is increasing, with 2/3 of people remaining on antidepressants longer than the recommended guidelines.
This is due to a variety of reasons, but one often overlooked problem is that 56% of people who try to come off antidepressants experience withdrawal symptoms. These, often severe, symptoms cause individuals to give up on the process entirely.
The most common way medical professionals advise their patients to come off of antidepressants is to “taper off”. Tapering off simply means: rather than stopping a medication abruptly, you gradually reduce the dose before stopping.
Why Taper: The reason for tapering is that when your body has become used to receiving a certain amount of medication over time, it learns to expect it. If your body expects to receive a certain dose, but then doesn’t, it has to figure out how to rebalance and adjust to this change. This adjustment, as the body is working hard to adapt, is what leads to withdrawal symptoms. To ease this adjustment, tapering is recommended so that the body can adjust one step at a time, rather than tackling a whole flight, or even multiple stories, all at once.
Tapering is very supportive when coming off of antidepressants. So what is causing people to experience disruptive symptoms when they stop their medication, even when they incorporate tapering?
Conventional Tapering - when slow isn’t slow enough.
You may have heard of a recommendation to come off of antidepressant medication by halving the dose for two weeks, halving it again for another two weeks, and then stopping it. This is an example of a conventional tapering time period - 4 weeks. And while this is slower than “cold turkey” and may work for some people, it is problematic for many.
The Slow Taper: One of the best solutions to this problem is a slow taper - a method with a higher success rate than a conventional taper. This is because it decreases doses by smaller increments, every two to four weeks or so depending on how you’re responding to each dose change. Compounding pharmacies are used here to ensure accurate and specific doses that are below doses available at your local pharmacy. A slower taper can take anywhere from a few months to a year or more. This tapering plan is personalized to you, and adjusted along the way based on how you’re feeling and life events that come up along the way.
Tapering and the Hyperbolic Curve
It’s logical to think that the relationship between the dose of the antidepressant is equivalent to its effect on the brain. For example, you might think that if you reduce your dose by 50%, you’ll reduce the effect of the medication on the brain by 50%. Research actually shows us that this isn’t the case. The relationship between the dose of the medication and its corresponding effect on the brain follows a hyperbolic curve, meaning that a smaller dose of the medication has a large effect on the brain, and as the dose gets higher, the effect that it has on the brain starts to plateau.
Source: Horowitz, M. A., & Taylor, D. (2019). Tapering of SSRI treatment to mitigate withdrawal symptoms. The Lancet Psychiatry, 6(6), 538–546. https://doi.org/10.1016/s2215-0366(19)30032-x.
To adjust for this, it’s important to reduce the dose of the medication by smaller increments when you reach lower doses. This is known as hyperbolic tapering, or the Horowitz-Taylor method of tapering.
If slower tapering is better, why does my GP recommend a faster taper plan?
The awareness of withdrawal symptoms that occur with antidepressant tapering has been coming into the spotlight more and more, however, as with many things, it takes time for this information to spread at the individual level.
There are many healthcare providers who are actively participating in research in this field and more who are aware of emerging evidence. They are advocating for greater awareness and updates to policies reflecting this change. In England, for example, The Royal College of Psychiatrists has updated their policies to recommend a tapering period of months or longer. Policies in Canada, on the other hand, continue to reflect dated expert opinion rather than current research. This isn’t to say our policies won’t be updated but rather that it will likely take time.
In the meantime, I, like many other practitioners, have studied the research and trained under experts in the field of antidepressant tapering in order to bring this option of safe tapering to people who are ready to come off of their antidepressants.
Tell me about withdrawal symptoms
Withdrawal symptoms occur while the body learns to recalibrate to a new normal of less (or no) available medication. There are many symptoms that can occur due to withdrawal, partly because serotonin receptors (the main receptor most of these medications target) are found all throughout your bodies. Symptoms can range from mood changes like sadness, irritability and anxiousness, to sleep trouble, dizziness, nausea and brain zaps. Serious withdrawal symptoms can include akathisia and risk of suicide.
How do you know if you’re in relapse or withdrawal?
Symptoms of withdrawal can often be mistaken for relapse. There are a few things we look at to differentiate between the two.
Timing: withdrawal symptoms are more likely to begin within a few days to a week or two of decreasing the dose of the medication. Relapse, on the other hand, appears over several weeks.
Symptoms: consider whether the symptoms you experience after decreasing the dose are similar to symptoms you experienced when you first went on the medication. Often, symptoms that are different point to withdrawal.
Resolution of symptoms: if you experienced symptoms after reducing or stopping your medication and decided to reinstate your medication, consider how long it took for symptoms to resolve. Often, symptoms of withdrawal will improve within hours to days whereas symptoms of relapse will take several weeks to improve.
The above considerations can be used as a guide but, like everything in life, there is no black and white answer. Every story is personal and it’s helpful to go over your experience with a healthcare provider experienced in this area.
Setting up for success
Lowering the dose of the medication slowly, listening to your body throughout the process and giving yourself the time you need to adjust, particularly toward the end, can be some of the most effective ways of safely stopping your antidepressant.
And, of course, health is multidimensional rather than linear. There are many holistic strategies you can incorporate to increase resilience prior to tapering and to cope with symptoms that may come your way. This differs from person to person, but can include prioritizing a healthy sleep routine, bringing more mindfulness into your day through meditation, grounding in nature, moving your body and eating balanced, nutritious meals.
A final note:
The decision to come off of antidepressants is not one to be made lightly and it’s important to do this at a time when you feel ready. Changes to your medications should always be done in collaboration with a qualified healthcare provider, who can work with you to go over your unique situation, develop an appropriate tapering plan and monitor symptoms that may come up, to ensure a safe and effective discontinuation of the medication.
If you want to learn more about how I can support this part of your journey, click below to schedule a FREE Intro Call where we’ll discuss more details about how tapering your medication together would look.