KORN KURATED RESEARCH

How to Help Your Clients Safely Step Off the Treadmill of Pills

The withdrawal from psychotropic medications, including antidepressants and antipsychotics, presents varied challenges, with inadequate tapering contributing to significant withdrawal symptoms. There is a clear need for personalized, clinician-guided tapering plans and improved healthcare support to address these complexities effectively.

I spend a great deal of my clinical time helping clients come off psychotropics slowly and successfully. As a result, I am thrilled that we are finally seeing exponential growth in research and clinical explorations about what we know about the need to reduce or eliminate psychotropic medications and how to do it with ease.

As I update Chapter 9 of my book, Nutrition Essentials for Mental Health, about how to taper from psychotropics, I am immersed in the most up-to-date research supporting the critical finding that the brain needs time, time, and more time to adapt to withdrawal. To help fellow clinicians navigate this process with their own patients, I’ve created a Deprescribing and Tapering page on my website, where you can find valuable resources and free worksheets to help your clients taper successfully.

The first research article addresses the method of hyperbolic tapering, which I find to be an essential part of a successful taper. The second article explores the hyperbolic approach with antipsychotics. The third article addresses the importance of incorporating a lens on sex and gender when addressing polypharmacy in elders. The final three articles reflect research asking patients about their experiences tapering.

The fourth article discusses research that finds that the patient generally initiates the need to taper and that patients do not experience willingness from practitioners to deprescribe and would like to discuss deprescribing more often. This research provides insight into how we can initiate these discussions with clients. The fifth article addresses that most participants reported that their prescribers were unable to help them safely stop antidepressants. The final article discusses the diverse needs of patients regarding tapering rates and whether it is possible to identify those who may have more challenges tapering.

Tags: tapering, deprescription, psychotropic medications, antidepressants, antipsychotic medications

Interested in Learning More?

• Course(s): Tapering Off Psychotropic Medications: Integrative and Naturopathic Strategies
• Course(s): Mental Health Disorders
• Book(s): Rhythms of Recovery
• Book(s): The Brainbow Blueprint

Referenced Research Publications

Therapeutic advances in psychopharmacology
2023, May 09
DOI: 10.1177/20451253231171518

Outcomes of hyperbolic tapering of antidepressants

Abstract

Background: In patients attempting to discontinue their antidepressant medication, there have been no prospective studies on patterns of withdrawal as a function of the rate of antidepressant reduction during the tapering trajectory, and moderators thereof.

Objective: To investigate withdrawal as a function of gradual dose reduction.

Design: Prospective cohort study.

Methods: The sampling frame consisted of 3956 individuals in the Netherlands who received an antidepressant tapering strip between 19 May 2019 and 22 March 2022 in routine clinical practice. Of these, 608 patients, majorly with previous unsuccessful attempts to stop, provided daily ratings of withdrawal in the context of reducing their antidepressant medications (mostly venlafaxine or paroxetine), using hyperbolic tapering strips offering daily tiny reductions in dose.

Results: Withdrawal in daily-step hyperbolic tapering trajectories was limited, and inverse to the rate of taper. Female sex, younger age, presence of one or more risk factors and faster rate of reduction over shorter tapering trajectories were associated with more withdrawal and differential course over time. Thus, sex and age differences were less marked early in the course of the trajectory, whereas differences associated with risk factors and shorter trajectories tended to peak early in the trajectory. There was evidence that tapering in weekly larger steps (mean per-week dose reduction: 33.4% of previous dose), in comparison with daily tiny steps (mean per-day dose reduction: 4.5% of previous dose or 25.3% per week), was associated with more withdrawal in trajectories of 1, 2 or 3 months, particularly for paroxetine and the group of other (non-paroxetine, non-venlafaxine) antidepressants.

Conclusion: Antidepressant hyperbolic tapering is associated with limited, rate-dependent withdrawal that is inverse to the rate of taper. The demonstration of multiple demographic, risk and complex temporal moderators in time series of withdrawal data indicates that antidepressant tapering in clinical practice requires a personalised process of shared decision making over the entire course of the tapering period.

Keywords: antidepressants, dependence, drug withdrawal symptoms, patient medication knowledge, tapering

Reference

van Os, J., & Groot, P. C. (2023). Outcomes of hyperbolic tapering of antidepressants. Therapeutic advances in psychopharmacology, 13, 20451253231171518. https://doi.org/10.1177/20451253231171518

Schizophrenia bulletin
2021, July 08
DOI: 10.1093/schbul/sbab017

A Method for Tapering Antipsychotic Treatment That May Minimize the Risk of Relapse

Abstract

The process of stopping antipsychotics may be causally related to relapse, potentially linked to neuroadaptations that persist after cessation, including dopaminergic hypersensitivity. Therefore, the risk of relapse on cessation of antipsychotics may be minimized by more gradual tapering. There is converging evidence that suggests that adaptations to antipsychotic exposure can persist for months or years after stopping the medication-from animal studies, observation of tardive dyskinesia in patients, and the clustering of relapses in this time period after the cessation of antipsychotics. Furthermore, PET imaging demonstrates a hyperbolic relationship between doses of antipsychotic and D2 receptor blockade. We, therefore, suggest that when antipsychotics are reduced, it should be done gradually (over months or years) and in a hyperbolic manner (to reduce D2 blockade "evenly"): ie, reducing by one quarter (or one half) of the most recent dose of antipsychotic, equivalent approximately to a reduction of 5 (or 10) percentage points of its D2 blockade, sequentially (so that reductions become smaller and smaller in size as total dose decreases), at intervals of 3-6 months, titrated to individual tolerance. Some patients may prefer to taper at 10% or less of their most recent dose each month. This process might allow underlying adaptations time to resolve, possibly reducing the risk of relapse on discontinuation. Final doses before complete cessation may need to be as small as 1/40th a therapeutic dose to prevent a large decrease in D2 blockade when stopped. This proposal should be tested in randomized controlled trials.

Keywords: D2 occupancy; discontinuation; dopaminergic hypersensitivity; hyperbolic; schizophrenia; withdrawal.

Reference

Horowitz, M. A., Jauhar, S., Natesan, S., Murray, R. M., & Taylor, D. (2021). A Method for Tapering Antipsychotic Treatment That May Minimize the Risk of Relapse. Schizophrenia bulletin, 47(4), 1116–1129. https://doi.org/10.1093/schbul/sbab017

The lancet. Healthy longevity
2021, May 02
DOI: 10.1016/S2666-7568(21)00054-4

Polypharmacy, inappropriate prescribing, and deprescribing in older people: through a sex and gender lens

Abstract

Polypharmacy is very common in older adults and increases the risk of inappropriate and unsafe prescribing for older adults. Older adults, particularly women (who make up the majority of this age group), are at the greatest risk for drug-related harm. Therefore, optimising drug prescribing for older people is very important. Identifying potentially inappropriate medications and opportunities for judicious deprescribing processes are intrinsically linked, complementary, and essential for optimising medication safety. This Review focuses on optimising prescribing for older adults by reducing doses or stopping drugs that are potentially harmful or that are no longer needed. We explore how sex (biological) and gender (sociocultural) factors are important considerations in safe drug prescribing. We conclude by providing a practical approach to optimising medication safety that clinicians can routinely apply to the care of their older patients, highlighting how sex and gender considerations inform medication decision making.

Reference

Rochon, P. A., Petrovic, M., Cherubini, A., Onder, G., O'Mahony, D., Sternberg, S. A., Stall, N. M., & Gurwitz, J. H. (2021). Polypharmacy, inappropriate prescribing, and deprescribing in older people: through a sex and gender lens. The lancet. Healthy longevity, 2(5), e290–e300. https://doi.org/10.1016/S2666-7568(21)00054-4

Tijdschrift voor psychiatrie
2022, January 01

Tapering of psychotropic drugs: current practice and needs of patients and their relatives

Abstract

Background: The prevalence of mental illness has remained stable in recent decades, yet the use of psychotropic drugs has increased. This trend suggests that psychotropic drugs are being prescribed with an unnecessary frequency. Internationally, there is growing attention for deprescribing.

Aim: To investigate what experiences and needs patients and their loved ones/relatives have with regard to deprescribing of psychotropics.

Method: An online questionnaire was distributed among members of the MIND mental health care panel, which consists of (former) patients with a psychiatric disorder and their loved ones.

Results: A total of 564 respondents took part in this survey. Most patients have phased out/stopped their psychotropic drugs (83.8%). This was usually done at the initiative of the patient (66.7%), in consultation with the practitioner (72.9%). The practitioner only took the initiative to deprescribe in 15.1% of the cases. In 68.6% tapering was not discussed at the start of psychotropic drug use. Patients did not experience willingness from practitioners in deprescribing, and would like to discuss deprescribing more often (79.5%).

Conclusion: There is an undeniable demand among patients and near ones for more emphasis on deprescribing of psychotropic drugs. We advise to include this topic in the shared decision making process.

Reference

Koomen, L. E. M., de Boer, J. N., van den Eijnden, M. J. M., Vos de Wael, N. M. A. M., Berg, N., Wilting, I., & Cahn, W. (2022). Deprescriptie van psychofarmaca; praktijk en behoeften van patiënten en naasten [Tapering of psychotropic drugs: current practice and needs of patients and their relatives]. Tijdschrift voor psychiatrie, 64(7), 424–430.

Journal of psychiatric research
2023, March 20
DOI: 10.1016/j.jpsychires.2023.03.013

Designing withdrawal support services for antidepressant users: Patients' views on existing services and what they really need

Abstract

Background: Public Health England has recommended that services be put in place to support people who choose to withdraw from antidepressants because of a current gap. This study aims to explore the views of members of online withdrawal peer-support groups about existing healthcare and what additional support is needed.

Methods: The administrators of 15 online support groups for people stopping antidepressants were asked to advertise an online survey to their members. The survey, which was online from May 2021 to April 2022, was completed by 1276 people from 49 countries.

Results: 71% of respondents found their doctors' advice unhelpful (57% 'very unhelpful') regarding stopping an antidepressant; the main reasons being 'Recommended a reduction rate that was too quick for me', 'Not familiar enough with withdrawal symptoms to advise me' and 'Suggested stopping antidepressants would not cause withdrawal symptoms'. One in three did not seek advice from their prescriber when deciding whether to withdraw, with the main reasons being 'I felt they would not be supportive' (58%) and 'I felt that they didn't have the expertise to help me' (51%). The most common prescriber responses to those who did seek advice was 'Suggested a quick withdrawal schedule' (56%) and 'Not supportive and offered no guidance' (27%). The most common discontinuation periods recommended by doctors were one month (23%) and two weeks (19%). A range of potential professional services were rated 'very useful', most frequently: 'Access to smaller doses (e.g. tapering strips, liquid, smaller dose tablets) to ensure gradual reduction' (88%) and 'A health professional providing a personalised, flexible reduction plan' (79%).

Limitations: This was a convenience sample, which may have been biased towards people who took longer to withdraw, and experienced more withdrawal symptoms, than antidepressant users in general. Black and ethnic minority people, and people without access to the internet, were underrepresented.

Conclusions: Most participants reported their prescribers were unable to help them safely stop antidepressants, compelling them to turn to online peer-support groups instead. Our findings indicate, in keeping with previous studies, that clinicians require upskilling in safe tapering of antidepressants, and that patients need specialised services to help them stop safely.

Keywords: Antidepressant discontinuation; Antidepressant withdrawal; Hyperbolic tapering.

Reference

Read, J., Moncrieff, J., & Horowitz, M. A. (2023). Designing withdrawal support services for antidepressant users: Patients' views on existing services and what they really need. Journal of psychiatric research, 161, 298–306. https://doi.org/10.1016/j.jpsychires.2023.03.013

Journal of the American Board of Family Medicine : JABFM
2023, January 18
DOI: 10.3122/jabfm.2022.220239R1

Antidepressant Tapering Is Not Routine But Could Be

Abstract

Introduction: When antidepressants are discontinued, severe withdrawal symptoms are possible. Some patients have few or no problems stopping, whereas others struggle. That struggle can be minimized or prevented with careful dose tapering. How often is that done?

Methods: Using 7 years of medical records, we determined the percentage of patients who received a prescription for the lowest available dose of their antidepressant before it was discontinued, as an indicator of a deliberate taper.

Results: Over that period, 8.9% of patients had evidence of tapering. The percentage increased from 4.9% in 2014 to a plateau around 10% in the past 4 years.

Discussion: While reports of severe withdrawal are increasingly recognized and must be addressed, our data suggest that many patients can discontinue their antidepressants without a taper through the lowest dose. However, it is difficult to identify which patients will struggle without a careful taper. A "one-size-fits-all" taper approach is recommended, balancing the need for withdrawal prevention with the need to avoid unnecessary complexity for the majority of patients. The first decrement is key for all patients: it must go well. Thereafter many patients may accelerate but all should receive a prescription for the lowest available dose of their antidepressant.

Keywords:
Antidepressants; Anxiety Disorders; Bipolar Disorder; Depression; Drug Tapering; Mental Health; Primary Health Care; Psychiatry.

Reference

Phelps, J., Nguyen, J., & Coskey, O. P. (2023). Antidepressant Tapering Is Not Routine But Could Be. Journal of the American Board of Family Medicine : JABFM, 36(1), 145–151. https://doi.org/10.3122/jabfm.2022.220239R1