The Simple ABC’s of Antidepressant Withdrawal
Updated on July 6, 2016
Antidepressant withdrawal is both complicated and simple. It was complicated when I first started in holistic psychiatry and didn’t know some of the nuances of antidepressant withdrawal, but now that I have gathered enough information to know the most important aspects of antidepressant withdrawal, it has become more straightforward. Well, as straightforward as a complicated process can be, that is. My learning curve, however, was a gradual one, and it stretched over many years. This article is not a comprehensive review of everything about antidepressant withdrawal. The purpose of this article is to alert individuals to key aspects of antidepressant withdrawal that everyone should know, before starting out on their journey. If you don’t, then withdrawal symptoms may become an ongoing source of suffering that can exact a large toll over many years. A successful withdrawal, defined by me, is one in which a person will be able to get off an antidepressant smoothly and stay off, even when under stress.
A. Content & Process
Antidepressant withdrawal can be divided into two aspects: content and process. The content of withdrawal includes what kinds of supplements, diet, or techniques are necessary to support or incorporate during withdrawal. The process, however, which has to do with the how, when, and what, is often poorly understood. In my practice, the process is facilitated by information and feedback learned through the field of energy medicine. In addition, it is supported by having years of clinical experience, working with complex patients and learning from them.
Lacking an overarching method for guiding the process of antidepressant withdrawal is often the main reason why people’s attempts at antidepressant withdrawal fail. Because of this, I would recommend antidepressant withdrawal only with the aid of someone who has had success in helping others through withdrawal. I have had patients who came to me after being taken off antidepressants, by those who lack experience with antidepressant withdrawal. They were told to lower the medication dosages “slowly.” Without true healing, such an approach often lead to a relapse, within a few months of stopping the medication.
Having said that, however, it is important to withdraw slowly (occasionally, energy healing allows a more rapid reduction). Compounding pharmacies are often necessary to help create liquid suspensions of medications that allow for gradual dosage reductions that are much smaller than available dosage forms. Typically, the time for lowering the medication is when the “functional dosage”—the way the medication dosage supports mental function– is being experienced as being slightly higher than needed. This mental state is usually accompanied by early and mild side effects from the medication, i.e. increased vivid dreams, increased gastric activity, or apathy. Lowering the medication at such a point will lead to a normalization of function, rather than a state of deficiency. The faster the healing process, the faster the pace of antidepressant withdrawal that may be required.
B. Underlying Illness & Medication Dependency
Even the most successful medication withdrawal, however, will only treat half the problem: medication dependency. Quite often, the forgotten half of withdrawal is the underlying illness. Only treatment that simultaneously heals both the underlying illness that led to depression and anxiety, as well as medication dependency, will lead to stable mental health after cessation of medications. Therefore, even with successful medication withdrawal, one may be left with the initial condition that led to medication use, plus the intervening years of progressive worsening of unhealed underlying causes. In short, just tweaking a few neurotransmitters will not accomplish the job.
When addressing psychological traumas and negative mental habits that led to the initial symptoms of depression and anxiety, it is imperative that patients heal their psychological issues at the subconscious level. To do so, they first need to gain insight into what those issues were, and then apply energy medicine techniques to help heal those problems. Emotional Freedom Technique, (EFT www.EFTuniverse.com), and other acupressure techniques are a quick and effective way to heal traumas.
To heal the underlying physiological imbalances that had led to the initial symptoms, a general blend of supportive nutritional supplements are critical. The diet may need to be cleared of foods that cause hypersensitivity reactions. General nutritional areas that often need to be supported through orthomolecular means are: vitamins, minerals, essential fatty acids, amino acids, antioxidants, gastrointestinal support, and detoxification. The higher the absorbability of the supplement, the less one will need to get the job done. So, absorption is the key to choosing high quality nutritional supplements, rather than dosage. If underlying infections such as Epstein Barr Virus, Staph or Strep, H. Pylori, viral hepatitis, Lyme or its co-infections are undermining one’s health, they need to be treated.
C. Antidepressant Psychopharmacology & Biochemical Support
To address medication dependency, the first thing to do is: know your medication. It is important to know how the medication helps and how it hurts the person, when trying to withdraw from it. Open up a PDR or look online to really know the medication’s psychopharmacology and its unique functions in the body. Two important areas to know for navigating withdrawal are: 1) which receptors are blocked or activated by this medication? And 2) which nutrients are affected by this medication? When withdrawing from a medication, everything that the medication suppresses will become elevated, and everything that it elevates will become depressed—unless you do something to ameliorate that condition beforehand.
To prevent the imbalance that will ensue upon lowering an antidepressant medication, one must anticipate what will happen during the taper process. There are different types of antidepressants. The most commonly used ones are SSRIs (Selective Serotonin Reuptake Inhibitors) such as Prozac, Zoloft, Celexa, Paxil, and Lexapro and SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors) such as Effexor and Cymbalta. Tricyclics are seldom used nowadays. For those that elevate specific neurotransmitters, it is helpful to use supplements that facilitate the production of these neurotransmitters, before attempting to lower them. If the medication is first lowered and the person has low levels of the corresponding neurotransmitters, adding supplements after a taper has already taken place may not allow for normal levels to be restored quickly enough, and withdrawal will ensue upon lowering the medication. There are companies devoted to the nutritional support of creating neurotransmitters such as Sanesco and Neuroscience. They have combined amino acids with other co-factors in a simple capsule to help patients build neurotransmitters naturally, which allows withdrawal to occur with much greater ease.
Beyond neurotransmitter support, there is a need for immune and hormone system support. For, antidepressants have an effect on hormones and the immune system. All medications are like two sided coins. They have a beneficial side and a toxic side. Antidepressant medications are beneficial, because they have, among their many side effects, some side effects that help lessen depression and anxiety. They are toxic, because they have been patented by a pharmaceutical company, which means they are unique molecules that are no longer a food item that the body will recognize. If the body does not recognize it as food, it is a foreign object, a xenobiotic and perceived by the body as foreign, treated as a toxin, and therefore, must be eliminated—both through detoxification pathways and through inflammatory pathways. (This is why, if a person’s body is already overwhelmed by too many foreign products, i.e. heavy metals, herbicides, or pesticides, the toxic aspect of medications will be poorly managed, and more side effects will ensue upon taking the medication. If a person has a healthy detoxification system, then the toxic aspects of a medication can be handled easily and effortlessly.
As medication levels get lower, its beneficial and helpful side effects diminish in a linear fashion, based on the dosage, but its allergenic effects–stress for the body–does not diminish proportionally. Compare this to what we know about vaccines. Vaccines contain small amounts of stimulus, antigens, but they can produce a powerful immune cascade. In a similar way, even a small amount of medication can cause a strong immune response—not the kind that causes hives, but like the kind that occurs with a kidney transplant. As withdrawal progresses, the imbalance between benefits and the inflammatory reaction will make the withdrawal gradually more difficult, unless you anticipate it and treat it. I have found Opsin II (Professional and Complementary Health Formulas) to be helpful in reducing the histamine response generated by medications, allowing for an easier withdrawal process.
With regard to hormonal support, I differ from other orthomolecular physicians in that I often use pineal gland support. My clinical experience has shown that pineal gland (Deseret Biologicals) eases withdrawal significantly. Patients tend to have better sleep, appetite, and lower stress levels when given this hormonal support.
At this point, you may have read more than you ever wished to know about antidepressant withdrawal, or you may feel like this article is more like an appetizer than the main course you had hoped it would be. You may also have the distinct impression that it may not be safe for you to attempt to do this on your own. However, by reading this article, you have the advantage of knowing more than I ever did, when I began my journey as a holistic psychiatrist. Through ten years of psychiatric training, the only useful piece of advice I remember receiving from my psychiatry mentors about medication withdrawal was to “do it slowly.” Three words on a topic that meant everything to my patients. Unfortunately, these three words may still encompass what many traditional psychiatrists know about antidepressant withdrawal, since their goal has not been to take patients off medication, but to put them on one. May these clinical pearls help you towards achieving a safe journey through your withdrawal process.
Alice W. Lee, MD, ABIHM
Ten Practical Considerations During Psychotropic Medication Withdrawal
While there are different approaches to psychotropic medication withdrawal and much left to be discovered, it is helpful to provide an overview and some key considerations that are central to a smooth medication withdrawal process, from beginning to end. The following points may be taken as clinical notes on this broad and complicated topic, from a holistic psychiatrist, who has helped patients withdraw from psychotropic medications since 2003. It is not meant to replace competent medical supervision and care, but to heighten awareness of key issues associated with withdrawal. During psychotropic medication withdrawal, some practical considerations include:
1. Duration of the withdrawal process: The withdrawal process does not end when the patient has stopped taking the psychotropic medication. Rather, adaptation to a medication-free condition continues long after the last pill has been taken. At a minimum, the need for vigilance for possible relapse should continue for three to six months after stopping a medication. During this time, the patient would benefit from continued healing through proper nutritional support, therapy, and stress reduction strategies. Many factors play a role in the ease of withdrawal. Some factors that may shorten or ease the withdrawal process (beside proper medical care) include: a) mild symptoms when ill, b) short duration of using the medication, c) healthy history, d) a whole foods diet, e) low stress levels, f) positive and open attitude, g) strong social supports, and h) exercising regularly.
2. Areas that need to be healed and supported during medication withdrawal: a) withdrawal symptoms due to a lower medication dosage, b) underlying health problems, which led to a need for medication, c) traumatic experiences that undermine stress resilience, and d) deterioration of health in the intervening period since initiating medication. How a patient presents (symptoms and complaints) does not determine how difficult the withdrawal will be. A patient, who seeks treatment after taking a medication for just a few weeks, experiencing many side effects after exposure to the medication, may be able to withdraw from the medication very easily, especially if the underlying problem has all but healed.
Medications have varying abilities to harm the body, some being harsher than others. As patients use these medications over time, this damage is likely to accrue over time. This damage is in addition to the emotional and psychological tolerance and dependence on psychotropic medications. Being aware that the amount of time a patient has been on medications will allow for a more accurate estimate of how difficult the withdrawal process will be.
Abruptly discontinuing medication can also be harmful to the body. Withdrawal side effects, from an inappropriately rapid taper, signal that the body is struggling biochemically and physiologically. The longer this continues without proper intervention, the more stress and harm the body endures. Waiting for withdrawal symptoms to stop on their own, may result in prolonged damage to the body that can make future medication withdrawals more difficult, if not impossible.
3. Factors that determine the rate of withdrawal: The advice I was given, as a psychiatric resident, is to withdraw “slowly.” However, a slow withdrawal is often relative to: a) how the patient is supported through orthomolecular and energy medicine, b) the person’s state of health and diet, c) the toxicity and addictive nature of the medication, d) psychosocial stressors during withdrawal, e) duration of medication exposure, and f) how many receptors are being affected simultaneously by the medication. Patients will be able to withdraw more easily if they receive appropriate support and healing before, during, and after stopping their medication.
I have found that it is important to provide support and healing before attempting to lower a medication, wait for mild signs of the medication being too strong, and then lowering dosages just enough to return the patient back to a state of balance once again. Signs of overmedication or the medication being “too strong” may include feeling tired, sleeping longer at night, or feeling apathetic/flat. When these symptoms appear, it is not a signal to add another medication, but to reduce the dosage of the medication that is creating excessive side effects. I avoid lowering medications when the patient is feeling balanced on the medications, because it will initiate withdrawal symptoms and stress the patient, if I do so.
Also, my clinical experience has been that medications, which simultaneously affect multiple receptors, will be more difficult to withdraw than medications that affect only one receptor. My assumption is that one taper of a multi-receptor medication would be the equivalent of lowering multiple single-receptor medications simultaneously. It would be more demanding on the body and more difficult to support both nutritionally and enzymatically.
4. What is “protracted withdrawal”? The term “protracted withdrawal” has been used to indicate that a medication is to blame for prolonged or recurring withdrawal symptoms, regardless of how adequately supported a patient has been. I believe, however, that prolonged withdrawal symptoms occur when the patient’s withdrawal/healing process has been incomplete. In other words, perhaps the healing has been incomplete due to some deficiency in nutritional support, detoxification, or amelioration of underlying causes (infection, social stressors, genetic mutations, or leaky gut etc.).
Taking a psychotropic medication is like covering one’s eyes when one is afraid of the dark. It gives one a sense of safety, while still remaining in the dark. A successful withdrawal is like an enlightening process that lessens the need to cover one’s eyes. If the room remains dark and creepy, removing one’s hands only leads to prolonged fear and discomfort. An incomplete withdrawal is like uncovering one’s eyes, before light has been fully restored. If a patient is adequately supported during their withdrawal, the patient will be able to move into the light of consistent health, without experiencing protracted withdrawal.
5. Limitations to supplementation. Although nutritional supplements are crucial for a successful withdrawal, there are limits to what they can do. Over the years, I have come to rely on many other forms of support for my patients. I have also come to appreciate the ability to collaborate with other holistic and integrative health practitioners, rather than trying to do everything on my own.
A supplement cannot change the curvature of a patient’s spine, replace a wholesome diet, or stop disruptive social stressors. It cannot replace proper sleep and exercise. Sometimes, despite the patient’s need for nutritional support, the most important thing may be to listen compassionately and silently. It would be premature to plant palm trees, if the island is drifting towards the Antarctic. When approaching medication withdrawal, it is helpful to be open to other tools that have the ability to heal root causes.
6. The proper order for the withdrawal process: In the rush to get off medications, patients may start their taper first and seek for medical expertise after withdrawal symptoms emerge. This puts the cart before the horse and creates unnecessary difficulties during the withdrawal process. To make the withdrawal process less painful, it is best to heal the body, increase stress resilience, and lessen stressors before one attempts to lower a medication. Then, as the body gets stronger and more fully functional, the medications will naturally feel too strong for the patient’s physiological needs. When that happens, ease down on the medication to a point of balance and comfort. Wait for further healing to occur, before the dosage is reduced, due to the medication being too strong again.
For patients who stop a medication abruptly, the effect of lowering a medication may follow this formula:
(original illness + underlying, undetected, untreated, and evolving illness + deterioration of underlying health due to aging + level of dependency of medication’s function) x years of medication use = degree of suffering.
This can lead to a surprising degree of discomfort. Often, the best remedy for premature withdrawal is to get back on a medication dosage that would rebalance the patient’s biological system (rather than change to another medication), initiate proper supports, and then reduce the medication at the proper point in the patient’s healing process.
7. The role of mind-body/energy medicine: While supplements provide the body crucial components for healing, energy medicine can provide the blueprint for the healing process. Both are equally important for recovery. Even before I start to lower a patient’s medication, I will ask my patients to listen to the “Minimizing Withdrawal Problems” track on my Infinite Intention CD (see the products section to download this useful track). They listen to the track once per week, using guided visualization, to support focused intention and the relaxation response, and to facilitate greater ease with withdrawal. When patients do this regularly, they have a smoother, easier withdrawal process. I believe this meditation track supports the body’s ability to quickly reduce the number of unblocked receptors, during withdrawal, by supporting the consciousness of the body’s response system.
8. The role of detoxification: Some patients have such a high toxic load that nutritional supplementation will not be able to create significant improvement in enzymatic functioning. Many supplements significantly support detoxification, such as methyl donors found in B vitamins, liposomal glutathione, or liver extract. However, in special situations--for example, in individuals who have a large number of genetic mutations that interfere with detoxification, or who have high levels of mercury or lead--adding nutritional supplements may only help modestly. In such a situation, it may be best to initiate treatment by detoxifying through homeopathic methods, eliminating food sensitivities, decreasing dysbiosis/leaky gut, or reducing viral or bacterial load. Heavy metal chelation may be a crucial piece of recovery. It is, however, necessary to remove any remaining metal fillings in one’s mouth before the chelation process.
9. How to support recovery through nutrition: At a minimum, general dietary and nutritional supplement support should adequately cover the following areas: vitamins, minerals (macro and micro), essential fatty acids, amino acids, G. I. support, anti-inflammatories, antioxidants, and detoxification. In order to heal, an individual would need to meet their total nutritional needs for the day plus have extra. The extra nutrients are then used to move health to a higher level. Once these basic areas are covered, additional supplements that mimic the beneficial effects of the medication to be withdrawn should be selected and used. For example, Sanesco makes a product called “Prolent,” which provides a combination of supplements that support serotonin production. I use it to help my patients gradually lower their need for an SSRI such as Prozac, Zoloft, Celexa, and Lexapro. I also suggest the use of germinated brown rice, called GABA rice, to help with creating calmness during withdrawal from tranquilizing or anxiolytic medications.
Supplements need to be carefully selected for absorbability and comprehensive coverage of physiological needs. With higher absorbability, the amount of nutritional supplementation lessens. Supplements that are highly absorbable often come as liquids or powders. Whole food supplements may seem to lack the amount of nutrients found in fractionated supplements, but because of their high rate of absorbability, their effect may be many times more potent. Sometimes, glandular supplements or protomorphogens may be helpful in supporting the liver, pineal gland, thyroid, or adrenals. An anti-inflammatory diet is important to the recovery process. This often means that the patient will need to reduce their consumption of wheat, dairy, and white, refined sugar.
10. Beyond biology. Repairing the body is like repairing a radio. Just because the radio is repaired, doesn’t mean that it will choose to play beautiful music. We are more than our biology. Healing our neurotransmitters and hormones, thyroid and adrenals are a wonderful way to proceed, but they only allow the person to be happy. They do not make a person happy. We may wish to find happiness from within a bottle, when happiness cannot be “found,” because it exists as a side effect of living life masterfully. Healing the whole person will often require healing from past traumas that block one’s ability to embrace love and happiness. Real growth takes place as we take tentative steps toward greater wisdom, love, forgiveness, and compassion. Before creating a state of well-being, there is a learned aspect of being that has to be reassessed and realigned. The road to health and well-being is paved with life’s lessons. Some of those lessons lead to self-mastery, some to spiritual strength, and some to forgiveness. In the end, healing leads to recognizing the journey as the blessing it has always been.
Alice W. Lee, MD, ABIHM
Ten Clinical Tips on Antipsychotic Withdrawal
When an individual becomes psychotic, typically an antipsychotic medication is used to ameliorate symptoms. However, there are many side effects associated with the use of antipsychotics, and often no clear method for coming off the medication once symptoms are under control. In addition, withdrawal from an antipsychotic medication, after taking it for several years, may often result in withdrawal symptoms that mimic the original psychotic illness, sometimes several months later.
Is it possible to withdraw from antipsychotic medications safely and successfully, without the recurrence of psychotic symptoms? I believe it is possible, though not easy. Knowing how to lessen the stress of tapering will improve your ability to experience a smooth, safe, and successful outcome.
Over the years, in the process of learning about medication withdrawal in general and antipsychotic withdrawal in particular, I have found that, in addition to supporting the body with proper nutritional support through diet and supplements, there are aspects of the withdrawal process that are valuable to know beforehand, for a smooth and safe withdrawal process. They are as follows:
- Carefully follow sleep patterns: Do not reduce antipsychotic medications until sleep has increased through nutritional and energy medicine support to at least 9 hours per day. Lowering antipsychotic medication when sleeping 8 hours or less would lead to insomnia--one of the early symptoms of stress during withdrawal. I have found that ultra CBD, a hemp oil extract, can be helpful to patients for supporting sleep and appetite, when needed.
- Use liquid antipsychotics if available: It is easier to taper down in small amounts when using liquid antipsychotics. Of course, this principle applies to antidepressants or anxiolytics as well. If liquid antipsychotics are not available, they can be specially compounded through certain compounding pharmacies, especially through pharmacies that also sell nutritional supplements.
- Antioxidant and anti-inflammatory support: typically I use a combination of whole food powders such as acai, goji, and maqui powder to lower oxidative stress. I also highly recommend an anti-inflammatory diet and restricting wheat, dairy, and white, refined sugar. Among the anti-inflammatory supplements I use are Restore (a supplement for the gastrointestinal system), probiotics, vitamin C, and omega-3 fatty acids.
- Strengthen the GABA neurotransmitter system: The GABA system provides the physical message of tranquility. By increasing the neurotransmitter that is central to creating calmness and peace, people are able to rely less on the effects of an antipsychotic. I often recommend GABA rice (about half a cup twice daily) or liposomal GABA. Zojirushi makes GABA rice cookers and can make GABA rice from organic, brown rice. Organic, germinated brown rice cooked in a regular rice cooker will also make GABA rice.
- A "step-down process of withdrawal":Although there are many factors that can make antipsychotic withdrawal difficult, different antipsychotic medications have different levels of difficulty during withdrawal, based on their psychopharmacology alone. Consider Zyprexa, it affects approximately 17 different subtypes of receptors, while Haldol affects two dopamine receptor subtypes. In between, we have Abilify, which affects 10 different receptor subtypes, while Seroquel affects seven different receptor subtypes. When these medications are lowered, the body has to adapt to the number of receptors that become unblocked. It follows that it is easier for the body to adapt to changes, when there are fewer changes to adapt to. When lowering an antipsychotic medication that affects many different neurotransmitter subtypes, such as Zyprexa, it may be helpful to use a "step-down process," tapering down the antipsychotic through the use of another antipsychotic that affects fewer receptor sites. For example, when tapering down on Zyprexa, gradually increase the dosage of Seroquel. Once the individual is only on Seroquel and has safely and completely weaned off of Zyprexa, then gradually taper the dosage of Seroquel while gradually increasing the use of liquid Haldol. Once the individual has transitioned to Haldol and has completely been weaned off Seroquel, then very gradually lower Haldol. All the while, the individual should be using supplements and energy medicine to facilitate the recovery process. Tapering off Haldol, the last step of the "step-down process" may be easier to achieve successfully than coming directly off of Zyprexa.
- Treatment of contributing causes: Infection, toxicity (heavy metals, pesticides, and herbicides), genetic mutations, and traumas all contribute to oxidative stress and inflammation, which affect mental health. Treatment of these underlying causes will be critical to a successful withdrawal.
- Minimize social stressors: Abrupt changes and demands, losses and traumas can undermine the ability to come off an antipsychotic medication. It is important to consider the social context and to support a calm, predictable, and yet, rewarding set of circumstances for optimal healing to occur. Psychotherapy is often a critical and central part of the healing process, by strengthening insight, forgiveness, presence, and healthy coping strategies.
- Guided Visualization/Meditation: I recommend to my patients the use of an audio track called "Minimizing Withdrawal Problems" to listen to once per week. It uses meditation and intention to support the body's ability to adapt to dosing changes. This track is available on my website to download from the digital products section.
- Collaboration with other integrative health practitioners: It is helpful to create a treatment team of integrative practitioners who can work together to help the patient heal. Each can bring to the process a special set of skills that can support the patient during this difficult process.
- Give it time: the journey is just as important as the end goal of being off a medication. It is often better to give oneself more time to heal, on a medication, than to force the process and experience physical discomfort from withdrawing too quickly. Medications are helpful in many ways and should not be viewed as an enemy in this process. Improvements in health will naturally result in a need to rebalance the dosage of medications to a lower amount.