1. Safely Withdrawing From Psychiatric Drugs Dr. Mark Foster, DO GOBHI Conference Bend, Oregon 17 May 2012

2. Five Case Studies Mr. G: “Something’s wrong with my brain!” (5 drugs: Celexa, Remeron, Wellbutrin, Xanax, Ambien) Mrs. B: “I started it two years ago for post- partum depressed, but I’ve gained 50 lbs and I’m still depressed.” (1 drug: Zoloft) Ms. A: “My psychiatrist says I’m schizophrenic. She says I’ll have to stay on these pills for life.” (7 drugs: Geodon, Lithium, Cymbalta, Lexapro, Ambien, Valium, Concerta) Mr. W: “I’ve been withdrawing from Paxil for 59 months.” (1 drug: Paxil) Ms. S: “I stopped 13 medicines at once!” (Too many to count!)

3. Withdrawal: It can and must be done... Many patients do well on psychiatric drugs and suffer from no harmful effects. Many patients do poorly on these drugs and become increasingly ill over time, with compounding mental and physical harm, poly-pharmacy and poly-diagnosing.

4. Withdrawal: It can and must be done... Assessing the need to withdraw from harmful and ineffective drugs prescribed by other doctors falls under the purview of a primary care physician. The primary care physician may be the only doctor looking out for the patient’s whole health.

5. But it’s difficult... It is far too easy to get on the medication highway. It is far too difficult to get off. Inertia conspires to keep patients and doctors there.

7. Begin with the end in mind Use caution when starting the meds. Set expectations early. At the moment of prescribing these drugs, verbalize an exit strategy. –“This medicine is for short term stabilization. We’re going to come off of it within the year, and when we come off it, we have to do it slowly to minimize the withdrawal effects. In the long run, you’ll do better off the meds than on.”

8. Begin with the end in mind...

9. Barriers: Patients Patients: –May be unprepared or unwilling to make a change. –May not be in a life position to make a change. –May be “addicted” to both drugs and diagnoses. –May have had prior bad experiences withdrawing. –May lack financial, social and intellectual resources. –May have been convinced by other doctors, counselors and family members that they need to remain on the drugs for life, and that to come off of them is irresponsible.

10. Barriers: Providers Primary care physicians: –May be unaware of side effects –May assume somebody else will address withdrawal from drugs –May have inherent bias about the effectiveness of their treatments –May receive biased information exclusively from drug reps –May not be informed about alternatives –May not be informed about appropriate withdrawal techniques –May underestimate the level of distress, the resolve and the resilience of their patients –May be wary of backlash from psychiatrists and the mental health community –May be wary of malpractice suits –May be embedded in the medical model

11. Scaling the barricades! Providers must first educate themselves. “Anatomy of an Epidemic” –by Robert Whitaker “Your Drug May Be Your Problem” –by Dr. Peter Breggin and Richard Cohen “Mental Health Naturally” –by Dr. Kathi Kemper Ask drugs reps to show you unbiased long-term efficacy studies of their psychotropic wares.

12. Scaling the barricades! Physicians must pass on vital information to their patients. –True informed consent. –What do the medicines actually do? –What evidence is there for long-term effectiveness? –What evidence is there for long-term harm?

13. Scaling the barricades! Providers must first attain, then convey to patients these traits: –Wisdom –Patience –Empathy –Optimism

14. Untangling the knot Start with a careful history: What medications? What diagnoses? What order? How long? What effects? What side effects? Level of preparedness to quit? Level of education? Current life situation? Current social support? Current financial and time resources? Current capacity for change?

15. Untangling the knot (Uh-oh. That list was intimidating. I don’t think my patient will ever be ready to quit. I’ll just refill their Effexor again.) “Hold on, good doctor! Have you considered the cost and risk of doing nothing, of just refilling their meds again? What is the risk of slowly tapering the meds under supervision versus the risk of staying on them indefinitely? Do not underestimate the resilience and humanity of your patients!”

16. Untangling the knot... because not everybody has a hard time! Don’t forget all the patients who told you they just stopped the meds and didn’t notice a difference, or stopped the meds cold turkey, felt a little sick for a few days, and then were fine. Spontaneously healing applies to overcoming withdrawal effects, too. Most people do just fine off the meds.

17. Untangling the knot Many patients are currently unable, unprepared, frightened or unwilling to withdraw from meds. That’s okay. Don’t cut them off. Plant seeds for the future. –“The time may come that you develop unwanted side- effects like weight gain, sexual dysfunction, or stomach problems, or that other doctors label you with multiple conditions and start treating side-effects of drugs with other drugs. If that happens, you may want to reconsider the need for the drugs in the first place, and consider slowly tapering off of them. Don’t stop all at once. Just think about it, and we can talk again sometime. At a minimum, I like to follow-up with my patients every six months and ask them if the cost and side-effects of the medicine are still worth the benefits.”

18. Untangling the knot It is unknown, but likely to be true, that some people suffer from permanent physiologic brain dysfunction after being on psychotropic medications. Sadly, some people will be unable to come of the drugs completely or safely. This must be acknowledged, and the patient and doctor should not feel defeated if this is the case. At least we tried. However, this is the rare exception. The ultimate goal is not to just “get ‘em off drugs.” The goal is to have them thrive in their life at minimal harmful effect to their brains, bodies, and wallets. For most, this will be off drugs. But for some, drugs will continue to be necessary.

19. Untangling the knot Questions to ask at every follow-up: –How is the medicine working for you? –Are you having any side effects? –Research shows that many people develop problems with the medicines the longer they are on them. Have you considered stopping them? –What are you doing besides medication to address your mental or emotional distress?

20. General Principles of Withdrawal Physiology SSRIs: Serotonin reuptake inhibition down-regulates, meaning more reuptake occurs, leading to less serotonin in the synapse. Benzos: Decreased natural GABA when meds are withdrawn. Without GABA, the synapse goes into excitatory state. Antipsychotics: Dopamine blockade is lifted. Synapse floods with dopamine, leading to possible withdrawal psychosis.

21. General Principles of Withdrawal The patient must be in the driver’s seat. Both patients and doctors must have a strong level of commitment to withdrawing. Patients should have a strong support system in place. Patients should be at a place of relative calm in their lives. Patients should replace the drug’s effects with new healthy habits and interventions: exercise, counseling, supplements, acupuncture, etc.

22. General Principles of Withdrawal: Before you start The patient must be aware of: –the reasons for quitting –normal withdrawal effects and time-frame –possible stumbling blocks –the necessity of alternative interventions –what life will be like off meds. It will be better! If not, then why are we doing this?

23. General Principles of Withdrawal: Before you start Timing is critical. I rarely start a withdrawal on the first visit. “This is a big life change. You need to think about it, read about it, and make sure you want to go through with it.” I have my patients purchase and read: –“The Depression Cure” –“Your Drug May Be Your Problem” –“Mental Health Naturally”

24. General Principles of Withdrawal: Before you start See them back in 1 month, if possible with their spouse or closest supporter. Ask them to draft a “withdrawal contract” that states their: –reasons for quitting –expectations of quitting –support system for quitting –aspirations after quitting. To be co-signed by: –Their spouse or closest supporter. –Their counselor (must have chosen one) –Their doctor (you) –Themselves

25. General Principles of Withdrawal Take it slow. Be flexible. Anticipate challenges. One drug at a time. Replace the drugs’ effect with healthy lifestyle choices. A gradual taper will limit the severity of the withdrawal.

26. General Principles of Withdrawal Start with a 10 to 25% dose reduction every 2-4 weeks. The fastest time to withdraw would be 6-8 weeks. Many people do fine with this. Normal time frame is 3-4 months... per drug. For higher risk patients (more fragile, longer history with drugs, prior bad experiences, multiple drugs) start slower and go slower. Stay flexible! Stay positive! Anticipate challenges! Replace drugs with healthy habits!

27. General Principles of Withdrawal Avoid backtracking. If the patient is experiencing serious withdrawal effects, slow down or stop the taper. Let them catch their breath and prepare for the next decrement. Some people take years to successfully quit. That’s okay. As long as we’re moving in that direction... Stay flexible! Stay positive! Anticipate challenges! Replace drugs with healthy habits!

28. Special Situations: Dosing Some medications come in very few doses, making gradual tapering difficult. Strategies: –For tablets—pill cutters –For capsules—counting beads –Liquid dosing: Paxil, Prozac, Zoloft, Celexa. –Every other day dosing –Compounding pharmacy!!! Try not to let dosing difficulties force you to accelerate the taper.

29. Special Situations: Polypharmacy How to deal with drug cocktails? –Identify the most harmful side effects. –Are they diabetic? Liver damage? More depressed? Panicked? Sedated? –In what order were the drugs started, for how long and for what reasons? –Start withdrawing the most harmful drugs first. –One drug at a time! –Typically, I withdraw them in this order: 1.Antipsychotics 2.Stimulants 3.Benzos 4.Mood stabilizers 5.SSRIs

30. Special Situations: Polypharmacy I have had some success in doing parallel tapering of two drugs when they seem to be causing simultaneous, additive problems. Taper down to the lowest dose of each medicine prior to stopping either.

31. Special Situations: The Prozac Switch For patients that have a hard time withdrawing from other SSRIs (such as Effexor or Paxil), switching to Prozac can be effective bridging. Prozac has the longest half-life and therefore the most gradual withdrawal effects. Start the patient on a low dose of Prozac when severe withdrawal symptoms occur. Wait two to four weeks, and then resume the prior tapering schedule. Once the first SSRI has been stopped, then taper the low dose of Prozac over another 4-8 weeks.

32. Special Situations: The Final Pill Slow is good, but at some point, you’re going to have to pull off the band-aid. If the patient is prepared, committed, and engaged in a healthy lifestyle with a strong support system, this final step can be decisive, minimally painful, and extremely rewarding. “I can be okay—better than okay--off of medications! I can feel well again!” Celebrate with them when they succeed!

33. Special Situations: The Final Pill Ultra-slow tapering methods: I am wary of methods that last greater than one year per medication. (Benzo withdrawals may need to last longer.) Ultra-slow tapering may be necessary in special cases, but I favor this as an exception after you’ve tried and failed a more expeditious taper. Online support groups can be helpful, but there can also be a lot of fear-mongering and extreme opinions. Proceed with caution. A support system of significant other, counselor, and physician is usually sufficient. Empowering peer counselors can be useful additions to this team.

34. Special Situations: Crisis Stay calm. Stay positive. Be wise. Be patient. Back track, but only if absolutely necessary. Try not to re-centralize yourself in the patient’s care. You are there to help, but not be a savior. If the patient is suicidal or in severe crisis, they may have to re-engage with the current mental health care system, which will certainly mean renewed poly-pharmacy. Unfortunately, we do not yet have a non-drug safety net for patients in crisis. Maybe someday.

35. Special Situations: Crisis A more rational system would have: –Tolerance for rare tragic events from withdrawing from medications. –Intolerance for common tragic events of people being kept on medications in spite of severe harmful effects and early death or suicide.

36. Conclusion Primary care physicians should consider how psychiatric drugs impact their patients’ whole health. They should feel empowered to recommend withdrawing patients from psychiatric drugs that are causing net harm. No one else is likely to do so. Patients must take responsibility for their withdrawal, replacing drugs with healthy habits. Slow, steady, supervised tapering wins the race. Stay flexible! Stay positive! Anticipate challenges! Replace drugs with healthy habits!

37. Conclusion You can do it! Your patients can do it! Good luck, and may the force be with you. Additional resources –www.theicarusproject.netwww.theicarusproject.net Harm Reduction Guide to Coming Off Psychiatric Drugs –www.benzo.org.uk/manualwww.benzo.org.uk/manual “The Ashton Manual” for coming off benzos –“Your Drug May Be Your Problem” by Dr. Peter Breggin and Richard Cohen –“The Antidepressant Solution” by Joseph Glenmullen