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Taking multiple psych drugs? Which drug to taper first?

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Altostrata   
Altostrata

ADMIN NOTE This topic is a general discussion about how to decide which drug to taper first. For case-by-case consideration of what YOU should do, please put your questions in an Introductions topic.
 
Do not put those questions in this topic, because detailed discussion of YOUR particular circumstances will take it off track and make this topic difficult for others to follow. The moderators will move any questions about YOUR particular case to the Introductions forum. Thank you.


 

Polypharmacy complicates tapering. Which drug to taper first?

Consider discussing the following considerations with your doctor.

 

You are having adverse effects from one or more of the drugs

Any drug causing a serious life-threatening adverse effect should be discontinued as soon as possible. Talk to your doctor about this immediately.

 

"Accelerators" and "brakes"
If no one drug is clearly causing an adverse effect, "discontinue the more activating drugs first," I have been advised by a doctor who studies withdrawal syndromes and iatrogenic damage.

 

Antidepressants and ADHD drugs (most are amphetamine analogs) tend to be activating drugs, causing jitteriness, anxiety, or sleeplessness.

 

Benzodiazepines, the "Z" drugs for sleep, anticonvulsants (such as lamotrigine), Lyrica, gabapentin (Neurontin), and antipsychotics tend to be regulating or sedating drugs, causing drowsiness, sluggishness, or dopiness.

 

The two types of drugs can be thought of as "accelerators" and "brakes."

 

Many people have a sedating drug -- a brake -- added to an activating drug -- an accelerator -- to treat drug-induced anxiety or sleep problems.

 

In those cases, unless you are having clear adverse reactions from a particular drug, taper the antidepressant or stimulant first. Otherwise, you will experience activation from the other drug as you decrease the "brake."

 

"Brakes" may temper withdrawal symptoms

The most common and significant antidepressant withdrawal symptoms are nervous system activations (indicating a too-fast taper): hyper-alerting, sleeplessness, abnormal anxiety, agitation, etc.

Withdrawal sleeplessness is a symptom you want to avoid. It makes tapering much harder and post-withdrawal syndrome more difficult to recover from.

If you reduce the accelerator while taking a sedating drug, the sedating drug may help alleviate the activation of withdrawal. You may plan to taper the sedating drug later.

BUT -- Don't add a "brake" to your cocktail to prepare for withdrawal
Do not increase your risk of neurological damage by increasing your polypharmacy. Adding drugs may conflict with a drug you're already taking.

The sedating drugs also will need tapering, and can incur a withdrawal syndrome of their own.

THE PROPER WAY TO MINIMIZE WITHDRAWAL EFFECTS IS TO TAPER AT A SLOW ENOUGH RATE FOR YOUR NERVOUS SYSTEM.

Benzos are addicting! Why not quit the benzo first?
Yes, benzos are defined as truly addicting drugs. But when it comes to withdrawal, the physical dependency incurred by other psychiatric drugs makes the concept of "addiction" moot.

Psychiatric drugs that are technically non-addicting can be just as hard to go off, and some cause much more physical damage than benzos.

I am not minimizing at all the difficulty of a benzo taper or the seriousness of benzo dependency. We are in the disgusting situation of always having to evaluate the least bad choice. I know many people are anxious to get off benzos once they find they're addicted, but even though ADs are not technically addictive, severe antidepressant withdrawal syndrome is just as bad.

When you are taking an antidepressant and a benzo, if you are not having significant adverse effects from the benzo, consider tapering the antidepressant first for these reasons:

  • Antidepressants are activating while benzos are sedating. The action of the benzo can soften the suffering from antidepressant withdrawal symptoms.
  • Conversely, a concurrent antidepressant will not reduce withdrawal symptoms during a benzo taper. With all due respect, Prof. Heather Ashton's suggestion antidepressants might help is misguided, see http://survivingantidepressants.org/index.php?/topic/1510-ashton-manual-recommendation-of-antidepressants/page__view__findpost__p__14205

    In Dr. Stuart Shipko's e-book Xanax Withdrawal (2012), he addresses the Ashton Manual's apparent recommendation of antidepressants to counter benzo-withdrawal depression, see http://survivingantidepressants.org/index.php?/topic/1510-ashton-manual-recommendation-of-antidepressants/page__view__findpost__p__28759
  • Often, benzos are prescribed to cover up adverse effects, such as anxiety, insomnia, and akathisia, from an antidepressant. When you remove the benzo, the antidepressant's adverse effects come to the forefront. You then may be in such distress, it is difficult to taper the antidepressant slowly enough to forestall severe withdrawal symptoms.
  • Benzo withdrawal before antidepressant withdrawal increases the risk of a difficult antidepressant withdrawal.

    Going into an antidepressant taper with GABA downregulated by prior benzo withdrawal is a very perilous strategy. Your nervous system will need GABA to deal with antidepressant withdrawal symptoms.

    You may more easily control an antidepressant taper. Fast recovery from antidepressant withdrawal will enable you to tackle your benzo taper.

    The people who have the worst withdrawal syndrome are those suffering from both benzo withdrawal and antidepressant withdrawal, because two systems -- serotonin and GABA -- that might help them recover are not functioning due to downregulation.
  • If you have already done the hard work of getting off a benzo and then suffer severe withdrawal syndrome from the antidepressant, you are faced with the decision of whether or not to get on the benzo merry-go-round again.

    Many doctors treat antidepressant withdrawal symptoms with benzos, although that brings in a whole other set of problems, which you know well. Still, many people can't get through withdrawal without an occasional benzo dose. Consider using benzos very, very sparingly.

And then there are antipsychotics...
To make this a little more confusing, if you are taking an antipsychotic, e.g. Seroquel or Risperdal, you may wish to discontinue that first, because of serious adverse health effects from antipsychotics, such as diabetes.

However, if you're taking an antipsychotic to counter an adverse effect of an antidepressant, such as sleeplessness or agitation, you may want to discontinue the antidepressant first.

Conceivably, one might systematically lower the antidepressant part way, then lower the antipsychotic. If sleep doesn't break up, continue to get off the antipsychotic. If it breaks up, stop lowering the antipsychotic, stabilize, and lower the antidepressant, managing the tapers in a way that preserves sleep.

Before tapering, be sure to discuss the above with your knowledgeable medical caregiver.

Edited by Altostrata
updated

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Nikki   
Nikki

I know people who are on cocktails of meds, and not feeling any better. From the knowledge I gained here I really see how dangerous these cocktails are. These doctors will take a patient off of one & immediately start another. When the patient complains they aren't responding the doctor's never really seem to realize that the poor patient is in WD from the pill they just took them off.

 

I can also see how, over time, there really is a sensitivity which develops, rendering the meds ineffective...

 

Alto this site will be up for years with people being prescribed these cocktails....

 

Hugs

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alexjuice   
alexjuice

I endorse.

 

It's sometimes said that benzo folks recommend benzo taper first without disturbing other meds, while AD folks promote the converse. But, from my personal experience, it's not a you say tomAto, I say tomato.

 

If there is rationale behind the "taper the benzo first" course, I don't know the basis for it.

 

If I could do it again, I'd taper slower and delay the benzo.

 

Alex

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alexjuice   
alexjuice

I'd add one thing. IMO, id advise an exception to the taper inversely to the level of stimulation.

 

Atypical antipsychotics are sedating but I would taper an atypical first because of the risk profile. The atypicals are especially, from my experience, observation and correspondence with clinicians, nasty.

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Skyler   
Skyler

Hi Alto, this is great, but given anecdotal reports, I'm wondering where in this pecking order anti-convulsants fall. They can take the edge off benzo withdrawal, so can have a legitimate role when prescribed judiciously and in low doses?

 

There is art in knowing how to withdraw when drug cocktails are prescribed.

 

Thanks.. you are Aces as usual.~S

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Altostrata   
Altostrata

Excellent point, Schuyler. The anticonvulsants are on the sedating side.

 

If they can help benzo withdrawal symptoms, they should be tapered last -- if they are not causing adverse effects.

 

alex, you have a good point too. One doesn't want to stay on an antipsychotic any longer than necessary. But they tend to be sedating, if not stupefying. If you're taking Seroquel to sleep, for example, you'll want to lower the antidepressant first.

 

It's all a big tangle. I sure wish doctors would deal with this.

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alexjuice   
alexjuice

Agreed. A dose of seroquel directed at 'psychosis' (600-1200+mg) poses entirely different risk than one directed at sleep disturbance (50mg, maybe 100).

 

It *is* a tangle, in so many ways. It's such a tangle these protocols and parameters are not standardized in the profession. It is an embarrassment (yet again) to psychiatry and pharma-psych that we, the patient aftermath, must use our time, effort, resources to define algos for de-Drugging and managing withdrawal risk.

 

I feel doubtly insulted, like I've been shot and tossed into a big room with hordes of other gunshot victims and we're all just supposed to put our heads together and decide how best to remove the bullet, treat the wound and prevent further injury. It's a massive injustice.

 

Everyday, though, someone (like me in 04) goes back on meds or back on meds plus more meds because an ill-informed attempt at discontinuation and subsequent w/d is misinterpreted as confirmation of psychiatric illness or even revealing new and additional diagnoses.

 

At least this site is rising in search and other cracks are forming in the dam. Hoping for fewer me's in the future. Also, nobody, especially someone under 25 should be on the lg doses of the antipsychotics. I watch people in meetings and think of my own life. I got two emails in a short span from the NAMI-affiliated clubhouse here in town. Two needlessly overmedicated people, friends of mine from there, are dead. One girl committed suicide about 6 weeks ago. The second email came last week, another man took his life. It just pisses me off.

 

Alex

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Skyler   
Skyler

Antidepressants and ADD drugs (methamphetamine analogs) are activating drugs. Benzodiazepines, the "Z" drugs for sleep, anticonvulsants, Lyrica, gabapentin (Neurontin), etc. are sedating drugs.

How long can after discontinuation may lamactil still help after a person stops taking an ADs? For example, a 2 months out, 4, 10? Do benzos have the same sort of window for post discontinuation use? I'm reading about someone now who is suffering after 18 months off. Why Lamactil as opposed to Lyrica, neurontin etc., do the latter work as well? Do the type of symptoms someone is exhibiting have any bearing on whether one of the anti-convulsants are prescribed?

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Altostrata   
Altostrata

Any of the anticonvulsants, including benzos, may help reduce prolonged withdrawal symptoms, but each drug carries its own risks, including triggering hyper-reactivity and paradoxical reactions. They are helpful because they reduce nervous system activity, in different ways. For example, benzos ramp up the GABA system, the body's natural regulatory (dampening) mechanism. However, they might do this too strongly, causing the body's alerting system set up an alarm, and they tend to weaken the native regulatory system, causing dependency.

 

Lamictal (lamotrigine) is unique in that it targets glutamatergic transmission in the alerting system, dampening that type of alerting. It does not downregulate GABA receptors.

 

Lyrica and Neurontin affect the GABA system in a different way than benzos.

 

While doctors may throw anticonvulsants at withdrawal symptoms, mostly going after the anxiety, so few doctors know anything about withdrawal syndrome, not much is known about what drugs are appropriate for what kind of withdrawal syndrome, or how to dose them.

 

From my observation, there definitely do seem to be a few types of withdrawal syndrome. The most common is based on hyper-alerting. Another is more like fibromyalgia and hyper-sensitivities. A third seems to trigger possibly pre-existing borderline auto-immune conditions.

Edited by Petu
fixed text

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Rhiannon   
Rhiannon

I'd add one thing. IMO, id advise an exception to the taper inversely to the level of stimulation.

 

Atypical antipsychotics are sedating but I would taper an atypical first because of the risk profile. The atypicals are especially, from my experience, observation and correspondence with clinicians, nasty.

 

Yep I would have to agree with this. ADs are actually more toxic than benzos, another reason to taper the AD first, but the antipsychotics are extremely toxic and cause high risk for other health complications which may not be easily reversible. I would be inclined to say, taper the most dangerous drug first.

 

Also want to add that there are exceptions to every rule, and there may be times when a person needs to taper their benzo first due to other issues they're having (such as paradoxical reaction to the benzo, health complications caused by the benzo, or work issues where excess sedation or problems with memory are a big problem).

 

However, I concur that in the absence of complicating factors, tapering the AD first makes the most sense.

 

Another possibility is to taper the AD to a lower dose, then taper the benzo for a while to a lower dose, then return to the AD taper. There would need to be breaks between the tapers to allow for healing and adaptation; this wouldn't be a fast process. But it might be an alternative for someone who needs to get off the benzo due to other factors.

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Rhiannon   
Rhiannon

Want to add something else: If you've been on a benzo for a while, its sedating effects aren't really going to help you with AD withdrawal. The sedating effect of a benzo goes away as tolerance develops, which happens pretty quickly (in a matter of four to eight weeks). After that the only thing the benzo is really doing is preventing withdrawal symptoms.

 

This isn't the case if you just take the benzo intermittently. If you take it intermittently enough that you don't develop tolerance, then you will get sedative effects from it.

 

I still concur that it's best to taper the AD first, though, because ADs don't seem to stop being activating over time, and if you're tapering a benzo the last thing you need is to be taking a drug that's stimulating.

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Altostrata   
Altostrata

the AD might help with the anxiety and depression brought on by benzo withdrawal

I know the benzo sites are saying this, but it is untrue.

 

It probably comes from Ashton, who didn't understand antidepressant withdrawal at all. She might have thought AD withdrawal is like relapse. Anxiety and depression are only one facet of AD withdrawal syndrome, as so many of us have found out. The surges of hyperalerting and sleeplessness are probably the most destructive AD withdrawal symptoms.

 

Even if you don't feel the sedative effects of a benzo you've been taking, it is dampening some reactions in your body, which can come in handy during AD withdrawal.

 

If the benzo has gone paradoxical, its dosage must be reduced. A paradoxical response to benzos is as bad as hyperalerting from antidepressant withdrawal. The alerting system is something you do not want to go haywire.

 

In case anyone has misinterpreted the first post, I want to emphasize it is only about polypharmacy, where you've already been taking several drugs for a while and you may be physically dependent on all of them.

 

While some people find they need an occasional benzo to get through antidepressant withdrawal, I am not advocating ADDING any kind of sedating-type drug to your drug regimen in order to make antidepressant withdrawal easier. This won't work; you'll just end up dependent on all of them and multiplying your withdrawal problems.

 

IF YOU ARE IN THE MIDDLE OF TAPERING do NOT count on adding a drug to make withdrawal symptoms more tolerable. If you are already having withdrawal symptoms, the addition of any other neuroactive drugs could make it worse.

 

If possible, deal with withdrawal symptoms during a taper by slowing the taper or updosing slightly.

 

You have much more control over a slow taper than you would have depending on a benzo to control your symptoms.

Edited by Altostrata
clarification

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alexjuice   
alexjuice

Want to add something else: If you've been on a benzo for a while, its sedating effects aren't really going to help you with AD withdrawal. The sedating effect of a benzo goes away as tolerance develops, which happens pretty quickly (in a matter of four to eight weeks). After that the only thing the benzo is really doing is preventing withdrawal symptoms.

 

Hey Rhi,

This bit is confusing to me. You mean continuining on a benzo prevents symptoms that would occur if the benzo itself is removed/reduced? That after a few weeks the benzo wouldn't ameliorate AD withdrawal symptoms? Reading you right?

 

Alex

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Barbarannamated   
Barbarannamated

Sedating vs anxiolytic effects, possibly? I've been taking Klonopin 1mg qhs for bruxism since 1995ish and it still seems to help. When i miss it or use generic, i wake with terrible facial pain/headache.

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alexjuice   
alexjuice

ADs are actually more toxic than benzos, another reason to taper the AD first, but the antipsychotics are extremely toxic and cause high risk for other health complications which may not be easily reversible. I would be inclined to say, taper the most dangerous drug first.

 

Last March when I first lost my lunch and things got really bad, I spoke with a Whitaker-friendly doctor, from Advocates in Framingham, MA and the faculty at Harvard med school.

 

He didn't understand protracted withdrawal at that time, however he felt taking the psych drugs presented horrific risks. When I told him I was off Effexor and Riperdal but not yet off the benzos, he told me that I'd wisely "gotten off the most dangerous ones" and he further advised to return to the benzo dose before my collapse and recommended I jut sit tight for another 1-2 years.

 

At the time, I was surprised how little he understood withdrawal. I'd been off Effexor and Risperdal for 12 months and he felt that, in spite of my poor health, I'd jumped that hurdle already.

 

So to your point, this doctor agreed. he categorized both ADs and atypicals as worse than benzos from a health consequence/risk perspective, independent of withdrawal.

 

I felt, nd continue to feel, that high therapeutic dose of ny atypical antipsychotic presents the worst health risk, disproportionately greater thaattune syndromes they mean to """treat"""". I think we all agree that the widespread writing of antipsychotics, prescribed so often to the downtrodden and young, is an abominable tragedy.

 

Alex

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Skyler   
Skyler

ADs are actually more toxic than benzos, another reason to taper the AD first, but the antipsychotics are extremely toxic and cause high risk for other health complications which may not be easily reversible. I would be inclined to say, taper the most dangerous drug first.

I did not know this before coming to this site, but the side effect profile from ADs is worse than benzos. The benzo forum I was on inadvertently supported the idea that benzos are the devil reincarnate.. that every ill stems from side effects.. this would lead to the faulty notion that one type of withdrawal is worse than another. When you are in withdrawal, all are horrible.

 

Want to add something else: If you've been on a benzo for a while, its sedating effects aren't really going to help you with AD withdrawal. The sedating effect of a benzo goes away as tolerance develops, which happens pretty quickly (in a matter of four to eight weeks). After that the only thing the benzo is really doing is preventing withdrawal symptoms.

 

I'm confused here.. I agree with what Rhi is saying, but Alto, are you referring to something else here, that there are non sedating effects from benzos that may cover some AD side effects? To put it another way, the action of benzos on neuroreceptors mitigate some of the withdrawal effects from GABA? So the clinical effects of benzos are not the reason you say this?

 

Do NOT add Lamictal. Do NOT add Seroquel. Do NOT add Topamax. Do NOT add Lyrica. Do NOT add Neurontin. If you are already having withdrawal symptoms, the addition of any other neuroactive drugs could make it worse.

 

I thought that in some very difficult instances anticonvulsants may help withdrawal and this was why you were put on this?

 

Also, I'm still unclear as to whether there is any rule of thumb about reinstatement for ADs, e.g if someone is off ADs for 2 months, after ct or too quick a withdrawal, they could reinstate ADs at a judicious dose. But if someone has been off for 6 months, it might be too late for reinstatement to help?

 

Alex, antipsychotics, aka the major tranquilizers make me cringe. I've seen their devastation in my family, they are truly and awsomely bad. Adjectives are insufficient. Carnage.

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Altostrata   
Altostrata

Schuyler, thanks for asking for clarification. I've edited my post above to say:

 

IF YOU ARE IN THE MIDDLE OF TAPERING Do NOT add Lamictal. Do NOT add Seroquel. Do NOT add Topamax. Do NOT add Lyrica. Do NOT add Neurontin. If you are already having withdrawal symptoms, the addition of any other neuroactive drugs could make it worse.

 

You have much more control over a slow taper than you would have depending on a benzo to control your symptoms.

 

If you have prolonged withdrawal symptoms after you finish your tapering, you'll have to be very, very careful adding any of the sedating drugs, including benzos, to deal with your symptoms. So few doctors understand how to do this, I cannot recommend it as something to do as a matter of course. If you try a very low dose of lamotrigine, for example, you'll be experimenting on your own.

 

 

Let me explain further:

 

I'm not saying benzo withdrawal is going to be easier than antidepressant withdrawal. The withdrawal symptoms are very similar. What I'm saying is don't further destabilize the GABA system with benzo withdrawal before antidepressant withdrawal, or you'll have double trouble.

 

The GABA system and the serotonin system help keep the nervous system in balance. They both help regulate the alerting system. Benzos produce similar withdrawal symptoms because when the GABA system is knocked out from being downregulated by the drug, the alerting system takes over in this situation, too.

 

(I've had my problems with benzos, too. In my case, I had severe AD withdrawal and tiny doses of the benzos went paradoxical fairly quickly. It was horrible and just about destroyed my nervous system.)

 

Bringing in antidepressant withdrawal symptoms in the context of GABA destabilization is the worst scenario. Both GABA and serotonin is downregulated. There are no brakes at all on the alerting system.

 

Even if someone has reached tolerance on the benzo, the GABA system is still stable. It is still working to suppress some activities in the nervous system, even if the person can't feel it. If the person is suffering adverse effects from the benzo at this point, I agree the benzo should be very carefully eliminated.

 

In my opinion (and that of an informed doctor), carefully reducing the more activating drugs first, minimizing nervous system dysregulation in that process, is preferable to reducing the activating drugs in the context of GABA downregulation, which is what you'd have if you reduce the benzo first.

 

It's true benzos are technically addicting, which makes being dependent on them scary and stigmatizing, and antidepressants are technically not addicting, a definition engineered by pharma that has been a big selling point for them. But the difference between benzo dependency and antidepressant dependency is largely semantic. In the body, one dependency is not worse than the other.

 

These are all terrible choices! I'm very angry that medicine forces us to make them on our own.

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Rhiannon   
Rhiannon

 

Want to add something else: If you've been on a benzo for a while, its sedating effects aren't really going to help you with AD withdrawal. The sedating effect of a benzo goes away as tolerance develops, which happens pretty quickly (in a matter of four to eight weeks). After that the only thing the benzo is really doing is preventing withdrawal symptoms.

 

Hey Rhi,

This bit is confusing to me. You mean continuining on a benzo prevents symptoms that would occur if the benzo itself is removed/reduced? That after a few weeks the benzo wouldn't ameliorate AD withdrawal symptoms? Reading you right?

 

Alex

 

This is my understanding based on what I've read. When we take benzos regularly, the body fairly quickly alters its GABA system (and other benzo receptors presumably, because they don't just act on GABA) to adapt to the benzo in the body.

 

When people in studies are given benzos for anxiety, at first they experience a reduction in anxiety compared to placebo, but after a few weeks the anxiety actually begins to increase relative to placebo. At the end of the study they don't seem to be getting any actual effect from the benzos any more, as far as the anxiety is concerned, relative to placebo. Once taken off the benzo at the end of the study the anxiety skyrockets to a level higher than it was before the study began.

 

Now, admittedly this is not nearly enough information to say "benzos do nothing at all once you develop tolerance to them, which happens in a few weeks time". I don't actually know what they're doing in all the body systems they affect. There are apparently benzo receptors in every cell in the body (in the mitochondria) and all kinds of GABA involvement in regulating pretty much everything. And that's just the limited amount that I actually know about.

 

What I think I can say with some confidence, though, is that the thing they do MOST is prevent the train wreck that would happen if they were suddenly removed.

 

Agree 100% that the last thing you need when you're trying to taper an AD is an already-wrecked GABA system from benzo withdrawal. Unless there are other complicating factors, tapering the AD first makes more sense to me than tapering the benzo first.

 

I disagree with Ashton on this and a few other points. She has a great deal of experience working with benzo withdrawal and her work is immensely important. But she did most of her work in the 80's and 90's before our current understanding of neuroplasticity. I get the impression she doesn't know much about ADs and what they really do to us. She's retired now--I think she's in her 80s or so--and I suspect that if she were more actively involved in current research she would not endorse ADs at all. I could be wrong. But she's human and I don't think she's infallible.

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Altostrata   
Altostrata

I think the only difference here is that one can get stuck on benzos faster.. but stuck is stuck, and it does not take all that long to get hooked on antidepressants either. Maybe a couple of months as opposed to a couple of weeks. Of course, to confuse, the hook time varies according to age, drug history, genes, etc.

That's hard to say. There are people who react so strongly to a serotonergic, within a few doses their nervous systems are dependent -- and they are suffering severe adverse effects. These people have withdrawal syndrome-like nervous system dysfunction when they quit, which may be after only a few days.

 

I believe the literature says antidepressant withdrawal symptoms are a risk after taking a medication for 60 days.

 

The only question I still have is about the window for reinstatement for ADs. How long would a person need to be off before the clinical efficacy of reinstatement is not worth the risk? Given each situation is different..

 

Unfortunately, this is unpredictable. Certainly reinstatement is more likely to work when it's done as soon as possible, within a few weeks or perhaps months. However, some people find reinstatement works after a much longer time while others find it doesn't work at all, or makes symptoms worse.

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Rhiannon   
Rhiannon

Well, I have to say that seeing it this way (that after the first couple of weeks the benzo isn't really doing anything much, just preventing benzo withdrawal symptoms) fits with my own experience in tweaking and tapering my multiple meds.

 

Unfortunately, the side effects (stupefying, amnestic, hormonal, etc.) don't seem to go away just because the GABA system has adjusted to the presence of the benzo.

 

I doubt that staying on a benzo during AD withdrawal would really help with the effects of withdrawal from an AD. That is, not in a sedative way. I think the sedative effects of a benzo, once tolerance is reached (after a few weeks of daily use, that is) are primarily relative--that is, sedating the stimulation that happens when the previous dose wears off.

 

But I suspect that being on an AD could complicate the effects of withdrawal from a benzo. And for sure, if you're tapering an AD, the last thing you need is to be suffering through benzo withdrawal or recovery from benzo withdrawal.

 

So if you're choosing which to taper first, an AD or a benzo, I think tapering the AD first does make sense. The only piece of the argument for that which I question is the idea that staying on the benzo is somehow going to sedate or help with the AD withdrawal effects. I don't really think that's a big contributor. (That's with daily regular use of the benzo. Intermittent use is different, if tolerance doesn't develop.)

 

(Nor do I think staying on an AD is going to help with benzo withdrawal effects. Except in the same sense, that trying to QUIT an AD that your body is adapted to, if you're in benzo withdrawal, will definitely make things worse.)

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Altostrata   
Altostrata

I will concede, Rhi, that if you've reached tolerance with the benzo and do not feel its sedating effects, it may not help with AD withdrawal symptoms. I don't know the answer to that. But -- let's say you're at this point and sleeping regularly. Stopping or decreasing the benzo may very well destabilize your sleep.

 

This is highly undesirable if you want to go off an AD, because it may further wreck your sleep and then you'll be extremely miserable.

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alexjuice   
alexjuice

Again, interesting responses.

 

In case it isn't clear (which it probably is not) I'm prodding here because I am preparing to start reducing the benzos. I have been hesitant, partly b/c i feared a return of some of my primary AD w/d symptoms which may not constitute a potent threat. But was a fear I wanted to explore to aid my comfort level.

 

I am also concerned about the timing. I've been waiting to taper the benzos until I settled on more of a symptom plateau, lately been peaks and valleys. But at some point the waiting probably costs more than just starting the taper. There will probably not come a perfectly rosy time to begin it.

 

Larger context, I hope it didn't come across as though I advocate benzos to alleviate AD or any other withdrawal syndrome. IMO, that'd make a perfectly terrible idea.

 

Alex

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Skyler   
Skyler

Larger context, I hope it didn't come across as though I advocate benzos to alleviate AD or any other withdrawal syndrome. IMO, that'd make a perfectly terrible idea.

 

Alex

 

Hi Alex, I think any sedating benzo effect that might take the edge off AD withdrawal would be very short lived, and the use would not be justified given one can get addicted to benzos in a month or sometimes less.

 

Alto..thanks for sticking with us on the benzos so we got it cleared up.~S

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Rhiannon   
Rhiannon

I will concede, Rhi, that if you've reached tolerance with the benzo and do not feel its sedating effects, it may not help with AD withdrawal symptoms. I don't know the answer to that. But -- let's say you're at this point and sleeping regularly. Stopping or decreasing the benzo may very well destabilize your sleep.

 

This is highly undesirable if you want to go off an AD, because it may further wreck your sleep and then you'll be extremely miserable.

 

Yep absolutely. If you stop taking the benzo it will definitely screw up any homeostasis you may have managed to achieve. I do think it makes sense to taper the AD first if there are no other complicating circumstances.

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Rhiannon   
Rhiannon

Again, interesting responses.

 

In case it isn't clear (which it probably is not) I'm prodding here because I am preparing to start reducing the benzos. I have been hesitant, partly b/c i feared a return of some of my primary AD w/d symptoms which may not constitute a potent threat. But was a fear I wanted to explore to aid my comfort level.

 

I am also concerned about the timing. I've been waiting to taper the benzos until I settled on more of a symptom plateau, lately been peaks and valleys. But at some point the waiting probably costs more than just starting the taper. There will probably not come a perfectly rosy time to begin it.

 

Larger context, I hope it didn't come across as though I advocate benzos to alleviate AD or any other withdrawal syndrome. IMO, that'd make a perfectly terrible idea.

 

Alex

 

I thought maybe you were thinking about starting down on the benzos.

 

Just be very careful, okay? teeeeny baby steps, long holds, especially at first.

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Altostrata   
Altostrata

I'm really worried about how this information is being misinterpreted.

 

It seems people are peeking in from the Internet on smartphones, failing to read the whole topic or even the entire first post, and thinking they can add Lamictal or something to their tapers to compensate for withdrawal symptoms.

 

DON'T DO THIS!!!!!! Don't count on being able to take a pill to fix whatever is wrong with you.

 

Anything you add may conflict with something you're already taking.

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Altostrata   
Altostrata

Talked to Stuart Shipko about discontinuing multiple drugs, he said he usually leaves the benzo for last, for all the above reasons.

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Altostrata   
Altostrata

We don't discourage switching to a longer-acting drug, we just suggest using it as a last resort if a direct taper fails, because sometimes the switch doesn't work.

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amarchand   
amarchand

Wow this is so helpful (read first post in full). Was going to taper off ativan first as its addictive and thought pristiq would help me through it and then drop pristiq! Will now go to beaded effexor (done twice before) and withdrawal from then taper from ativan.

Thank you Alto for taking the time to help people like me know there's an end in sight. :)

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dante   
dante

Hello,

 

 I am very glad to read these opinions, thank you so much.

Me too Taking multiple psych drugs xanax and citolopram together almost 10 years

xanax mostly for sleeping and helping side effects of citolopram...

 

I wonder if we get help of herbs for withdraval symptomes ?

I heard abot valerian, kava-kave both similar to benzo,

and  atarax as medicine for anxity ?

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Altostrata   
Altostrata

Hello, Dante. If we knew such herbs might help, we would be sure to tell you right off.

 

We do not have recommendations for those herbs.

 

If you have questions about any herb or supplement, please go to the Symptoms and self-care forum and use search.

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elbee   
elbee

The conundrum I've faced: On benzo websites, they generally say taper the benzo first. On this website (focused on AD withdrawal / disuse), the advice is mostly to taper the AD first. In general, I think the advice / guidance on this site is THE BEST I have found online. However, I'm not sure I agree that it's generally best to taper the benzo before the AD if taking both.

 

I thought I would add my 2 cents on this topic. I'm posting about it on my own thread, but I think this is an important thread for folks taking both benzo and AD, so I want to contribute based on my own experience. I've been alternating the taper of my benzo and AD, and so far I haven't had a panic attack (my primary issue). However, having become more attuned to my body, mood, symptoms, etc., AND being fortunate enough to NOT have to work at this period in my life nor have any other major obligations (for now), the alternating approach has worked well, and I'm going to move forward with the benzo taper/jump before the AD taper/jump moving ahead. First, I'll quote what Rhiannon said in this thread which mirrors my experience (her first comment below, anyway), and at the bottom I'll copy and paste what I wrote in my own thread about my own experience. 

 

Earlier in this thread, Rhiannon suggests that it may make sense to taper the benzo first, and then somewhat backs off on that position: 

 

On 5/7/2012 at 3:16 PM, Rhiannon said:

 

Want to add something else: If you've been on a benzo for a while, its sedating effects aren't really going to help you with AD withdrawal. The sedating effect of a benzo goes away as tolerance develops, which happens pretty quickly (in a matter of four to eight weeks). After that the only thing the benzo is really doing is preventing withdrawal symptoms.

 

 

On 5/14/2012 at 1:30 PM, Rhiannon said:

 

Well, I have to say that seeing it this way (that after the first couple of weeks the benzo isn't really doing anything much, just preventing benzo withdrawal symptoms) fits with my own experience in tweaking and tapering my multiple meds.

 

Unfortunately, the side effects (stupefying, amnestic, hormonal, etc.) don't seem to go away just because the GABA system has adjusted to the presence of the benzo.

 

I doubt that staying on a benzo during AD withdrawal would really help with the effects of withdrawal from an AD. That is, not in a sedative way. I think the sedative effects of a benzo, once tolerance is reached (after a few weeks of daily use, that is) are primarily relative--that is, sedating the stimulation that happens when the previous dose wears off.

 

But I suspect that being on an AD could complicate the effects of withdrawal from a benzo. And for sure, if you're tapering an AD, the last thing you need is to be suffering through benzo withdrawal or recovery from benzo withdrawal.

 

So if you're choosing which to taper first, an AD or a benzo, I think tapering the AD first does make sense.

 

 

My plan is to continue the alternating AD / benzo taper until I get to 75 mg of Zoloft (half of the original dose at 82 currently), and then taper the Klonopin down to zero / jump. Because of my understanding of how the Benzo works (generally, reach tolerance very quickly, 4-8 weeks), I believe I'm simply going through a dosing/withdrawal affect with each benzo dose I take - twice daily. I take some in the morning and some at night, so in other words, I take my morning pill in the morning, get back up to tolerance level, then spend the rest of the day simply going through benzo withdrawal. Then the same cycle with the nighttime dose. Whereas the SSRI has a much slower effect on changing brain structure (based on the scant research out there I have found). My goal with the alternating taper has been to heal both neurotransmitter systems (GABA and Serotonin) at a time, but reducing only one med at a time. I do think this has worked relatively well, and continuing this method through my taper of both drugs would probably (hopefully) bring me to a successful zero on both (if I go slowly enough).

 

However, I'm at 25% of the benzo now (.5 mg) than when I started this taper (2 mg), and I think it now makes sense to take the benzo all the way down and end the quickly repeating withdrawal symptoms of that drug first I experience twice daily. THEN I focus on reducing the SSRI as slowly as I need to until zero/jump. My experience is that while the benzo withdrawal seems to be more acutely intense, the SSRI withdrawal is much slower, yet also much more dramatic with regards to my anxiety panic symptoms. With regards to “activation,” the benzo seems to be much more activating in the short term, the AD much more activating in the long term. At this point, I'm now much more concerned about experiencing a panic attack through the SSRI withdrawal than the benzo, and I don't believe the benzo will help with the SSRI withdrawal symptoms, but in fact may exacerbate them. Again, this is based on my own research and my own experience. I could very well be totally wrong! :)

 

In short, I think the SSRI MAY stabilize the benzo withdrawal, but I don't believe the benzo will at all help to stabilize the SSRI withdrawal. Will doing the benzo withdrawal first exacerbate the SSRI withdrawal after? Perhaps … we shall see how it goes. But it FEELS to me that the continuous daily effects of simply being on the benzo at a constant dose (dosing /withdrawal twice a day) is worse overall than any benefit that would be derived from being on benzos during the AD withdrawal.

 

 

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bubble   
bubble

As you can imagine, I'm very interested in this topic while trying to figure out how to best deal with my 'combo'.

 

I agree with you that it sounds very logical we can't expect much of a sedating effect from a benzo I've been on for almost 20 years. It stopped doing anything for me a very long time ago. Although xanax is the one with the shortest half lives I'm taking it 4 times a day and can't say I'm experiencing any WD from it while holding to taper the AD. But who knows.

 

After having reduced the benzo significantly I'm very sensitive to the AD cuts (making only 2 % per month) and the WD is still as debilitating as I can take.

 

A very intriguing aspect of the whole story is how their interplay (and the resulting effect on our symptoms) changes as their ratio changes.

 

I definitely notice a big difference in type of symptoms and my personality (!) as the ratio between the drugs is being changed.

 

Browsing through some old threads I came across this quote (not sure how reliable it is but it would be interesting to hear opinions and experiences).

 

Anyway, I think I figured out from "alternative" sources that my AD was interacting with my benzo, so stopping the AD made the benzo metabolize faster. So it was like a dosage cut, even though the dose was the same. I have maybe 80% recovered from that now. So I did a quick goggle on your drugs...even a mainstream source said both those ADs have moderate potential to interact with your benzo. So you probably had a really significant drop in your benzo level once the ADs got out of your system. Just something to think about.

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elbee   
elbee

Bubble, thanks for sharing your experience on this. I'm definitely open to the idea of there being some type of interaction occurring between the benzo and the AD, particularly as the doses get lower. And of course, there is just no way to know for sure. While the alternating taper approach I think has worked well so far, I'm just feeling like focusing on getting off the benzo completely (once I get the Zoloft down to 75 mg as a holding spot for convenience) will be best moving forward. I seems like I used to have a better sense of which drug was creating the various WD symptoms I was experiencing with the multi-drug taper, but that feels much less clear now for whatever reason (again, perhaps getting to lower doses?). So by reducing the taper to one drug, there will be fewer "moving variables" involved moving forward. 

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Shep   
Shep

Bubble and Elbee, this is an article I came across dealing with antidepressants and benzodiazepines (and other drugs) and how they can increase / decrease blood levels of each other:

 

What are some drug interactions for anti-anxiety drugs?

 

From the article:

__________________________________________________________________________

 

Alprazolam increases blood levels of the antidepressants imipramine and desipramine. Alprazolam may also interact with some calcium channel blockers and with grapefruit juice. Carbamazepine decreases blood levels of alprazolam.

 

Combining benzodiazepines with alcohol or other central nervous system depressants can cause increased sedation and potentially dangerous respiratory depression.

 

Fluoxetine, propoxyphene, and oral contraceptives increase blood levels of alprazolam (Xanax), as do ketoconazole, itraconazole, nefazodone, fluvoxamine, and erythromycin.

 

Oral antifungal agents such as ketoconazole and itraconazole may significantly decrease blood levels of clonazepam (Klonopin).

 

Serious side effects, including respiratory arrest, may occur if lorazepam (Ativan) is combined with clozapine. Dosage of lorazepam should be halved when taken with valproate or probenecid.

__________________________________________________________________________

 

The article lists a number of other interactions involving psych drugs and other drugs. It also mentions the fact that Wellbutrin lowers the seizure threshold, so people tapering off a combination of Wellbutrin and a benzo need to keep that in mind. 

 

So these drugs do play off each other. 

 

There are also some articles in PubMed about this:

 

A Case of Suicidal Thoughts With Alprazolam

 

From the article, citing how fluoxetine (Prozac) interacts with alprazolam (Xanax): 

__________________________________________________________________________

 

Fluoxetine significantly increased the half-life of alprazolam from 17 hours to 20 hours and significantly decreased its clearance from 61 mL/min to 48 mL/min. The mechanism of action is thought to be through inhibition of the cytochrome P450 3A4 isoenzyme, which is responsible for alprazolam metabolism.

 

__________________________________________________________________________

 

And you can probably find other articles out there, as well. 

 

 

Edited by Shep
added information and link

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elbee   
elbee

Thanks for your reply, Shep. I don't see anything in that article specifically about Zoloft and Klonopin. Here is one that does . . .

 

"Ambien, Ativan, Neurontin, and Klonopin should all be avoided while taking Zoloft. The risk of central nervous system and respiratory depressant effects are greatly increased if these medications are combined. This can lead to confusion, decreased motor function, difficulty breathing, blurred vision, low oxygen levels and even sudden death. These side effects are greatly increased in elderly and debilitated patients. If a patient is prescribed one of these medications while on Zoloft, they should talk with their doctor to ensure safety."

Source: Zoloft Drug Interactions (Sertraline) - Drugsdb.com http://www.drugsdb.com/rx/zoloft/zoloft-drug-interactions/#ixzz4l41pN1he

 

However, I never see any specific research cited on these "curation-based" public websites. Also, the warnings that are proclaimed differ from site to site. I really haven't found a source for cumulative researched-based information yet that I trust. I know some folks on this site have gone deep into looking at the actual research published, but I haven't done that.

 

In short, I've no doubt there are probably interactions between the two drugs I'm on. I just don't trust any source out there to tell me what they are likely to be, and how likely it is that I might experience the effects. So again, I guess I'm just trying to listen to my body, which is generally easier when I'm tapering more slowly and much harder when I've picked up the pace.

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