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Guides to tapering off psychiatric medications

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Altostrata

Also see

 

Official guides to tapering off psychiatric medications

 

NMSIS Tips to manage and prevent discontinuation syndrome

 

Harvard Women's Health Watch 2010 Going off antidepressants

 

____________________________________________________

 

From GPnotebook.co.uk, a widely used UK medical site for general practitioners:

 

Stopping antidepressant treatment

 

  • the timing of when to stop antidepressant treatment is discussed...below (length of antidepressant treatment)

  • patients should be advised not to stop treatment suddenly or omit doses - patients should also be forewarned about possible symptoms that may occur when treatment is discontinued

  • Drug and Therapeutics Bulletin (1) advises:
      [*] after a 'standard' 6-8 months treatment it is recommended that treatment should be tapered off over a 6-8 week period

    • if the patient has been on maintenance therapy then an even more gradual tapering e.g. by 1/4 of the treatment dose every 4-6 weeks, is advised

    • if a treatment course has lasted less than 8 weeks then discontinuation over 1-2 weeks is considered safe

  • this contrasts with the Maudsley prescribing guidelines (2) which recommend that antidepressants should be withdrawn slowly, preferably over four weeks, by weekly increments for example,

     

     

     

     

    Drug maintenance dose (mg/day) dose after 1st week (mg/day) dose after 2nd week (mg/day) dose after 3rd week (mg/day) dose after 4th week (mg/day)
    amitriptyline 150 100 50 25 Nil
    paroxetine 30 20 10 5 (liquid) Nil
    trazadone 450 300 150 75 Nil

    If withdrawal symptoms occur then the rate of drug withdrawal should be slowed or (if the drug has been stopped) the patient should be given reassurance that symptoms rarely last more than 1-2 weeks (2).

  • NICE also suggest a four week period for withdrawal of antidepressant

    treatment (3):

    • stopping or reducing antidepressants

       

    • advise people that discontinuation symptoms may occur on stopping,

      missing doses or, occasionally, reducing the dose of the drug. Explain

      that these are usually mild and self-limiting over about 1 week, but

      can be severe, particularly if the drug is stopped abruptly

    • normally, gradually reduce the dose over 4 weeks (this is not necessary

      with fluoxetine). Reduce the dose over longer periods for drugs with

      a shorter half-life (for example, paroxetine and venlafaxine)

    • advise the person to see their practitioner if they experience significant

      discontinuation symptoms. If symptoms occur:

       

    • monitor them and reassure the person if symptoms are mild

    • consider reintroducing the original antidepressant at the dose

      that was effective (or another antidepressant with a longer half-life from the same class) if symptoms are severe, and reduce the dose

      gradually while monitoring symptoms

    [*]for detailed guidance then consult the full guideline (3)

Swapping antidepressant treatment (2):

  • when swapping from one antidepressant

    to another, abrupt withdrawal should usually be avoided. Cross-tapering is preferred, where the dose of the ineffective or poorly tolerated drug is slowly reduced while

    the new drug is slowly introduced for example,

        week 1 week 2 week 3 week 4
    withdrawing dosulepin 150 mg od 100mg od 50 mg

    od

    25 mg od Nil
    introducing citalopram Nil 10

    mg od

    10mg od 20 mg od 20 mg od

Antidepressant

use: swapping and stopping

The table below has been adapted from the

Maudsley prescribing guidelines (2). However it is recommended that local prescribing guidelines and/or specialist psychiatric advice must be consulted when swapping antidepressant medication. Also the specific summary of product characteristics for each of the antidepressants involved should be consulted. It has been noted that there are no clear guidelines on switching antidepressants, so caution is required (2).

 

 

changing from to tricyclics to

citalopram

to fluoxetine to paroxetine to

sertraline

to venlafaxine
tricyclics

(TCA)

cross taper cautiously halve dose

and add citalopram then slow withdrawal

halve dose and add

fluoxetine then slow withdrawal

halve dose and add paroxetine

then slow withdrawal

halve dose and add sertraline then slow

withdrawal

cross taper cautiously starting with 37.5 mg per

day

citalopram cross taper

cautiously

  withdraw citalopram then start

fluoxetine

withdraw citalopram and then start paroxetine at

10 mg per day

withdraw citalopram and then start sertraline

at 25 mg per day

withdraw and then start venlafaxine at 37.5

mg per day. Increase very slowly

fluoxetine stop

fluoxetine. Start tricyclic at very low dose and increase very slowly

stop

fluoxetine. Wait 4-7 days; start citalopram at 10mg per day and increase slowly

  stop

fluoxetine. Wait 4-7 days; start paroxetine at 10mg per day and increase slowly

stop

fluoxetine. Wait 4-7 days; start sertraline at 25 mg per day and increase slowly

stop

fluoxetine. Wait 4-7 days; start venlafaxine at 37.5 mg per day. Increase very

slowly

paroxetine cross taper

cautiously with very low dose of tricyclic

withdraw paroxetine

then start citalopram

withdraw paroxetine then start fluoxetine   withdraw

paroxetine then start sertraline at 25 mg per day

withdraw

paroxetine. Start venlafaxine at 37.5 mg per day. Increase very slowly

sertraline cross taper cautiously with

very low dose of tricyclic

withdraw sertraline then start

citalopram

withdraw sertraline then start fluoxetine withdraw

sertraline then start paroxetine

  withdraw

sertraline then start venlafaxine at 37.5 mg per day

venlafaxine cross

taper cautiously with very low dose of tricycli

cross taper

cautiously. Start with citalopram 10 mg per day

crosss taper

cautiously. Start with 20 mg every other day

cross taper cautiously.

Start with 10 mg per day.

cross taper cautiously. Start with

25 mg per day

 
stopping reduce

over four weeks

reduce over four weeks

 

at 20mg per day - just stop

at 40 mg per day, reduce over four weeks

reduce

over four weeks, or longer if necessary *

reduce over four

weeks

reduce over four weeks or longer if necessary

NICE guidance regarding switching antidepressants is less detailed (3):

  • do not switch to, or start, dosulepin

    • because evidence supporting its tolerability relative to other antidepressants

      is outweighed by the increased cardiac risk and toxicity in overdose

  • when switching to another antidepressant, which can normally be achieved

    within 1 week when switching from drugs with a short half life, consider the

    potential for interactions in determining the choice of new drug and the nature

    and duration of the transition.

    Exercise particular caution when switching:

    • from fluoxetine to other antidepressants, because fluoxetine has a long

      half-life (approximately 1 week)

    • from fluoxetine or paroxetine to a TCA, because both of these drugs

      inhibit the metabolism of TCAs; a lower starting dose of the TCA will

      be required, particularly if switching from fluoxetine because of its

      long half-life

    • to a new serotonergic antidepressant or MAOI, because of the risk of

      serotonin syndrome

    • from a non-reversible MAOI: a 2-week washout period is required (other

      antidepressants should not be prescribed routinely during this period).

Notes:

Do not co-administer clomipramine and SSRIs or venlafaxine

When switching between one SSRI and another, cross-tapering the doses is generally not considered necessary. The effects of the first SSRI are likely to be so similar

to that of the second one, that the second SSRI will reduce the discontinuation effects of the first (2). The abrupt switch between SSRIs may still produce discontinuation

symptoms, and vigilance is still advised. In cases where discontinuation symptoms

arise a short period of dose tapering is recommended before starting a different SSRI.

* withdrawal effects may be more pronounced. Slow withdrawal over 1-2 months may be necessary.

 

Reference:

Edited by Altostrata
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alexjuice

NICE's advice to taper 50% a week over four weeks to d/c paxil is very bad advice. And, I feel confident in asserting, not the advice that would be offered by any of the posters on this site.

 

I thought pointing this out was worthwhile considering the possibility that a new visitor first could land on the instructions and decide to follow them.

 

Alex.i

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Altostrata

You could also use this as a start to educate your doctor about the most recent advice from the conservative wing of psychiatry.

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Neuroplastic

My doctor had always this advice; cut the pill in half, wait two weeks, then get rid of the rest. Yes, after eight years on it. :rolleyes:

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Altostrata

....

When switching between one SSRI and another, cross-tapering the doses is generally not considered necessary. The effects of the first SSRI are likely to be so similar to that of the second one, that the second SSRI will reduce the discontinuation effects of the first (2). The abrupt switch between SSRIs may still produce discontinuation symptoms, and vigilance is still advised. In cases where discontinuation symptoms arise a short period of dose tapering is recommended before starting a different SSRI.....

 

Note the conflicting and confusing advice regarding switching. :blink:

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Altostrata

From advice given to U.S. family practitioners. Note reference is from 1997:

 

Antidepressant Withdrawal

Aka: Antidepressant Withdrawal, Antidepressant Discontinuation Syndrome, SSRI Discontinuation Syndrome

 

Pathophysiology

  • Occurs with sudden Antidepressant Withdrawal

    • Selective Serotonin Reuptake Inhibitor (SSRI)
    • Tricyclic Antidepressant
    • MAO inhibitor
  • Symptom onset occurs within 24 hours to 2-3 weeks
  • Likely results from cholinergic overdrive

    Symptoms similar to Organophosphate Poisoning

  • Most common with Paxil
  • Least common with Prozac (naturally tapers)
Symptoms

  • Cholinergic rebound (See Cholinergic Toxicity)

    • Diaphoresis
    • Nausea or Vomiting
    • Diarrhea
  • Non-specific Withdrawal symptoms

    • Dizziness
    • Anxiety
    • Headache
    • Malaise
    • Myalgias
    • Weakness
    • Sleep Disturbance
  • Extrapyramidal effects

    • Paresthesias
    • Restless legs
Differential Diagnosis

Bipolar Disorder with Antidepressant-induced mania

 

Management: Approach

  • Mild Symptoms: Resolve spontaneously
    • Withhold treatment
    • Reassurance and observe
  • Moderate to severe symptoms

    • Restart medication and then slowly taper
    • See specific medications for taper schedule
    • Symptoms abate soon after restarting medication
Management: Specific Withdrawal Symptoms

  • Cholinergic rebound symptoms (See above)

    • Atropine 0.8 mg PO tid to qid
    • Cogentin 0.5 to 4 mg PO qd
    • Artane 1-4 mg PO tid to qid
    • Donnatal 2 tablets PO tid-qid
  • Anxiety

    • Lorazepam 0.5 to 1 mg PO tid prn
  • Dizziness

    • Antivert 12.5 to 25 mg PO q6 hours prn
    • Dramamine 50 mg PO q6 hours prn
Reference

Wolfe (1997) Am Fam Physician 56(2):455-461

 

 

http://www.fpnotebook.com/psych/pharm/antdprsntwthdrwl.htm

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Barbarannamated

What do you make of the reference from 1997? I've noted trends in literature... info ceased in early 2000s or thereabouts.

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Altostrata

New-generation antidepressant withdrawal syndrome became recognized in the late 1990s -- the initial hype from pharma was, as opposed to the tricyclics, there were no withdrawal difficulties -- and there was a burst of research that ended in the early 2000s.

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jr1985

My psychiatrist told me I could just stop taking Effexor at 75mg, as it was a "small dose". But I knew from past experience that missing a single dose would cause me horrible w/d symptoms the next day (depression, anxiety, diahorrea, nausea, etc). I decided to taper over a month, based on the official guidelines, and I thought by doing so I was playing it safe.

 

After I had terrible w/d symptoms, I saw a different psychiatrist and told her I'd tapered over a month, she nodded and said, "yes, that's what we recommend" and that it was "your old symptoms returning". Even though I was put on it for social anxiety, not horrific morning anxiety with restlessness, burning nerves, tremors, diahorrea, loss of appetite, etc.

 

So now I think they're all a bunch of idiotic quacks, and wouldn't dare trust them with my life/wellbeing again. The info I've found online has been much more reliable and helpful, as sad as that sounds.

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Altostrata

Yes, unfortunately that's true. Doctors are not well informed about getting people off psychiatric drugs.

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Rhiannon

My psychiatrist told me I could just stop taking Effexor at 75mg, as it was a "small dose". But I knew from past experience that missing a single dose would cause me horrible w/d symptoms the next day (depression, anxiety, diahorrea, nausea, etc). I decided to taper over a month, based on the official guidelines, and I thought by doing so I was playing it safe.

 

After I had terrible w/d symptoms, I saw a different psychiatrist and told her I'd tapered over a month, she nodded and said, "yes, that's what we recommend" and that it was "your old symptoms returning". Even though I was put on it for social anxiety, not horrific morning anxiety with restlessness, burning nerves, tremors, diahorrea, loss of appetite, etc.

 

So now I think they're all a bunch of idiotic quacks, and wouldn't dare trust them with my life/wellbeing again. The info I've found online has been much more reliable and helpful, as sad as that sounds.

 

If doctors in general and psychiatrists in particular knew how much psych med withdrawal experiences are undermining their credibility and authority I think they might take the problem more seriously.

 

I'm not the only person around who will never trust medical advice again. About ANYthing. Especially prescriptions or expensive testing.

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Barbarannamated

RE: testing - I have several tests and scans ordered but wondering "what info will this test yield?" and "what is/are the treatment/s" Inevitably, it's more drugs and that's where I get stuck wondering what's reasonable and worth doing.

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Aria

My former pdoc used to titrate my doses by 25% a week and got me off each drug within one month. Of course he had me start another one after that. My body was on a "continuous merry go round of stop this -- start this" for too long.

 

I last time I took his advice was when he told me it was OK to stop the Seroquel due to profound Akathisia. "You're not on much of it so it's no big deal to just stop it". It was 300mg of Seroquel and my body howled. When I called his office his nurse told me to go to the ER. I knew better.

 

I successfully tapered off all of the psych drugs on my own.

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meistersinger

My former pdoc used to titrate my doses by 25% a week and got me off each drug within one month. Of course he had me start another one after that. My body was on a "continuous merry go round of stop this -- start this" for too long.

 

 

In a footnote under tips for quitting psychiatric drugs on www.crazymeds.us, there is a citation for Julien--A Primer of Drug Action. The calculation there is take the half-life of the drug, multiply by 5 and round up to the nearest day. Anyone ever hear of this tome?

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tezza

My GP said " T, most people have no problem coming off Risperdal ". He, now, knows that I do.

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Altostrata

Many guides to tapering off psychiatric medications have been published. Some are more specific than others about the amount of reductions and rate of taper.

 

Gradual tapering is generally accepted medical practice, it's not controversial at all. Cold turkey is universally condemned as dangerous.

 

NONE of these guides suggest alternating or skipping doses to taper.

 

2010 APA Practice Guidelines

Practice Guideline for the Treatment of Patients With Major Depressive Disorder Third Edition

From the American Psychiatric Association

Selection and discussion: http://survivingantidepressants.org/index.php?/topic/372-2010-apa-practice-guidelines-about-discontinuation/

 

National Institute for Health and Clinical Excellence (NICE) guidelines (UK)

PDF: CG90 Depression in adults: full guidance 28 October 2009

Selection and discussion: http://survivingantidepressants.org/index.php?/topic/2448-nice-antidepressant-discontinuation-guidelines-for-uk-doctors/

 

US National Guidelines

For all US medical professionals, derived from APA practice guidelines.

Discussion: http://survivingantidepressants.org/index.php?/topic/1177-us-national-guideline-discontinue-antidepressants-after-4-9-months/

Icarus Project Harm Reduction Guide *

For tapering off psychiatric drugs, 2012 edition

PDF: http://www.theicarusproject.net/downloads/ComingOffPsychDrugsHarmReductGuide2Edonline.pdf

Selection and discussion: http://survivingantidepressants.org/index.php?/topic/207-icarus-project-harm-reduction-guide/

Mind UK's Making Sense of Coming Off Psychiatric Drugs *

An excellent summary of tapering.

Selection and discussion: http://survivingantidepressants.org/index.php?/topic/2331-mind-uks-making-sense-of-coming-off-psychiatric-drugs/

Dr. Peter Breggin's 10% taper method *

From Your Drug May Be Your Problem: How And Why To Stop Taking Psychiatric Medications by Peter R. Breggin and David Cohen

Selection and discussion: http://survivingantidepressants.org/index.php?/topic/803-dr-peter-breggins-10-taper-method/

 

Ashton Manual for benzodiazepine withdrawal

Also applies to "Z" drugs for sleep. Information on antidepressants is poor. 2002 version. Be sure to read 2011 update.

Discussions:

http://survivingantidepressants.org/index.php?/topic/206-2002-2011-ashton-manual-for-benzodiazepine-withdrawal/

http://survivingantidepressants.org/index.php?/topic/1510-ashton-manual-recommendation-of-antidepressants/

http://survivingantidepressants.org/index.php?/topic/1516-ashton-on-ssri-discontinuation-and-drug-development-2007/

NHS Advice: Benzodiazepine and z-drug withdrawal - Management *

Current NHS advice to doctors, informed by research by Ashton and Lader.

Discussions:

http://survivingantidepressants.org/index.php?/topic/2931-current-nhs-advice-for-doctors-about-benzo-tapering/

 

Gianna Kali's Withdrawal 101 on BeyondMeds.com *

 

NMSIS Tips to manage and prevent discontinuation syndromes

Circa 2005 from a physician education group, the Neuroleptic Malignant Syndrome Information Service. As usual, potential severity and possibly frequency of withdrawal are understated and descriptions of symptoms are incomplete. Recommends tapers of 10% per week, with close monitoring.

Selection and discussion: http://survivingantidepressants.org/index.php?/topic/2965-nmsis-tips-to-manage-and-prevent-discontinuation-syndromes/

Withdrawing Safely from Psychiatric Drugs *

by psychologist Maureen B. Roberts, Director, Schizophrenia Drug-free Crisis Centre

http://www.jungcircle.com/schiznatural.htm (Caution: We've found some of the supplements aggravate withdrawal symptoms, and have found orthomolecular physicians are not particularly knowledgeable about tapering or withdrawal.)

 

Drug package inserts (US)

In the US, each of the newer antidepressants and many other psychiatric drugs comes with an FDA-mandated package insert advising something like this:

Discontinuation of Treatment with Lexapro

During marketing of Lexapro and other SSRIs and SNRIs (serotonin and norepinephrine reuptake inhibitors), there have been spontaneous reports of adverse events occurring upon discontinuation of these drugs, particularly when abrupt, including the following: dysphoric mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesias such as electric shock sensations), anxiety, confusion, headache, lethargy, emotional lability, insomnia, and hypomania. While these events are generally self-limiting, there have been reports of serious discontinuation symptoms.

 

Patients should be monitored for these symptoms when discontinuing treatment with Lexapro. A gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose but at a more gradual rate....

 

(There is no more detail than this about tapering.)

 

UK psychologist Mick Bramham summarizes other tapering guides here http://www.mythsandrisks.info/coming-off-psych-drugs.html#Slow_taper 

 

*Recommends decreases of 10% or less

Edited by Altostrata
updated

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GiaK

I've got a (relatively) short piece that's an intro to withdrawal...with links to other sources of info etc:

 

I've alternately called it a Beginner's Guide to Psychiatric Drug Withdrawal and Withdrawal 101.

 

I also refer to "safer" withdrawal practices and point out elsewhere that withdrawing from psych drugs always presents some risk.

 

anyway, when I was withdrawing I found it helpful to read as many sources of info as possible...it's like I needed to hear stuff over and over again...of course there is more available now then there was then.

 

http://beyondmeds.com/withdrawal-101/

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Rhiannon

Excellent collection of resources. I recommend printing out this list and taking it with you when you go to the doctor and giving it to your doctor. If they seem open and interested and willing to check it out, that's a good sign. If they act angry or resentful that you're trying to inform them and take control of your own taper, you may need to do some doctor-shopping.

 

You can also print out a guide in full and take it with you. But I think this extensive list is even better.

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Rhiannon

I've got a (relatively) short piece that's an intro to withdrawal...with links to other sources of info etc:

 

I've alternately called it a Beginner's Guide to Psychiatric Drug Withdrawal and Withdrawal 101.

 

I also refer to "safer" withdrawal practices and point out elsewhere that withdrawing from psych drugs always presents some risk.

 

anyway, when I was withdrawing I found it helpful to read as many sources of info as possible...it's like I needed to hear stuff over and over again...of course there is more available now then there was then.

 

http://beyondmeds.com/withdrawal-101/

 

Want to mention that this guide of G's has been recommended by John Grohol of the Psych Central website...

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Altostrata

Thanks, Primrose. The author is one of our esteemed members, GiaK, who posted above.

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Barbarannamated

Gia, any thoughts on Ann Blake-Tracy's book or CD on withdrawal? Someone mentioned in another thread that it is very, very heavy scientific info. I want to read it, but have been too overwhelmed to tackle it yet. The little I have read in her articles is inline with advice on this board: very slow tapers, less than 10% in many cases.

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GiaK

no...I've not read it...

 

In the past (it's been years since I looked at any of it) her work struck me as sensationalized and I stopped looking at it.

 

As I said, it's been years so that's not something I stand by at this point. I don't really remember particulars about why I reached that impression.

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hippopotamus

In the guide, it says: 'Some people may go slower or faster, but a good guideline is 10% or less

of their original dose, every 2-3 weeks or longer.'

 

Shouldnt it say 10 % of every last dose someone is taking?

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GiaK

yes...it should...is that the updated manual (2nd edition) or the first one?

 

I'll let Will know if it's the new edition

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hippopotamus

It's in the second edition, that I got from his own website.

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John

I know that what I learned on this site, everyone says that while tapering, if you get withdrawal symptoms, pushing back up the dosage doesnt always work.  I read Glenmullen's book, and he never mentions that. He also says that your original disorder would come back between 1-2 months after stopping the pill, and withdrawals come within days?  When I went cold turkey, I started the Effexor back 2 months after, and it took 6 months for me to start feeling better.

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Altostrata

Read the insert in your package of Effexor XR. What does it say about discontinuation?

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John

I see nothing there that says reinstating may not work, nor does it mention how to determine if your original disorder returns.

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Altostrata

This is the limit of what medicine knows, and most doctors don't even know this:

 

From FDA advice about discontinuation

Discontinuation of Treatment With Venlafaxine Hydrochloride Tablets

Discontinuation symptoms have been systematically evaluated in patients taking Venlafaxine, to include prospective analyses of clinical trials in Generalized Anxiety Disorder and retrospective surveys of trials in major depressive disorder. Abrupt discontinuation or dose reduction of Venlafaxine at various doses has been found to be associated with the appearance of new symptoms, the frequency of which increased with increased dose level and with longer duration of treatment. Reported symptoms include agitation, anorexia, anxiety, confusion, impaired coordination and balance, diarrhea, dizziness, dry mouth, dysphoric mood, fasciculation, fatigue, flu-like symptoms, headaches, hypomania, insomnia, nausea, nervousness, nightmares, sensory disturbances (including shock-like electrical sensations), somnolence, sweating, tremor, vertigo, and vomiting.

During marketing of Venlafaxine, other SNRIs (Serotonin and Norepinephrine Reuptake Inhibitors), and SSRIs (Selective Serotonin Reuptake Inhibitors), there have been spontaneous reports of adverse events occurring upon discontinuation of these drugs, particularly when abrupt, including the following: dysphoric mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesias such as electric shock sensations), anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania, tinnitus, and seizures. While these events are generally self-limiting, there have been reports of serious discontinuation symptoms.

Patients should be monitored for these symptoms when discontinuing treatment with Venlafaxine. A gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose but at a more gradual rate....

 

We know reinstatement doesn't always work because we see people here who have tried it and not had good results.

 

There are many studies in the scientific literature that show doctors cannot recognize withdrawal syndrome and almost always misdiagnose it as "relapse." This contaminates every study of antidepressant efficacy where patients have been taken off the drugs and said to have "relapsed," thereby demonstrating a need for continuing to treat the psychiatric condition with antidepressants.

 

There is a giant question mark about how often relapse actually does happen after going off drugs.

 

John, this site exists because of a vacuum of knowledge among doctors. I would be happy to close it tomorrow if doctors took the responsibility for tapering people off drugs and monitoring for withdrawal symptoms.

 

I suggest you read 10 of the Introductions topics and decide for yourself if people are being well-served by their doctors.

 

If you don't want to believe what you see here about reinstatement, you are free to reinstate or not as you wish.

 

The basic premises of this site are explained in the Read this First forum and in pinned topics at the top of the Tapering and Symptoms forums. If these premises doesn't fit your understanding of your reality, you are welcome to go elsewhere.

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Altostrata

bumping for those who are looking for information to take to their doctors

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