Considering guidelines
The following guidelines are recommended by the NHS for antidepressants:
Antidepressants should be reduced 'over 1 to 2 weeks if treatment has lasted less than 8 weeks' or 'over 6 to 8 weeks if treatment has lasted 6 to 8 months'.
However, the NHS acknowledges that antidepressant discontinuation can be problematic if done too quickly…
Antidepressant withdrawal symptoms ‘are usually mild and self-limiting over about 1 week, but can be severe, particularly if the drug is stopped abruptly’. (NICE, 2009).
‘…[antidepressants] can cause serious withdrawal symptoms if stopped suddenly. These symptoms may be entirely new or similar to some of the original symptoms of the illness’. (NHS).
As well as this, there is research that suggests tapering should be a much slower process:
‘…SSRIs should be tapered slowly to doses much lower than those of therapeutic minimums, in line with tapering regimens for other medications associated with withdrawal symptoms’ (Horowitz and Taylor, 2019).
General guidelines
Although this is a drug specific matter there are general guidelines when it comes to tapering off mental health medications.
If, for example, you are experiencing difficulties at home, or are currently going through some kind of temporary crisis situation, such as the threat of homelessness, then it might be best to postpone any tapering until these issues have been resolved.
If you think you are ready consider the following steps to taper safely:
Go slow as can be slower than NHS guidelines
u003cdiv class=u0022pageu0022 title=u0022Page 34u0022u003ernu003cdiv class=u0022sectionu0022u003ernu003cdiv class=u0022layoutAreau0022u003ernu003cdiv class=u0022columnu0022u003ernrnThe NHS says that antidepressants and other medications can be stopped over a period of weeks, but for some people this can be far too fast. Sometimes it may take 2 years or longer to stop a medication, so you need to exercise extreme patience. The evidence, however, shows that tapering extremely slowly can allow people to come off a drug successfully. For example, a 2010 paper by Murata and colleagues found that almost four fifths of people trying to come off paroxetine suffered from severe discontinuation symptoms. When they tapered slowly, for an average of nine months, only 6% of subjects experienced severe discontinuation symptoms. Another paper by Groot and Van Os (2018) found that 70% of people who had problems coming off paroxetine or venlafaxine were able to do so by tapering slowly, down to a fortieth of the original dosage.rnrnu003c/divu003ernu003c/divu003ernu003c/divu003ernu003c/divu003e
Cut 10% at a time
u003cdiv class=u0022pageu0022 title=u0022Page 35u0022u003ernu003cdiv class=u0022sectionu0022u003ernu003cdiv class=u0022layoutAreau0022u003ernu003cdiv class=u0022columnu0022u003ernrnFor example, if you are taking 20mg of a drug, you would take 10% off this dosage, so you’d take 18mg. Next you’ll take 10% off this dosage, which will give you 16.2mg, and so on.rnrnu003c/divu003ernu003c/divu003ernu003c/divu003ernu003c/divu003e
Hold for 2-6 weeks
u003cdiv class=u0022pageu0022 title=u0022Page 36u0022u003ernu003cdiv class=u0022sectionu0022u003ernu003cdiv class=u0022layoutAreau0022u003ernu003cdiv class=u0022columnu0022u003ernrnHolding the drug for a few weeks may allow you to catch any delayed withdrawal or discontinuation symptoms that can occur.rnrnu003c/divu003ernu003c/divu003ernu003c/divu003ernu003c/divu003e
Speed up or slow down
u003cdiv class=u0022pageu0022 title=u0022Page 36u0022u003ernu003cdiv class=u0022sectionu0022u003ernu003cdiv class=u0022layoutAreau0022u003ernu003cdiv class=u0022columnu0022u003ernrnIf you managed the first couple of drops in dosage with few or no symptoms then you could speed up, maybe waiting a week or two between decreases, but at the same time continuously reading your body to ensure that you aren’t either getting withdrawal or discontinuation symptoms or finding out that your original condition is returning. In that case you might want to hold the dosage for a long period of time until you feel better, then resume the taper.rnrnu003c/divu003ernu003c/divu003ernu003c/divu003ernu003c/divu003e
Keep a diary
u003cdiv class=u0022pageu0022 title=u0022Page 37u0022u003ernu003cdiv class=u0022sectionu0022u003ernu003cdiv class=u0022layoutAreau0022u003ernu003cdiv class=u0022columnu0022u003ernrnKeeping a diary can let you identify if any symptoms you are experiencing appear shortly after a change in dosage, or whether they are related to any kind of life events.rnrnu003c/divu003ernu003c/divu003ernu003c/divu003ernu003c/divu003e
Ask for lower tablet dose or liquid
u003cdiv class=u0022pageu0022 title=u0022Page 37u0022u003ernu003cdiv class=u0022sectionu0022u003ernu003cdiv class=u0022layoutAreau0022u003ernu003cdiv class=u0022columnu0022u003ernrnA lot of medications are found as liquid forms, for example fluoxetine, and you can use a small dropper to accurately measure out the correct dosage. Other medications such as pregabalin are found in different strengths to make dropping the dose slightly easier. For example, if you are on 225mg of pregabalin, say 75mg in the morning and 150mg at night, you could be prescribed 200mg. The morning dosage would still be 75mg but in the evening you could have a 50mg and a 75mg capsule rather than two 75mg capsules.rnrnu003c/divu003ernu003c/divu003ernu003c/divu003ernu003c/divu003e
Jet’s Story
Jet has decided to stop taking his antidepressant medication, Sertraline. He feels he has been stable for some time now and his life circumstances have changed for the better.
The below scenarios are what could result from the above situation. As you can see there are numerous possible outcomes from the one situation.
Scenario 1
Jet decides to take himself off the medication
Jet wants to stop the medication on his own but he isn’t sure whether to stop it ‘cold turkey’ or to research how to stop it.
Jet decides to stop ‘cold turkey’.
Jet stops the medication the next day and feels happy that he has made this decision.
However, within a few days he starts to feel unwell with stomach upset, anxiety and trouble sleeping.
Jet decides to manage the symptoms on his own.
The adverse effects continue and get worse over the next few days. Jet is starting to struggle and wonders whether he made the right choice.
Jet persists with stopping the medication and suffers with the adverse effects for several weeks. However, eventually they start to subside and he begins to feel better.
Scenario 2
Jet decides to take himself off the medication
Jet wants to stop the medication on his own but he isn’t sure whether to stop it ‘cold turkey’ or to research how to stop it.
Jet should stop by researching how to taper slowly off.
Jet decides to research how to taper his medication slowly.
Jet does some research and finds out that cutting back the medication 10% at a time in 2 week intervals is recommended for a slow taper with the best chance of success.
Jet decides to taper the medication slowly at 10% at a time in 2 week intervals.
Jet notices a few adverse effects but they aren’t troubling him and he can carry on his life as usual.
However, he starts to struggle as he gets towards the penultimate dose.
Jet decides to stay at the lower dose.
Jet decides that he is happier on the lower dose and that for now he will maintain it. He thinks he might stop entirely in the future but isn’t in a rush.
Scenario 3:
Jet decides to take himself off the medication
Jet wants to stop the medication on his own but he isn’t sure whether to stop it ‘cold turkey’ or to research how to stop it.
Jet should stop by researching how to taper slowly off.
Jet decides to research how to taper his medication slowly.
Jet does some research and finds out that cutting back the medication 10% at a time in 2 week intervals is recommended for a slow taper with the best chance of success.
Jet decides to taper the medication quickly at 50% at a time.
Jet halves his medication for the first two weeks and then stops it entirely.
However, within a few days he starts to feel unwell with stomach upset, anxiety and trouble sleeping.
Jet decides to talk to his care co-ordinator.
Jet decides to talk to his care co-ordinator, Bev, about his attempt to stop medication. Although Bev agrees that things have changed for Jet, she also has concerns about him stopping his medication.
Bev thinks the reason Jet is stable is because he is taking the medication and that in the past when he has tried to stop taking it things have got worse.
Bev is concerned that Jet tried to stop the medication on his own and reassures Jet that she will support him either way. She suggests that Jet speak to his psychiatrist about how to taper properly.
Jet decides to speak to his psychiatrist.
Jet sees his psychiatrist who is concerned that Jet tried to stop the medication so quickly on his own. He tells Jet that he would like to work with him, if he is sure, to slowly taper off the drug.
Jet’s psychiatrist restarts the medication and then works with him to plan out a slow taper off the medication and says he would like to meet regularly with Jet to make sure things are going okay.
Jet sees his psychiatrist regularly and slowly tapers off the medication with minimal adverse effects.
Scenario 4:
Jet decides to take himself off the medication
Jet wants to stop the medication on his own but he isn’t sure whether to stop it ‘cold turkey’ or to research how to stop it.
Jet should stop by researching how to taper slowly off.
Jet decides to research how to taper his medication slowly.
Jet does some research and finds out that cutting back the medication 10% at a time in 2 week intervals is recommended for a slow taper with the best chance of success.
Jet decides to taper the medication quickly at 50% at a time.
Jet halves his medication for the first two weeks and then stops it entirely.
However, within a few days he starts to feel unwell with stomach upset, anxiety and trouble sleeping.
Jet decides to manage the symptoms on his own.
The adverse effects continue and get worse over the next few days. Jet is starting to struggle and wonders whether he made the right choice.
Jet decides to carry on and deal with the symptoms on his own.
Jet persists with stopping the medication and suffers with the adverse effects for several weeks. However, eventually they start to subside and he begins to feel better.
Scenario 5
Jet decides to talk to his community team
Jet decides to talk to his care co-ordinator, Bev, about stopping his medication. Although Bev agrees that things have changed for Jet, she also has concerns about him stopping his medication.
Bev thinks the reason Jet is stable is because he is taking the medication and that in the past when he has tried to stop taking it things have got worse.
Bev suggests that Jet wait a while longer before trying to stop the medication but if he is sure about stopping then she will meet with him regularly to see how things go.
Jet decides to stay on the medication.
Jet thinks Bev has a point and decides to stay on the medication a while longer to make sure that he is ready before attempting to stop.
Scenario 6
Jet decides to talk to his community team.
Jet decides to talk to his care co-ordinator, Bev, about stopping his medication. Although Bev agrees that things have changed for Jet, she also has concerns about him stopping his medication.
Bev thinks the reason Jet is stable is because he is taking the medication and that in the past when he has tried to stop taking it things have got worse.
Bev suggests that Jet wait a while longer before trying to stop the medication but if he is sure about stopping then she will meet with him regularly to see how things go.
Jet decides to stop the medication.
Bev suggests that if Jet is certain about stopping the medication he should meet with his psychiatrist to discuss the best way to taper off the drug safely.
Jet decides to meet with his psychiatrist.
Jet meets with his psychiatrist who also thinks that it would be better to wait a while before trying to stop his medication for the same reasons as Bev. Jet trusts his psychiatrist but isn’t sure.
Jet decides to stop the medication.
Jet’s psychiatrist works with him to plan out a slow taper off the medication and says he would like to meet regularly with Jet to make sure things are going okay.
Jet isn’t sure, he thinks a slow taper isn’t necessary.
Jet decides to stop the medication quickly.
Jet stops the medication the next day and feels happy that he has made this decision.
However, within a few days he starts to feel unwell with stomach upset, anxiety and trouble sleeping.
He meets with his care coordinator who suggests he should meet with a psychiatrist to plan a slow taper.
Jet sees his psychiatrist again who is concerned that Jet tried to stop his medication on his own. He recommends restarting the medication and then slowly tapering off of it, if Jet is sure.
Jet’s psychiatrist restarts the medication and then works with him to plan out a slow taper off the medication and says he would like to meet regularly with Jet to make sure things are going okay.
Jet sees his psychiatrist regularly and slowly tapers off the medication with minimal adverse effects.
Consider more:
u003cdiv class=u0022pageu0022 title=u0022Page 78u0022u003ernu003cdiv class=u0022sectionu0022u003ernu003cdiv class=u0022layoutAreau0022u003ernu003cdiv class=u0022columnu0022u003ernrn1. What do you think about the current guidelines on tapering? Should they be revised?rn2. If you were going to taper off a medication, would you do it slowly with support?rnrnu003c/divu003ernu003c/divu003ernu003c/divu003ernu003c/divu003e