Mental health medications affect the neurochemistry of the brain. A good way to understand this is the idea of a plant growing with the support of a trellis.
Your brain gets used to the medication like a plant gets used to a trellis. The neurochemistry of the brain is re-balanced based on the changes that the substances in the medication are causing. The brain then relies on the medication like the plant relies on the trellis.
But if the trellis is removed suddenly, a plant cannot expect to be okay. Your brain also requires time to remodel when medication is reduced or stopped.
When you take medications, they change the chemistry of the brain, as the brain adjusts its structure in an attempt to return to a homeostatic (or stable) state. For example, the serotonin in the brain, after carrying a message, is usually reabsorbed by the nerve cells (reuptake). What SSRI (Selective serotonin reuptake inhibitor) drugs do is to block or inhibit this reuptake, which means that more serotonin is available in the space between neurons.
However, the brain, at all times, wants to return to a stable level. The brain has to adapt to the increase in serotonin. It does this by down-regulating serotonin receptors and decreasing the amount of serotonin being produced (Harmer et al., 2017). The time taken for the brain to readjust is the reason why SSRI drugs typically take around 4 to 6 weeks to start working (and may often make you feel worse at first). However, the changes that occur in the brain are much more complex than this. For instance, genes have to be turned on and off, new cells have to be made, and new proteins have to be made. This is a complex physical remodeling.
When you stop taking a drug, the remodeling has to be done in reverse. Some people seem to have brains that can remodel fairly easily, while others may find that it takes longer for the brain to return to how it was beforehand, as we are all different after all. Stopping a drug abruptly is akin to taking a trellis away from a plant and expecting it to be okay. A plant that has had the trellis taken away from it will find it takes a while for it to adapt to life without the trellis.
Things get more complicated if someone has changed medications multiple times, been on a multitude of medications, or been on medications for a long time. Likewise, if someone has had long-term issues with alcohol or other unprescribed substances. The person can become sensitised to rapid changes, explaining why someone can stop a drug and have no problems, then go back on the drug, come off it again, and experience withdrawal or discontinuation symptoms. This increased sensitisation of the brain over time is known as ‘kindling’ and has commonly been associated with substances like benzodiazepines and alcohol, but it is hypothesised that it can also occur with other drugs.
Lower Dosages
Relationship between striatal serotonin transporter occupancy and dose of fluoxetine in 18 healthy and depressed subjects. Source: Meyer et al (2004)
Low doses of antidepressant medication are associated with considerable occupancy of the serotonin transporter.
- 20mg fluoxetine = 80% (standard dose).
- 5mg fluoxetine = 60%.
- 2.5mg fluoxetine = 50%.
What this means is that if you are on 5mg of an antidepressant, it may still be have an effect on the brain. So if you are prone to getting discontinuation symptoms you may need to taper down slowly. Even from 5mg, using liquid if necessary. This may be a sub-therapeutic dose but it can still have a significant effect.
How do I know it is not relapse?
If you think things like:
“This doesn’t feel like my depression or anxiety”.
‘These symptoms are completely new.’
‘I don’t feel like myself at all.’
Then there is the considerable possibility that it is discontinuation symptoms rather than a return of the original condition.
Additionally, withdrawal or discontinuation effects from stopping medications usually happen quickly. This is often within a few days (depending on the half-life of the medication). They subside if the medication is started again. Where as, an underlying mental health problem would likely get worse more slowly. It would then continue to remain the same. It may get better again if the medication is re-started.
Consider more:
u003cdiv class=u0022pageu0022 title=u0022Page 20u0022u003ernu003cdiv class=u0022sectionu0022u003ernu003cdiv class=u0022layoutAreau0022u003ernu003cdiv class=u0022columnu0022u003ernrn1. Has this information changed what you think about tapering?rn2. Could you tell if symptoms were adverse effects or signs of relapse?rnrnu003c/divu003ernu003c/divu003ernu003c/divu003ernu003c/divu003e