Lots of people hit this site wanting to know how to stop taking their crazy meds. That’s understandable. There are many good reasons to stop taking the meds. There are also many bad reasons to stop taking them. I’ll try to help you sort out the good from the bad reasons. But if you do have good reasons, you have to stop taking the meds safely. Sudden or rapid discontinuation can lead to many problems. This guide is just to use to make sure that you and your doctor have worked out a good discontinuation schedule for a medication, presuming you have the luxury for such.
You must work with your doctor! You are not qualified to make this decision on your own. Got that? What you and your doctor need to do is work out a discontinuation schedule for any medication. This is the reverse of the titration schedule (if any, which I’m actually against), which was the plan of how your dosage was increased. The discontinuation schedule is the plan of how you’ll decrease the amount of a med you’ll take. Ask your doctor what it is based on. There are three things a discontinuation schedule should be based on:
the half-life of a drug
looking for the return of any symptoms
experience with taking someone off a med
The last one is either other people going off the same med or you coming off of the same or other meds. Or both.
If you’re lucky enough to get an explanation from your doctor, the half-life of a psychiatric medication is often explained like this, “It’s out of your body in that many hours, but it’s still in your brain.” That’s a gross oversimplification, but it’s close enough for government work. Here’s a way to picture the half-life in action. Take a glass and fill it half full with some beverage. Now fill it the rest of the way with water. OK, now empty it half of the mixture out and top it off with water. Keep doing that until you have something you’d drink and that could pass as water. The number of times it took to do that is the half-life, expressed in a quantity of water, of a particular beverage. Try it with a different beverage and you’d get a different half-life. Half-life means how long it takes for half of the metabolites to get flushed out of your system. The half-lives of meds is expressed in time because the process of adding water to the glass is more-or-less constant in your body. And in the environment for the half-lives of radioactive materials. So using Effexor (venlafaxine), if you’re down to your last 37.5mg dose after 20 hours you’ll have 18.75mg left in your body. Twenty hours after that you’ll have about 9.4mg left. And so forth until it’s gone, about 80-100 hours after your final 37.5mg tablet. Please, don’t get all Xeno’s Paradoxical on me, after four or five passes, as it were, a med is so broken down that the effects shouldn’t be noticeable. The only real variable is not if it’s four or five times the length of the half-life, but if you metabolize the med quickly or slowly. These half-life numbers are the based on the arithmetic mean averages from clinical trials and studies. Read the pharmacokinetics section of the med’s PI sheet carefully to see what the known range of a drug’s half-life is.
All right so where does this “In your brain but out of your body” come from? Well when they measure half-life in humans during the clinical trials it’s by blood tests. With critters in earlier tests it’s a different story. Anyway, the drugs do clear out of your blood a lot faster than they do from your brain. But they hang around other organs, usually your liver and kidneys, maybe others, for four to five times the period of the half-life. So while they do all their work in your brain and that’s where they like to hang out, there are other parts of your body that the meds might be hanging around as well. It all depends on the med, your body and a host of other factors. So “Out of your body but still in your brain” is mostly true and covers much of the concept neatly in the time allowed in a typical doctor’s appointment. Anyway, the metabolites that are in your liver, kidneys and digestive system are what might be causing a bunch of the side effects you’re complaining about in the first place.
So if you take the half-life of a med and multiply it by five that’s the minimum number of hours between when you can next lower your dosage by whatever the lowest dosage the med comes in is. The problem, of course, is that some meds get metabolized more than once, they have active metabolites, or they have really short half-lives and you’d be coming off to fast to give yourself a good idea to know if it was a good idea or not to stop taking this particular med. However, I do note in most of the med’s profiles what the minimum amount of time that I recommend is between stepping down each dosage.
Monitor return of symptoms. Unless you’re replacing one med with another you have to be on the lookout for symptoms coming back. In this case you’ll want to reduce the dosages really slowly, taking a couple weeks at a time to get an idea of how you’ll be doing with less and less of a med. You’ll want to keep some kind of diary, a blog, something to keep track of how you feel every day. At some point if it starts to suck, then you know you’ve lowered your dosage too far. But, hey, maybe you can get along at a lower dosage! Nothing wrong with that. From what I’ve read on support fora and in e-mails I get I think a lot of people wind up on dosages that are too high. When it comes to affective mood disorders, panic/anxiety disorders and many other psychiatric disorders we can afford to experiment with lower dosages. Things may hurt us emotionally for a bit, but we can get back up to a dosage where we were OK and we’ll be OK again. It’s not that big a deal. For schizophrenia, for epilepsy and other disorders the decision to lower dosages isn’t that simple. Again a doctor must always be involved with this decision.
The most important thing to remember is this – your symptoms have gone away BECAUSE THE MEDS ARE WORKING! It’s not necessarily because you’ve been cured. There are no cures for a lot of these disorders. It’s not your fault that you’re crazy, but it is your responsibility to stay as sane as possible. You’re not the only person you hurt if you really flip out.
If you’ve been taking anticonvulsants (also known as “mood stabilizers” in Bipolarland) for a few months or longer and need to stop, you can’t stop cold turkey at all. Unlike stopping SSRIs the effects of sudden discontinuation aren’t just viciously unpleasant, they are dangerous. You run the risk of having seizures on top of your bipolar getting worse. These run the gamut from partial complex or absence seizures to tonic-clonic grand mals. Maybe you’ll have this problem, maybe you won’t, there’s no way to tell. If you never had a seizure before that doesn’t mean you won’t start flopping around like a fish out of water. The risk is worse if you’re taking a lithium variant, and/or any antidepressant, especially Wellbutrin (bupropion hydrochloride). Anticonvulsants need to be gradually discontinued to prevent any seizure activity from happening. With gradual discontinuation the worst most people experience is slight dizziness, confusion and sensitivity to sound and/or light. If you’re already taking another anticonvulsant and are in the therapeutic range already, then you can probably stop one cold turkey with little risk of seizures, presuming you have no past history of seizure activity. You’ll feel other wacky effects, and those will vary from med to med, but you won’t be risking seizures. Let me qualify that, it has to be an anticonvulsant that is known to be effective for you. If it’s a new anticonvulsant, well, you just never know. The odds are in your favor at least. If you do have a history of seizure activity, stopping any anticonvulsant cold turkey is never a decision you should make based upon information gleaned from any stupid website on the goddamn Internet you jackass, you should be discussing that with at least two neurologists! Get off your computer and on the telephone and start making appointments!
SSRI discontinuation syndrome. Read the article to learn more about it. SSRIs are some of the most physically addictive drugs in existence. Addictive isn’t really the right word, you develop an intense physical and psychological dependency without a craving and urge to abuse them (unless you’re bipolar, then you may abuse them), but addictive is close enough. To suddenly stop taking them is to feel so very much worse than you were feeling before you ever considered taking meds. There’s a term, “brain shivers.” You’ll know it if you ever experience it. Mouse and I have kicked opiates and we have kicked SSRIs cold turkey. We’ll take the opiate kick. If you’re taking an atypical antipsychotic along with an SSRI, the discontinuation is often not nearly as bad, so if you have some Seroquel (quetiapine) on hand for insomnia, you’ll want to take some for your SSRI discontinuation. Not everyone experiences SSRI discontinuation syndrome, and for those who do the effects range from mild to extreme. Not all doctors recognize this as an issue, so that sucks even more. Be sure to read the section about how long it takes for a med to clear out of your system and wait that long to taper down to the next stage in your dosage. And, as Paula writes in her article, invest in a pill splitter. Another option is to switch to the liquid form that many of the meds have available, that way you can reduce your dosage by as much as you damn well please and take as long as you can afford to discontinue to med. If it’s really bad you may want to switch to liquid Prozac (fluoxetine hydrochloride) for the final discontinuation. That can take a very long time, but because of Prozac’s 9.3 day half-life it usually has the mildest discontinuation syndrome effects of all the SSRIs. The long half-life is a double-edged sword. If you’re on a high dosage and especially sensitive to the discontinuation syndrome, it will take forever to get off of Prozac, but at least it won’t be as bad as the other meds. If you’re not as sensitive to the discontinuation syndrome, Prozac’s long half-life makes it easier to discontinue than any of the other SSRIs.
Abrupt discontinuation of high doses of benzodiazepines can lead to seizures in addition to dysphoria, insomnia, muscle cramps, vomiting and sweating. If you do wind up taking them daily for longer than four weeks and don’t build up a tolerance and don’t abuse them, be sure to refill your prescription a few days before running out, just in case something happens to prevent you from getting that refill when you do run out. Otherwise a normal discontinuation schedule is usually all it takes to safely and painlessly withdrawal from benzodiazepines. There’s just one proviso – you can only discontinue from Xanax (alprazolam) using Xanax. All other benzos are interchangeable for purposes of discontinuation, but not Xanax. It figures that Xanax is the most addictive of them all.
The withdrawal from atypical antipsychotics has been likened to taking small amounts of psychedelic drugs. Whether that is a good or bad thing is up to individual experience. Others get rebound symptoms for a day or two, sometimes longer and that’s about it. The big problem is that the bipolar and the schizophrenic are the worst about stopping their meds. The good news is you can just start right back up on the atypicals and get back to where you were in controlling your symptoms.
There isn’t much in the way of good evidence if meds are effective if you stop them and start taking them again. So far I’ve found some studies that indicate you’re screwed if you stop taking Paxil (paroxetine) and then want to start taking it again. I’ve come across some anecdotal evidence (i.e. people’s experiences) that indicate the same for lithium, the valproates and Lamictal (lamotrigine). As mentioned above, the atypical antipsychotics seem to be OK with people who use them as required, as are the benzodiazepines. There are also people who rotate through SSRIs because of SSRI poop-out, with mixed results on Paxil’s second use. The vaunted weight-loss effect of Topamax (topiramate) is a one-time offer. If you stop taking Topamax then take it again the odds are it won’t affect your appetite. So you have to take into consideration that the med that is working well for you now may not work so well for you again if you stop taking it and want to take it again.
Please read 12 Steps to Stay on Drugs to make sure you’re not just addicted to some of your crazy behaviors. Strange as it may sound, some people are. There’s also a physical condition known as anosognosia that prevents people from recognizing that they are ill. I think that it can be extended to where it prevents people from dealing with their illness in the proper way. It affects approximately 50% of the bipolar and schizophrenic communities. I’m pretty sure I have it. I went for years without getting the right meds to treat my bipolar and seizure disorders, and even now I have days when I want to throw away all of my meds and just go back to using my Soul of Iron to deal with all of my problems. It’s just crazy so I don’t do it.
Just be damned sure you’re stopping a med for the right reasons. For some disorders meds are temporary parts of an overall therapy strategy to get your brain working in a less messed-up way. For example – depression or panic/anxiety disorder the meds may be permanent or they may be temporary. But for epilepsy and bipolar disorder, for instance, the odds are that the meds, or some kind of treatment like VNS or TMS, is going to be a long-term, if not permanent part of your life. It’s going to be many years of taking the right meds before you can even think of not taking any. Anticonvulsants (“Mood stabilizers”) do, in theory, prevent the brain from getting into a state that causes seizures and/or mood swings. But it takes a long, long time to train your brain to stop acting that way. If it can happen at all. Epilepsy kills. Mood swings are dangerous. You are literally taking your life in your hands when you’re considering a slow, steady discontinuation of anticonvulsants.