Tapering Information

Tapering Information

This topic is not medical advice; it is simply sharing the collective experience of those harmed by antidepressants or having difficulty coming off to give you talking points you can share with a medical practitioner who is knowledgeable about AD drug harm and tapering. 

How do any antidepressants work?

Antidepressants work by occupying receptors in our brains. Our pre-drug brains have a natural balance or homoeostatic state but, after taking antidepressants, our brains have to adapt to the presence of the drug and achieve a new post-drug balance. They are not addictive in the technical sense of the word in that they do not create a compulsion to take more of them, rather the brain has become dependent on the drug being there in order to continue operating at its newfound setting.

Dependence can occur in as little as a few weeks from starting to take an antidepressant. 

If the drug is removed suddenly, the body metabolises the drug quickly from the system, however, the brain misses the presence of the drug in order to function in its new state and takes a period of time to recalibrate back to normal. 

What is withdrawal?

The time it takes for the brain to recalibrate and return to a pre-drug homeostatic state is called withdrawal. 

While many users of these drugs taper off in a relatively short time without major issues or adverse effects, Dr Mark Horowitz explains in his video (linked below) ‘How to Taper Off Lexapro’, “If you are on the drugs for more than 3 years, most people are having withdrawal effects and about half of them are saying they are moderately severe or severe.” 

These withdrawal effects can continue after stopping the drug with a significant proportion of people ending up experiencing protracted withdrawal syndrome (PWD, PWS or PAWS).

Protracted means that the process of readaptation and return to a normal balanced state can take much longer, anywhere from months up to 4 years according to some studies. Online peer support communities, like surviving antidepressants, have seen some members suffer for even longer than this. A prominent patient voice study carried out in the UK found a median average duration of symptoms of approximately 2 years, this is in line with what has been observed in online peer support communities.

Withdrawal can cause a wide range of very distressing symptoms in the body ranging from psychological symptoms such as memory problems, low mood, panic attacks, suicidality, anxiety, depression & akathisia and include other symptoms like pain, nausea, vertigo, dizziness, gut issues and sleep disturbances.

These symptoms start often immediately, or within one half-life of the drug, but can be delayed in onset by a few weeks or even a few months.

The only known way to prevent, or at least mitigate withdrawal, is to taper slowly enough to give the body time to adapt to the smaller changes in dose being made, rather than making large drops too quickly for the body to handle. It must be emphasised that this is not an exact science, everybody is different and currently any dedicated scientific research into PAWS is very limited.

Hyperbolic curve

It is unfortunately still very common for doctors and prescribers to advise their patients to taper too quickly. A common schedule might look like, cut the pill in half, hold for two weeks, cut in half again, hold for two weeks and then stop completely. This process is way too quick for most people’s brains to get a chance to adjust to the decreasing levels of the drug. 

(This graph is a reconstruction for illustrative purposes only and should not be used to calculate dose drops)

The graph above shows the effect on the brain Escitalopram has from 0-25mg. As you can see it is not a linear progression as might be expected. If you tried to drop from 25mg to 20mg the decrease in the effect on the brain is only slight. Again, 20-15mg the decrease in effect is greater but still relatively small. By the time you get to 5mg the effect on the brain is still sizable compared to the original dose. Even at 1mg the drug is reading very high!

What we are seeing here is the law of mass action. When there is a smaller amount of drug available to the brain it has a bigger effect as receptor occupancy is low and availability high. As receptor occupancy increases, further amounts of a drug have an increasingly lesser effect due to lowering number of available receptors. Doubling the amount of drug available doesn’t double the effect on the brain.

While intuitively it might make sense to drop doses by the same amount each time, the chart shows us that the lower the dose, the smaller further reductions should be, each drop has a proportionally and increasingly larger effect on the brain then the last.

Exponential Tapering

Taking the above phenomenon into account, for many years now Surviving Antidepressants has recommended a 10% per month reduction as best practice for tapering off your antidepressants. They learned through experience that, if this reduction was calculated on the previous dose NOT on the original dose, members found a speed of taper much more tolerable with less withdrawal symptoms. Reducing the dose in this way automatically meant the dosage drops became smaller and smaller towards the end of a taper. This form of taper works in harmony with the Hyperbolic profile of antidepressants discussed above.

This is just a guide and not a rule. It is important to listen to your body and monitor for withdrawal symptoms on the way down.

If you get WD symptoms it is best to hold for a week and see if you stabilise at that dose. If you don’t, you might try a small up dose and see if this elevates the symptoms. Once symptoms are tolerable you can continue your taper, then consider adjusting the size of the dose to reduce the chances of further WD symptoms. 

As you can see this is very much a ‘patient’ led approach. Patience is key. Slow and steady wins the race!

It is important to not reduce or rush a taper, whilst experiencing WD symptoms, as further drops to an already irritated CNS will likely cause an increase or worsening in WD symptoms and lead to a potential protracted withdrawal syndrome after stopping completely.

Hyperbolic tapering

Dr Mark Hotowitz has co-written a book called the Maudsley Deprescribing Guidelines. It’s an excellent publication designed to educate both prescriber and patient alike. You can buy a copy of it on Amazon and it’s well worth a read.

There are sections in it for most of the well-known and often prescribed drugs, each section contains information about the drug such as graphs showing the effect on the brain at different doses. There are also three different speed taper schedules suggested which are designed to accommodate different patient requirements as well suggestions as to suitability criteria for each.

The schedules show reductions that work in harmony with the receptor occupancy levels at a given dosing, they also suggest recommended formulation needed to achieve the increasingly lowering dose. 

As with the 10% reduction guide from SA, these schedules are just that - a guide, and reduction should be ‘patient led’ to allow for the nuance of an individual’s drug history as well as other lifestyle and practical considerations.

Kindling

It is often observed that a user starts an antidepressant for the first time, takes it for a few weeks or months and manages to abruptly stop it without any issues. 

This can cause some confusion as those who have this experience assume this will always be the case for them. Many then, unfazed by their experiences so far, return to their doctor for additional medications later on, only to find they can’t now stop the drug as easily as before or even experience adverse reactions whilst taking it.

Every time we do the following, we risk further irritating our nervous systems:

-‘Cold Turkey’ an AD

-Reduce a dose too quickly

-Switch drugs

-Experience an adverse reaction

-Suffer drug interaction between two medications taken con-currently

This state of irritation primes us for further harm from more changes to our drug states; this is sometimes referred to as kindling. It should be noted that this is not currently an accepted medical term, this is a word for something observed numerous times in various prescribed harm communities and online peer support groups etc.

It is best to attempt to reduce the number of these events as much as possible to reduce the chance of kindling. Repeated irritations stack on top of each other causing worsening symptoms. A slow hyperbolic taper from your antidepressant is the best way to avoid this in the first place.

Adverse Drug Effects

Being symptom free whilst tapering off your antidepressants is goal but not a certainty. Adverse drug reactions can cause symptoms whilst at the same time having WD effects from reducing your dose. The way to tell is the timing. If the symptoms came on from having dropped your dose it is likely WD from the drop and a hold and or up dose may resolve this. However, ADRs will often persist during a hold and cause confusion differentiating between the two. However, when multiple drugs are involved, with multiple dose changes and starts and stops, it can become extremely difficult to unpick what has caused the harm and your body/nervous system is also likely in a state of struggling to return to homeostasis.

If one of the drugs that you are currently taking is suspected of causing an ADR or interacting negatively with another, it is worth considering tapering off this one first. In this instance a faster taper is to be considered, but this is very much balancing the risk of a fast taper against the harm being done by continuing to take a drug you are experiencing a significant adverse reaction to. There is often no obvious "right" answer. 

Adverse reactions tend to reduce with the dose and so become less of an issue the lower you go. The trick is to try to reduce quickly enough to get down to levels where your ADRs are more bearable but not so quickly that you cause unacceptable WD symptoms and mitigate kindling from a too speedy taper.

This isn’t ideal and may require a long hold after to allow your system to recover before continuing to taper your other medications.

If you think one of your medications is interacting with another you can use the interactions checker here to find this out: https://www.drugs.com/drug_interactions.html  

If you are experiencing life threatening symptoms from an adverse reaction to a medication this is the only time you stop it immediately and this should be under close medical supervision. It is not advised to cold turkey an Antidepressant or Benzo under any other circumstance. Stopping abruptly under ANY circumstances is extremely dangerous and must be taken VERY seriously.

Delayed onset WD symptoms

Withdrawal symptoms can take months to develop; this is a reason to be cautious with your dose drops at the beginning. It is better to play it safe and avoid getting symptoms than it is to cause more irritation by shifting doses to stabilise after WD symptoms kick in. Having two monthly periods with reductions pass without severe withdrawal symptoms allows you to check for delayed onset WD.

Short term use

Picking the right taper schedule to match your circumstances is important, it may not be necessary to spend many years tapering if you are in the lower risk category. 

Short term use and no previous adverse reactions may mean you can go quicker. Faster tapering schedules are available in the Maudsley Deprescribing Guidelines for this reason. 

It’s worth advising caution here though as dependence can be achieved in as little as a few weeks so the faster plans may not suit you. Patient led is key, listen to your body. Protracted withdrawal is very serious and there is no cure other than time. The harms you might be concerned about remaining on the drug, for the longer taper period, are not likely as severe as the harms you may experience from tapering too quickly. 

It is important to note that there are a number of individuals in various peer support communities who have been harmed by fast tapering after very short-term use. Everybody is different.

Altostrata from Surviving Antidepressants has an excellent post which inspired this one and I would highly recommend you go read: Why taper by 10% of my dosage?

Also this video on Hyperbolic Tapering with Dr. Mark Horowitz is a great watch: Hyperbolic Tapering with Dr. Mark Horowitz | Webinar

I would recommend everyone tapering from their antidepressants gets a copy the Maudsley Deprescribing Guidelines its available from amazon: Maudsley Deprescribing Guide - Amazon UK Link

How to Taper Off Lexapro (escitalopram) with Dr. Mark Horowitz | Webinar (Referenced quote above is @ 15.24) How to Taper Off Lexapro (escitalopram) with Dr. Mark Horowitz | Webinar