Saturday, June 25, 2011

The Ten Percent Solution

Duane and others have mentioned this "10% rule," which essentially suggests making small changes in medication doses over extended periods of time (~1 year). A 10% decrease in dose every 4-6 weeks is often quoted. It's a rule that makes a lot of sense.

In response to a change in the brain's biophysicochemical stew (meds, trauma, chronic stress, etc), it generally takes neurons a couple weeks to fully generate new or recycle old protein machinery -- to adapt to changes. This duration can be shorter for some proteins, longer for others. Thus, small changes would be expected to minimize the shock to the system. This just makes good homeostatic sense.

There are problems with this as dogma, however. There is not useful research, at least that I am currently aware of, to demonstrate whether the "best" interval percentage change is 10% or 5% or 25%. We also don't know if the "best" interval is one week, two, four or eight. Or which medications and their affected pathways are best tapered at what intervals and amounts. Please share original source (ie, PubMed) links to peer-reviewed research below if you have relevant references.

80 comments:

Sunny CA said...

I have no research to cite, but I did successfully wean myself off all psychiatric medications 5 years ago with no side-effects. I looked up each medication on the website of the manufacturer and there are recommended tapering schedules given. I went twice as slow as recommended and had no trouble.

Anonymous said...

Hi Roy,

Thank you for this blog entry. It is greatly appreciated.

With all due respect to Duane, I was the one who initially suggested the 10% rule.

I am curious, if you feel this rule makes alot of sense, why do you need research, particularly if it isn't dangerous?

Your patients who aren't as lucky as Sunny in not suffering side effects when tapering off of meds, can't afford to wait for research.

As far as relevant research, I could be wrong but I am not aware of any links regarding this method. Not to sound insulting but studying a slow taper and withdrawal issues hasn't exactly been a high priority of psychiatry. Hopefully, this will change with Dr. Belaise's study on prolonged withdrawal cases.

As far as your questions about the percentages and time frames, they are good ones. It is my understanding that because it usually takes three weeks for withdrawal symptoms to show up, that someone needs to take wait at least that long before tapering. Obviously, if you make a cut and then get hit with withdrawal symptoms from a previous cut, that is not a good thing.

As for when you make your next cut, it is a matter of listening to your body. Some people can taper every 3 weeks where others might have have to wait two months.

The 10% solution was chosen on withdrawal boards because that seemed to be the amount that caused the least amount of shock to the system. Many people can get away with 25% initially but will have problems as they go lower in the taper.

And there are folks who are so sensitive that they need to taper at 5% of current dose.

Anyway, let me see what I can do about finding relevant research and again, thanks for the blog entry.

AA

Duane Sherry, M.S. said...

"Ditto" on the "Thank-You"

I think it's best to err on the side of caution with this.

In other words, I'm not sure a person can go "too slow", only "too fast."

I have read from a variety of sources to "listen to your body," and not be persuaded to move any more quickly than someone can tolerate. Not to be persuaded by even a doctor to go too quickly.

Also, drug withdrawal is NOT for everyone. It can be very risky, it can be very painful, especially for someone who has been on large amts, and/or for a long period of time.

It's a personal choice.
One that only the person involved can make, and one that only s/he SHOULD make.

Even those of us who despise these drugs, need to have respect for others who have been on them, and have no desire to get off of them. (How's that Dinah... surprised you, huh?)

On a completely different note...

I think many of the things I post are seen as "simple"... "too simple."

Read these words, if you don't mind... they come from an old song (one that was popular many years ago, in grade school) -

Sunshine
You are my sunshine
You make me happy
When skies are grey
You'll never know dear
How much I love you
Please don't take my sunshine away

Simple.
Boring.

If you read them the way (for any of us who are old enough to remember) the way we "heard" this song back in the day...

Not everyone hears them the same way.... Some people see magic in simplicy... and put life into the music.... Simple often works, just beautifully.

'Sunshine' by Mr. Ray Charles -

http://www.youtube.com/watch?v=pOJzDyT8cCc

Duane Sherry

rob lindeman said...

Roy,

There you go again! Please don't refer to biophysicochemic(sic) stews and recycled protein machinery as if these are more than fanciful terms.

The truth is we have no idea how these meds work, we have only conjecture. It cannot be the case, then, that we have anything better than conjecture regarding weaning.

WV = tratick. A trick we play at others by pretending we know where it's at

Anonymous said...

Also - given that there's no research, the length of time this sort of taper takes has to be taken into consideration. If you're coming off medication because you're severely clinically depressed and have been for months, and barely able to function, you don't have the time that sort of a taper would take and then tapering up on another drug. You quite simply won't survive.

Another thought - I was taken off a year spent on 375mg Effexor XR with a too-fast taper and it was hell. Several years later was taken off Cymbalta and had a similar response. But...it was hell that cleared up in about 3 weeks, and that had no lasting effects. If I had to pick between 3 weeks of physical withdrawal hell vs an extra 6 months before getting onto a potentially effective antidepressant -- you can bet I'd pick the three weeks of hell. And I've lived through it, so don't tell me I don't know how bad it would be.

I'm not a huge fan of medication or overmedication. But I'm also not a fan of flat out denial of all potential benefits of appropriately administered medication.

Anonymous said...

Anonymous,

I was thinking with the 10% rule of people primarily who wanted to get off of medications permanently and who had problems tapering the way psychiatry has traditionally done it.

You make a good point that if you are severely depressed and need to switch to another medication that a slow taper may not be a good idea.

But just as you are rightfully reminding folks that we are all different as far as the benefits of medication, I wanted to make the same point about withdrawal. Not everyone is lucky as you as far as not having lasting effects from a too fast taper.

AA

Anonymous said...

Well, I was wrong, as I found one citation. It doesn't mention the 10% rule or the amount but suggests a 3 to 6 month taper.

Personally, I feel that may too short of a time frame depending on the situation but still to recognize that a longer taper should take place is progress.

http://www.ncbi.nlm.nih.gov/pubmed/9809213

I will keep checking.

AA

Sarebear said...

Once upon a time, my insurance ran out when I was on effexor. I wasn't on the ball and hadn't thought of making an appt with my doc (my depression was being managed by gp at the time, wasn't diagnosed with bipolar yet but it's obvious in hindsight) in order to get samples to help taper off of it.

So, the insurance ran out, and I cold-turkeyed Effexor.

Yeah, like the person above says, it's hell, for about a month. Although I wonder if a side-effect I have that started with Effexor and never went away, is because of the Effexor, but anyway. Wish 'dve thought to ask for a taper but I wasn't really educated on these things at the time, although I DID know Effexor had a short half life and would maybe get ugly if you stopped it.

I found out fast . .. any movement was pain, especially my head, for two weeks. Among many other things.

Altostrata said...

See these links:

See Icarus Project http://survivingantidepressants.org/index.php?/topic/207-icarus-project-harm-reduction-guide/

1993 Greden: http://survivingantidepressants.org/index.php?/topic/674-antidepressant-maintenance-medications-when-to-discontinue-and-how-to-stop/

1998 Maixner SM, Greden JF.: http://survivingantidepressants.org/index.php?/topic/672-extended-antidepressant-maintenance-and-discontinuation-syndromes/

2001 Shelton: http://survivingantidepressants.org/index.php?/topic/673-steps-following-attainment-of-remission-discontinuation-of-antidepressant-therapy/

2003 Harvey et al: Neurobiology of Antidepressant Withdrawal http://survivingantidepressants.org/index.php?/topic/671-neurobiology-of-antidepressant-withdrawal-implications-for-the-longitudinal-outcome-of-depression/

2007 Fava et al: http://survivingantidepressants.org/index.php?/topic/669-effects-of-gradual-discontinuation-of-selective-serotonin-reuptake-inhibitors-in-panic-disorder-with-agoraphobia/

2010 Baldessarini et al: http://survivingantidepressants.org/index.php?/topic/668-illness-risk-following-rapid-versus-gradual-discontinuation-of-antidepressants/

2010 APA Practice Guidelines: http://survivingantidepressants.org/index.php?/topic/372-about-discontinuation-from-us-apa-practice-guidelines/ leave rate of tapering up to the doctor


You might also contact Jonathan Lichtmacher, UCSF Psychiatry http://psych.ucsf.edu/faculty.aspx?id=324 He is supposed to have a protocol for slow tapering. Please say hello for me.


[b]Point being: Slower is better, 10% is a conservative approach for harm reduction, to avoid damaging the nervous systems of your patients and spurious diagnoses of relapse.[/b]

Altostrata said...

By the way, I have a Web site full of people who are having difficulty tapering off antidepressants or who are suffering prolonged withdrawal syndrome for years after too-fast tapering.

It seems perhaps the majority, can taper off in a few weeks and suffer mild or tolerable withdrawal symptoms for perhaps a few months. It is on these people medicine has built its assumptions about the transience and triviality of antidepressant withdrawal symptoms.

Others need much more gradual tapering, at 10% or less per month. Some can tolerate only a fraction of a milligram reduction at a time. You won't know which group your patient is in until he or she starts exhibiting withdrawal symptoms.

If your patient is in the group that is more sensitive to reduction of dosage, too-fast tapering can damage that person's nervous system for a long, long time.

The 10% rule, therefore, is to protect your patient from risk of an extremely adverse effect.

Personally, I've had Paxil withdrawal syndrome for 7 years. My case is very well documented at UCSF.

Maggie said...

"I am curious, if you feel this rule makes alot of sense, why do you need research, particularly if it isn't dangerous?"

Why, why, WHY are you speaking as though research is irrelevant? Research -- objective reasearch -- is exactly what we need more of.

Once upon a time, people believed that illness was caused by imbalances among four humors correlated to "the four elements." This "made sense" to them based on what information that they had at the time. Sometimes remedies seemed to work, they never knew quite for certain what did harm; after all, it could have just not worked, or it could have been the will of God. (Not that I'm discounting the will of God or anything. I just believe that science helps us understand God, rather than the other way around.) At the time, it made sense.

If not for research, we'd still be stuck there. "Makes sense" is all well and good, but that sense has to translate into quantifiable results. Otherwise it's nothing but speculation. If a hypothesis makes enough sense, somebody tests it and gets results as to the validity of what "made sense."

I have a friend who always likes to remind people what alternative medicine is called once it's been demonstrated to actually work.
Medicine.

"Makes sense" is a decent starting point from which a testable hypothosis can be formed. It is not a conclusion.

Sunny CA said...

I apologize for this being off topic, but does anyone wish to recommend some summer reading for me? I just finished teaching and want to find some novels or mysteries that I can read over the summer. I plan to read the Shrinkrappers book, then what? I like "women's" books like "The Help" by Kathyryn Stockett, and "Snow Flower and the Secret Fan" by Lisa See, but I also like books that appeal to a male audience. I'd love to download something on my Kindle and start reading it tonight. Thanks!

rob lindeman said...

In the mood for non-fiction?

"The Myth of Mental Illness", by Thomas Szasz (1961)

jesse said...

Sunny, how about "Let the Great World Spin" by Colum McCann?

jesse said...

You could also try "Tarzan of the Apes." Well worth reading.

Dinah said...

Sunny CA:
I loved Unbroken (non fiction)
and The Immortal Cells of Henrietta Lacks (also non fiction)
Little Bee was excellent, but very heavy (not Little Bee-ish at all)

Did you read Middlesex?
Trying to think of what else was great.

Assuming you've read The Kite Runner, and Memoirs of a Geisha

Anything Malcolm Gladwell

I loved Cutting for Stone (Abraham Verghese)

If you want something shrinky try Just Like Someone with Mental Illness Only More So by Mark Vonnegut--he's a pediatrician with a recurrent psychotic disorder and son of author Kurt Vonnegut Jr.

Maggie said...

Sunny CA, I just finished Poison by Sara Poole, if you like historical fiction, that was good. And it looks like the Kindle edition is 2.99.
The Tudors have had their day, now historical fiction is starting to shift to the Borgias. (I *think* it's Showtime that's following the trend rather than the other way around.. I gotta say, I'm afraid to watch their Borgia series, I know it'll be badly mangled.)

I've also been big into C.S. Friedman books lately. Someone recommended In Conquest Born, and then I ended up buying most of her other books too. This Alien Shore was really great. Now I've just started into the Coldfire trilogy.

Roy said...

There are many who just don't want to take a year to get off a med, especially if it isn't helping or is causing other side effects. Then there is the very practical problem of coming up with 10%. Say you are on 150mg of Effexor XR. The smallest capsules are 37.5mg. So you cannot easily go down by 15mg per month. This involves opening up capsules, guesstimating amounts, measuring out granules, etc. It is doable, but is a challenge. So, most can come off using the standard 150>112.5>75>37.5>0. I tell pts the symptoms of withdrawal so they can monitor for this, and adjust the taper as needed.

SG said...

You'd be amazed how patient you can be when you've had a taste of withdrawal, Roy. And as for how to taper off Effexor, see this link http://survivingantidepressants.org/index.php?/topic/272-tapering-off-effexor-venlafaxine/

Also, here is a link from the same site on general tapering techniques that go well above and beyond the pithy and sometimes woefully inadequate advice most psychiatrists give on how to withdraw from meds: http://survivingantidepressants.org/index.php?/topic/235-tapering-techniques/ The sole reason I have been on SSRIs for 13 years (since age 14!) is because I could not withdraw according to my doctors' protocol. I am now tapering with the 10% method by having my medication (Lexapro) compounded.

Welcome to the world of guerilla psych med tapering. It's surprising how innovative people can be when they can't rely on the medical community to help them.

Anonymous said...

Maggie,

Geez, you would think in reading your post that I was asking psychiatry to accept that crystals and mysticism help with withdrawal.

I mean no disrespect but I am laughing at your description of the slow tapering method as alternative medicine. Many of the alternative med folks are just as clueless about tapering people off of psych meds as psychiatry is and will throw supplements at the problem. That can throw a system that is already in chaos from withdrawal into upheaval big time.

Of course, I am not against research and I am sorry if I gave the impression that I was. That is how we have made great advances in science.

But meanwhile, people are spending extra years needlessly on antidepressants because they couldn't withdraw according to their doctor's protocol. SG is a perfect example of that.

Would you have wanted him/her to wait for the research that may or may not have taken place?

By the way, when a compound pharmacist said I was tapering too slowly, I said, "Oh really, is there a problem with safety in doing it the way I am doing it? His response was no but that it just wasn't done that way.

Speaking of the research, doctors prescribe meds off label all the time without studies, http://health.dailynewscentral.com/content/view/0002240/40/.

It seems to me this is more dangerous than having a patient taper a med slowly who has been unable to do it under the standard protocol.

AA

Anonymous said...

To add to Rob's non fiction suggestion, I would suggest "Anatomy of an Epidemic" by Robert Whitaker.

AA

Anonymous said...

A great post by Dr. Stuart Shipko, a psychiatrist, that is so relevant to this blog entry even though he doesn't mention a specific tapering rate.

http://tinyurl.com/3fmry6n

In the name of full disclosure, it is on Peter Breggin's site. I know that many people on this site can't stand him and I respect your views. But I ask you to keep an open mind and read this article since I feel Dr. Shipko beautifully sums up the points I have been trying to make regarding withdrawal and relapse.

Some thoughts on stopping psychiatric medications

PHARMA has been able to purchase a standard of care that involves giving a drug, usually a SSRI, but now also antipsychotics, when a person describes emotional discomfort. Now, it is estimated that one out of 10 Americans are taking one or more of these drugs. The PHARMA spinners speculate about why depression is on the increase. One explanation that they leave out is that depression is not on the increase, but that people who take these drugs are often unable to stop the drug. This issue is not that depression and anxiety are on the rise, the issue is that people are put on psychiatric drugs and then not taken off of them. After a few years pass, the consequences of trying to stop the drugs becomes increasingly serious.

There are people who can pretty much stop taking the drugs whenever they want with little or no problem. The percentage of people who stop on their own with little problem is not known, but anecdotal in my practice, this seems pretty common. A lot of patients have tried to taper or stop their drugs and found it to be too uncomfortable, so they continue to take their drugs, despite being clinically asymptomatic. Some unfortunates taper their drugs, go into 'withdrawal' and restarting the drug does not improve the situation.

Continue at above link.

AA

PS - I know I am posting alot but I hope folks will forgive me since obviously, I care greatly about this issue

Anonymous said...

I wanted to apologize as I just realized I might have inadvertently violated netiquette by posting a portion of someone's post without permission.

I thought it was an article before I realized it was forum post.

Oy, as Dinah says.

Shrink Rapper please feel free to adjust my post as necessary and again my profuse apologies.

AA

Maggie said...

AA, I wasn't reacting to the idea itself; my objection was to the fact that you seemed to find it strange that Roy had asked if there was any peer-reviewed research. The way you asked that question, it seemed that you were implying that if a hypothesis made sense and didn't seem to do any harm, research would be superfluous.

And of course as Roy pointed out, given that the biggest reasons for getting off a medication that the side effects are unbearable or that the medication isn't working, wouldn't slow tapering generally be reserved as a backup, something to use if standard tapering caused problems?

I wasn't saying that it was a bad hypothesis. I was just saying that without research, it's a hypothesis. Lots of things make sense. They're not science until they're tested under controlled conditions.

Roy didn't say "Well I would never think about doing that until I saw research." He just said that he couldn't consider it "dogma" without research, and raised questions about precisely what intervals would be optimal.
If a particular person is having trouble getting off a med, tapering more slowly would be the next obvious step. But to state particular numbers as a rule for tapering implies that research has been done to determine those numbers.

rob lindeman said...

Just ordered Whittaker, one-click, on the strength of the rec above and Marcia Angell's review in the NYTRB

Anonymous said...

Interesting that AA and Altostrada are the same person but never wanted to mention that? Altostrada runs the surviving antidepressants forum.
http://survivingantidepressants.org/

moviedoc said...

The longer you take to "wean" from theses terrible toxins, the longer your brain is exposed to them, and the more of those terrible 15' minute checks I get to do. More work for me. I doubt there is any reliable long term evidence that benefits of dragging out the process outweigh the costs, provided the patient does so comfortably. This idea also ignores the substantial differences among drugs used in psychiatric, including those for which detox, rather than taper, is appropriate.

Anonymous said...

Anonymous, who think I am Altostrata, I am lol hysterically at the assumptions people make on the Internet.

While I obviously wouldn't have wanted to suffer the problems this person has been though, I sure wish I had some of the skills she/he has.

I couldn't create a website in my dreams:)

Anyway, AA and altostrata are two different people:)

AA who really is who I am claiming to be


AA

Anonymous said...

Hi Maggie,

I understand what you're saying and you make some good points.

Regarding slow tapering prolonging the agony, let me use this analogy.

Let's say you feel sick while driving a car over a bumpy road. Obviously driving faster will get you to your destination quicker but the sensation of the bump road cause you to feel worse.

On a more practical level, I am not a medical professional but here is my understanding of what takes place. Roy or Movie Doc can correct me if I am wrong.

These drugs make neurochemical changes throughout the body and as a result, when you lower the dose, your brain needs time to adjust. If you're the type of person who has the brain that needs longer to adjust, a quick taper is not going to save you time.

The WD symptoms that you encounter as the result of tapering too quickly will add on to your withdrawal time. Kind of like worsening your condition by driving over the bumpy road too quickly.

Now there are people who can taper quickly and not have any problems. Personally, if I were one of those folks, I definitely wouldn't want to spend forever tapering.

But then again, I have talked to people who had no problems with quick tapers initially. Unfortunately, when they tried it a third time, all h-ll broke lose.

Obviously, there are no easy answers.

AA

Anonymous said...

Hi Movie Doc,

On a totally off topic note, you might want to visit this site, http://www.despair.com. I could be totally off base but I think you would like it.

You said,

"More work for me. I doubt there is any reliable long term evidence that benefits of dragging out the process outweigh the costs, provided the patient does so comfortably. "

The key words, "doing it comfortably". The only way some of us could be comfortable was with the slow taper.

So even if you are right, if someone is suffering horribly from a way too fast taper, that outweighs everything.

And when I say suffering horribly, the person literally can't function with their day to day activities.

As far as detoxing off of meds, you might want to ask folks on the benzo forums how well that worked.

My med checks with my former psychiatrist were like 5 to 10 minutes which was my choice:) I had nothing to say and wanted to get out of there as soon as possible.

Rob, I am glad to hear you are purchasing Anatomy of an Epidemic.

AA

Anonymous said...

I find it interesting that in skimming through these comments, I find nothing about benzodiazepines.

They are the most hellish drug to come off, especially long-term use, or higher doses.

The sensible thing to do in my opinion, is to be slow and listen to your body. Slow and steady wins the race. I think that is especially true of benzos. And, if you find the symptoms becoming too unbearable, hold at one dose for as long as you need before attempting to cut further.

It's an interesting fact that many benzo abusers who take huge quantities, for a period of time, sometimes have less trouble coming off them than the poor patient who has been prescribed them and never told of the addictive properties.

moviedoc said...

AA, I can't think of a situation in which a patient should suffer more than slightly during a taper. Incidentally a common fallacy implicit in the 10% rule is assumption that dosing occurs at regular intervals. Another way to taper is to keep the dose constant and gradually extend the interval until no abstinence symptoms return.

We should also keep in mind that drug addicts regularly stop using a abruptly by choice or from lack of supply. That's where the term "cold turkey" came from. Should nicotine addicts taper by 10%?

moviedoc said...

And as for benzos, the best practice is never to prescribe or take them to begin with.

SG said...

Movie doc said, "I doubt there is any reliable long term evidence that benefits of dragging out the process outweigh the costs, provided the patient does so comfortably."

But that's precisely it, isn't it? There are NO long-term studies done on how to withdraw properly! NONE! Don't you find that the least bit interesting? Don't you think it's pathetic that psychiatry has offered no scientific insight into how to withdraw from these meds safely? Isn't it only fair that a doctor who puts someone ON a med should know how to taper them OFF it safely? And even if the majority of patients CAN withdraw easily, what of the patients who CAN'T? Are they to suffer and fend for themselves?

Do you not believe that a segment of the patient population can suffer from prolonged withdrawal that can last years? If you don't believe that is true, I invite you to post your thoughts on a peer recovery board.

In fact, I just spoke to a woman in person who was just starting to come out of three years of Paxil withdrawal after a 6-month taper (which, in hindsight, she said was too fast). Maybe she's just delusional.

You also said, "I can't think of a situation in which a patient should suffer more than slightly during a taper."

I can think of plenty, such as if the taper is too fast or a patient takes their medication every other day, which can wreak havoc on some patients' nervous systems since it yo-yos the levels of medication in their system, especially if it's a short half-life medication like Effexor.

Anonymous said...

Glad to see some psychiatrists are talking to patients about how to taper off meds. I never had one that did. Of course, I was told I would need meds for the rest of my life so maybe they just never saw a reason to discuss it. The psychiatrists I saw would titrate up on some of the meds (i.e effexor), but never taper down. Could be why I felt like crap.

When I decided to go off of them for good, I tried to cold turkey off of my drug cocktail. Uncontrollable vomiting and diarrhea lead to hospital visit for dehydration, not to mention all the other CNS stuff - the brain zaps which no one even talked about back then, unsteady gait, dizziness, agitation. It wasn't fun. I ended up restarting effexor and backed off of it more slowly, the others I left off. It took a good year before I felt like my brain was back to baseline. Obviously the diarrhea, vomiting, brain zaps stopped much earlier than that.

Glad to know patients today have info available to them about withdrawal or discontinuation sydrome or whatever they call it. Maybe that will prevent some of the misery I went through.

Leslie

Anonymous said...

And, I'm very, very glad none of the docs I saw handed out benzos. I definitely didn't need addiction to add to my list of woes.

Leslie

moviedoc said...

Speaking on behalf of "psychiatry" I would like to thank SG for supporting research into guidelines for withdrawing from psychiatric drugs. I propose that, since "psychiatry" is a little short of funds right now, thanks to the mess in health care, Shrinkrap and Behavenet set up a joint account. We will accept donations from SG and anyone else with lots of spare cash and earmark all the funds for said research. We will promise none of the $ will pay dividends to anyone's mutual fund or retirement account like those horrid big pharmas do.

Oh, and we'll need guinea pigs. Who wants to volunteer?

Shame on "psychiatry" for not having thought of this before.

Anonymous said...

Well, maybe if pharma wasn't spending so much money paying huge fines for illegally promoting psych meds for various and sundry off label uses they would have more money available for research?

Duane Sherry said...

One of the readers made a derogatory comment about "throwing supplements" into the mix in with drug withdrawal...

Another about "alternative medicine"....

Supplements can often help... so can neurofeedback, exercise, sauna, other things...

All I can say is "What a mess!"
What an absolute mess!

Psychiatric drugs for everyone... according to Mark Hyman, M.D., one in ten adults in the U.S. is on an antidpressant...

Moviedoc,

I agree with your comment on benzodiazepines... I know someone who took six years to get off of them, having to titrate the dose...

If anyone is interested in some good sites to learn about psychiatric drug withdrawal, go here - (scroll down)

http://discoverandrecover.wordpress.com/warning

I wonder if we would all be in a much-better spot had psychiatrists had better parents...

"You made a mess, you clean it up."
- from mothers

"If you're going to do something, do it right." - from fathers

Too simple I suppose.
And of course, simple doesn't work... not when it comes to something as complex as drugging the brain into health.

What a mess!

Duane

moviedoc said...

"You made a mess, you clean it up." You got that right, Duane. That's what I say to docs who got their pts hooked on benzos, just last week I believe.

BTW: when I said no one should have to suffer much, I meant there almost always a relatively painless way to detox or discontinue meds, sometimes by taking time, sometimes by substituting, but there's no reason to torture yourself unless you're facing an allergic reaction or some other dangerous effect by not stopping right away. Evidence or not.

Duane Sherry, M.S. said...

Moviedoc,

I think it depends on the person.
I've met many people who have made the decision simply to reduce harm... Others who find it so painful, they decide to stay on the drugs.

I've learned to respect those decisions. Dr. Breggin explains that cold-turkey withdrawal can be "emotionally life-threatening."

I agree with him.

There's been some talk on this blog from psychiatrists on the financial aspects of running a private business... Reimbursements, what to charge, how much, etc.

I would think that any psychiatrist who was willing to put in the time would be able to make a couple of hundred thousand dollars a year, or more... along with good benefit package... with a non-profit organization with the sole purpose of helping people get off these drugs.

It's needed.
It's a valuable service... and one that I think people would gladly support... financially and otherwise.

To do so would require an 'MD' after your name... I cannot think of any more-needed service.

For the docs.... anyone interested?

Duane Sherry

SG said...

Moviedoc said, "I propose that, since "psychiatry" is a little short of funds right now, thanks to the mess in health care, Shrinkrap and Behavenet set up a joint account. We will accept donations from SG and anyone else with lots of spare cash and earmark all the funds for said research. We will promise none of the $ will pay dividends to anyone's mutual fund or retirement account like those horrid big pharmas do."

Actually, The Foundation for Excellence in Mental Health Care has already had workshops on medication tapering protocols, among other workshops on subjects that psychiatry has largely avoided, to the detriment of its patients.

And Dr. Mark Foster has already begun the preliminary planning of a psychiatric medication withdrawal clinic in Colorado, the first of its kind in the states. Keep in mind he was fired from his practice for his views that not all patients had to be on psychiatric medications long-term if it wasn't helping them or even harming them. More here: http://madinamerica.com/madinamerica.com/Whitakerblog/55E5019A-A259-491D-A4C2-5FA6E704EF7B.html

You see how far people can go when they don't get bogged down in status quo/defeatist thinking? The money can be found if there's a desire and need. Hell, there was a time where no one thought enslaved blacks would ever enjoy equal rights, and yet here we are with a black man in the White house. Revolutionary changes like that don't happen when everyone surrenders to defeatism and don't dare to think big.

More on the foundation here: http://madinamerica.com/madinamerica.com/Whitakerblog/DF02C0F5-B103-4C2B-B17B-F2DC7A7B8EC1.html

*PS: Good point anonymous about how drug companies prefer to spend their money. If the medical and psychiatric community rallied hard against drug company influence and the neutering of the FDA, maybe SAFER drugs would be on the market and countless costly class action lawsuits and tragic patient outcomes could be avoided. Not to mention all the extremely costly, wasted diagnostic tests patients undergo to explain their withdrawal symptoms that gouge the health care system. But no, it's far easier for the medical community to throw its hands up and insist it's hopeless, that the health care system is broke, and big pharma has too big an influence. Better to leave that to "outsiders" like Robert Whitaker.

Duane Sherry said...

sg,

You wrote:

"Revolutionary changes like that don't happen when everyone surrenders to defeatism and don't dare to think big."

Wow!
I love this stuff!

Duane

Anonymous said...

Sunny CA--"The Elegance of the Hedgehog" by Muriel Barbery.

Brilliant.

Altostrata said...

Roy: "So, most can come off using the standard 150>112.5>75>37.5>0. I tell pts the symptoms of withdrawal so they can monitor for this, and adjust the taper as needed."

Roy, the more conservative approach is to start with a 10% taper and wait a few weeks to see how it's tolerated. If the patient does well, the rate of taper can be increased a bit. Follow closely for withdrawal symptoms, at least weekly. The other way, you risk touching off withdrawal symptoms that will make the rest of the taper difficult, even if you do slow down.

The above method identifies the fast taperers with less risk to those who require a slower taper. This way, you can taper at an optimum speed for each individual.

And you're very welcome for the links to references, as you requested.

(No, I'm not AA. If I wanted to post repeatedly, I'd do it myself. However, there is at least one troll among those commenting here.)

rob lindeman said...

Benzodiazepines can be effective used on a PRN basis, dispensing low doses, small amounts, and no refills.

Now after reading a fair number of these comments, I must repeat. All of these ideas are as good as any others because there is absolutely nothing known about the mechanism of action of these drugs, including SSRIs. As the mechanism of action is not known, how much more so is the pathophysiology of withdrawal a mystery!

One minor, nit-picking quibble: A true 10% taper would result in the individual taking the drug for ever, as 10% of whatever dose you're on is still a finite number.

wv = unshoet; barefoet

Discover and Recover said...

Rob,

Good point on the quibble.

I wonder about the "half-life" of these drugs...

In other words, does the half-life indicate that the effects of the drug last forever?

Once in the body, brain, do they have lasting effects?

Who knows?

I try to be optimistic, and believe in the mind and psyche's (spirit's) ability to overcome.

Neuroplasticity of the brain is a fascinating subject, as is Epigenetics.

If psychiatry would put half as much interest in these areas, I think we would see enormous recovery rates... thriving rates!

You mentioned briefly about a person having a right to take these drugs, "as long as they are able to pay for them"(on another post).

The cost of these drugs.

The costs have not taken place in a vacuum. The research has been largely federally-funded. The states have paid enormous costs (particularly for antipsychotics, off-label, for children), in Medicaid, foster care (where in Texas, the levels are off the charts).

Joseph Biederman, M.D.... with his 40-fold increase in the diagnosis of "bipolar disorder" for children... Charles Nemeroff, M.D., Karen Wagner, M.D....

These folks have cost the taxpayer (while they've double-dipped with Pharma).

None of this happens in a vacuum.

IMO, we've created not only an unsustainable private health care system, but an unsustainable Medicaid/Medicare system in large-part because of the cost of drugs for children... along with elderly in nursing homes, the massive drugging of troops (1 in 5 in war theater on antipsychotics).

The first thing to do is prevent further injury - physically, the other issue to to stop financial ruin - both private and goverment due to the costs.

I don't have all the answers.

But, I think it's fair to say we have a mess on our hands.

"That spill is not going to clean itself up... You know where the mop is..." - A good parent

Duane Sherry

Discover and Recover said...

correction

one in five troops in war theater on antidpressants (not antipsychotics)

duane

Discover and Recover said...

A healthy debate on psychiatric drugs for children should not include bubble-gum flavored amphetamine for three-year olds.

We have such a product.

Liquadd by Auriga Pharmaceuticals.

Parental authority.
Normally, I'm right with anyone on this subject.

Government oversight.
In this case, yes. Big-time.

We need some sanity here.
And we need it pretty quickly, or we are going to lose a generation of kids!

Duane Sherry

Anonymous said...

Rob,

You said,

""One minor, nit-picking quibble: A true 10% taper would result in the individual taking the drug for ever, as 10% of whatever dose you're on is still a finite number.""

Good point.

Many people make the decision to jump off at around 1 to 2mg.

Personally, I jumped off at 3mg. I felt the drug was not going zilch and simply felt it was time to end the taper. It was the right choice.

Duane, I am sorry you perceived my comment about supplements as being derogatory.

I am not anti supplements and have take some myself. But during withdrawal, many people's systems are very sensitive and may react quite strongly to them.

Many people in withdrawal couldn't take them at until they were completely off of the meds.

AA

Discover and Recover said...

AA,

Thank you for clarifying.
Yes, I know folks who have had trouble with supplements during withdrawal as well.

I don't want to be called for hogging the comment board, but wanted to quickly say, "Thank you, and I understand."

My best,

Duane

Anonymous said...

Movie Doc said,

" I can't think of a situation in which a patient should suffer more than slightly during a taper. Incidentally a common fallacy implicit in the 10% rule is assumption that dosing occurs at regular intervals."

I am totally perplexed at this comment. I took the same dose every day until I was ready to make my next cut.

Contrast that with many doctors who put their patients on an every other day approach with causes extreme havoc on the system.

""We should also keep in mind that drug addicts regularly stop using a abruptly by choice or from lack of supply. That's where the term "cold turkey" came from. Should nicotine addicts taper by 10%?"

Hmm, so are you suggesting that justifies people suffering horrific symptoms from tapering too fast or cold turkeying just because drug addicts do it?

Regarding the nicotine addicts tapering by 10%, if that was the only they could get off of cigarettes, why not? Of course, there is no way for that to occur but if it were possible, better to taper slowly than to remain completely on cigarettes.

Now if I could just figure out how to taper coffee by 10%, I would be in business.

AA

Anonymous said...

Well, I don't have any issue with people trying whatever medications they want to try as long as it's by choice. Roy is telling patients things to look for when it comes to withdrawal from medications, so that sounds like informed consent to me. As long as it's by choice and as long as there is discussion about possible side effects, then I don't see any problem. These days you would have to live under a rock to not know of possible discontinuation problems with drugs like Effexor.

But, if we're talking about using force or coercion to get people to take medications, then that's entirely different matter. I don't agree with that at all.

Leslie, proud owner of Cluster A Traits

Sideways Shrink said...

If anyone is looking for ways to help patients instead of having pissing matches there's are two things to do for very difficult tapers. Patients who are polysubstance abusing addicts trying to get into rehabs will often not be accepted if they are on any benzos at all--let alone high doses of benzos. To get them off relatively quickly and safely so don't seize or want to die of agony their is something called The Cleveland Rapid Taper Protocol. It involves switching to clonazepam and neurontin from whatever benzos they are on now. It is very specific. Google to see if it is found on NIDA, etc. Works well.
For discontinuing effexor XR, I switch people to Pristiq which contains only a metabolite of effexor XR but has a much longer half life. Then patients start taking pristiq 50mg every other day and then, per tolerance, every 3rd day and then, per tolerance, every 4th day. These tablets can not be broken open so the 10% decrease idea would not work with med or with many other meds like wellbutrin XL which are coated.
I have never heard of this 10% decrease idea before and while I always strive for the most comfortable taper off of medication possible, I doubt it could be achieved by a one size fits all percentage number that does not take into account the half life of the drug, whether it is an agonist or antagonist, and whether it is a voltage regulator/enzyme auto-metabolizer. Let alone the drug a patient may be switching onto (yes, it happens all time in real life and won't be changed by the theoretical discussions of those who hate and/or are afraid of psychiatry, it's practitioners, and the medications they prescribe to restore and maintain health and save lives).

SG said...

Sideways Shrink said,

"I have never heard of this 10% decrease idea before and while I always strive for the most comfortable taper off of medication possible, I doubt it could be achieved by a one size fits all percentage number that does not take into account the half life of the drug, whether it is an agonist or antagonist, and whether it is a voltage regulator/enzyme auto-metabolizer."

This is very interesting. Could you elaborate a little more about why it matters if a med is an agonist/antagonist and whether it is a voltage regulator/enzyme auto-metabolizer? I've never heard of these concepts before.

Also, your concept of cross-tapering Effexor XR to Pristiq makes sense.

Thanks!

rob lindeman said...

Ditto, SG: I have never heard of a "voltage regulator" or an enzyme "auto-metabolizer". What are these?

wv = hawea. What you scream when being zapped by a voltage regulator

Anonymous said...

Sideways Shrink said,

"If anyone is looking for ways to help patients instead of having pissing matches there's are two things to do for very difficult tapers"

Even if you think the tenor of the comments has been hostile which I vehemently disagree with, how does this type of statement contribute to the discussion?

What about simply asking people politely to tone things down?

Anyway to your points about tapering Effexor:

While Pristiq may have a longer half life than Effexor, it is my understanding that it is still shorter than most antidepressants.

Even having a patient take a antidepressant every other day with a longer half life is putting them into withdrawal and would cause chaos in the brain. That is why folks end up on the Surviving Antidepressants website due to protocols like yours.

I am still cringing that you would actually do that.

The options for tapering Effexor slowly:

1. Count beads which I admit seems like a royal pain in the neck. But then again, I value not putting my brain into chaos.

2. Use a compound pharmacist to make the doses you can't get at your local CVS Disadvantage is your insurance company might not provide coverage.

Advantage - If it is doable financially, you get a consistent does and don't have to worry about counting those "wonderful" beads.

3. Crossover to Prozac and taper that drug since there are so many options for tapering.

AA

Sunny CA said...

Thank you to Rob, Jesse, Dinah, Maggie, Anon, and Anon for helping me with my summer reading list. I appreciate the thoughtful and prompt suggestions which all seem like good choices. I do read nonfiction also, so those are also appreciated. Dinah, yours was an especially detailed list. This will help me transition from working 12+ hours a day to being off 7 days a week! THANKS!!

Anonymous said...

Sideways Shrink said,

"I have never heard of this 10% decrease idea before and while I always strive for the most comfortable taper off of medication possible, I doubt it could be achieved by a one size fits all percentage number that does not take into account the half life of the drug, whether it is an agonist or antagonist, and whether it is a voltage regulator/enzyme auto-metabolizer.""

I reread your comment and wanted to respond to what I missed. Like SG, I would love to hear more about the agonist and regular/enzyme issue.

The 10% taper would be alot more comfortable for patients than tapering them every other day or every other third day.

As I previously mentioned, these drugs make neurochemical changes throughout the body as far I understand. I asked any medical professional to correct me if I was wrong and no one has said anything.

Anyway, your brain needs time to adjust to having less of the med as the result of these neurochemical changes and as a result needs a consistent dose.

On the AD support boards, people found that 10% was a comfortable reduction. I am not saying that is scientific proof ok but just trying to explain how it came into being.

Even though I think a greater cut than 10% is way too fast for alot of people, if it was a consistent every day dose, that would still be better than what you are proposing in my opinion with every other day tapers.

When I tapered Wellbutrin XL, I did it via the Compound Pharmacy route. I was lucky my insurance covered most of it.

If people don't have that option. they can switch to regular Wellbutrin to make the cuts. I am not sure if it is possible to do 10% but if I remember correctly, with the various manipulation of doses, people can come quite close.

Yes, it is a pain in the neck to figure out but in my opinion, better that, than putting your brain in chaos.

AA

Anonymous said...

Another possible idea for tapering Pristiq,

http://www.dr-bob.org/babble/20110529/msgs/986940.html

Again, I ask the medical professionals to correct me if I am wrong.

Apparently, you can buy enteric coated capsules which would allow you to safely cut Pristiq as long at it went in the capsule.

If this can be done, then someone could purchase a .001g measuring scale on Ebay and figure out the appropriate reductions.

Again, a royal pain in the neck to do. But as I keep saying, better that than brain chaos with an every other day tapering.

AA

Dinah said...

20ish years and I just have not seen patients have these type of withdrawal reactions. Many patients go off their meds without any problems. With Paxil, Effexor, and cymbalta, I ask them to taper slowly. With lithium, I ask them to go off slowly because the risk of mania is higher for sudden cessation. Benzos, obviously, can be a more difficult taper for some patients, but I discourage anything other than prn use, so I'm not generally trying to rapidly taper those.

I've said this, and the response I've gotten is that My patients are obviously afraid to speak to me, that I'm confusing relapse with withdrawal symptoms, this all said by someone who I'm assuming has never spoken to one of my patients.

Some of the wonderful things we've learned writing Shrink Rap is that people are extremely different in their reactions to things, and that individual differences must be respected. Lumping everyone together doesn't work, or as wise Clink says, "There is no one size fits all psychiatry."

These posts feel hostile, and they difficult to read with respect. There are non-clinical people telling experienced psychiatrists what they 'should' be doing with their patients, assuming a one-size fits all approach to tapering, informed consent, involuntary (at that moment) treatment. They include no respect for the idea that perhaps the psychiatrist is listening to the patients, that the patients aren't complaining about their care, and that they don't see us as the enemy, but as someone working with them on their terms.

Any patient who said to me that they felt ill tapering a medication, I would slow the taper and respect their wishes. This just hasn't been a problem in clinical care. It's not that I doubt that it's been a problem for you or for the people who come to your message boards--though I do in fact wonder if something else might explain a myriad of symptoms that might not be withdrawal and are presumed to be so--- it's that I just don't see this, and the instructive quality of the posts is a little strange.

It's still the issue of delivery, not of the content.

Maggie said...

AA, Actually I HAVE heard of the 10% reduction thing in terms of coffee! You just mix regular and decaf according to those ratios; from plain regular down to 9:1 regular:decaf, 8:2, etc.

Now I don't remember exactly where I heard that. I don't do coffee much anymore, I usually stick to tea. When I do drink coffee, I have this silly habit of drinking, say, a 24 ounce coffee.. and then wondering why I'm nervous! (You'd think it would be obvious, but somehow it never registers.
Every freaking time I decide I want a Wawa coffee.)

Sunny CA, This Alien Shore also has plenty of shrinkiness in it!

SG said...

Dinah -

At the end of this post are citations for a few journal articles about PSSD (Post-SSRI-Sexual Dysfunction), which is a syndrome in which patients still have persistent sexual dysfunction even after stopping their SSRIs. Sometimes these symptoms last for years and for some, seemingly indefinitely. I have these articles full-text in PDF format if you're interested in reading them. Just post a message here with your interest and I'll email them to you (to the shrinkrap blog email, I presume?).

In fact, the co-author of some of these articles, Audrey Bahrick, currently has a PHD student writing her dissertation on the subject of PSSD.

Also, Italian researcher Giovanni Fava is currently accepting case studies of SSRI patients who are in protracted withdrawal for a study. I can assure you there is growing clinical interest in this issue.

If benzos weren't considered addictive for quite some time, isn't it at least fair to look closer into the possibility that SSRIs may have withdrawal problems of their own?

You may not have seen such withdrawal difficulties with SSRIs in your practice, but that doesn't mean they don't exist. Indeed as you said, "there is no one-size fits all psychiatry."

And I would like to point out that it's not just the patients that are having issues with tone/delivery in this thread.

I guess all I have to say is this: just imagine how much pain people are in who suffer from PSSD and protracted withdrawal. And to have a medical profession who doesn't believe them makes the pain that much greater. In fact, it's terrifying, as hopelessness of ever getting better sets in. Please ask yourself, "What if? What if it IS true for some patients?" I'm not asking this as a patient to a doctor, but as a human being to another human being.

Citations:

-Bahrick, Audrey S., and Mark M. Harris, "Sexual Side Effects of Antidepressant Medications: An Informed Consent Accountability Gap." Journal Of Contemporary Psychotherapy, Vol 39(2), June 2009, pp 135-143.
-Csoka A, Bahrick A, Mehtonen O. Persistent sexual dysfunction after discontinuation of selective serotonin reuptake inhibitors. Journal of Sexual Medicine [serial online]. January 2008;5(1):227-233.
-Farnsworth K, Dinsmore W. Persistent sexual dysfunction in genitourinary medicine clinic attendees induced by selective serotonin reuptake inhibitors. International Journal of STD & AIDS [serial online]. 2009;20(1):68-69.
-Bahrick, Audrey S, "Post-SSRI Sexual Dysfunction." ASAP Tablet, Vol 7(3), Sept 2006, pg 2.
-Kauffman, R., Murdock A. "Prolonged Post-Treatment Genital Anesthesia and Sexual Dysfunction Following Discontinuation of Citalopram and the Atypical Antidepressant Nefazodone." The Open Women Health Journal, 2007 (1), 1-3.
-Bolton J, Sareen J, Reiss J. Genital anaesthesia persisting six years after sertraline discontinuation. Journal of Sex & Marital Therapy [serial online]. July 2006;32(4):327-330.

Anonymous said...

Dinah,

I have said repeatedly in my comments in various ways that I realize that this 10% method is not for everyone. You obviously did not read my comments very carefully.

Anyway, since my posts were offensive even though I said nothing inflammatory, here is a link to one of your colleagues who talks about medication sensitive folks when putting them on meds.

http://www.medicationsense.com/sideeffects.html

"Are You Sensitive to Medications?
Approximately 10 percent of adults, that is 20 million Americans, are medication sensitive. These individuals are sensitive to just about every medication they receive. As one pharmacist said: "You run into patients all of the time who don't tolerate standard drug doses."

So if this is the case when putting folks on meds, it would seem the same situation applies when taking them off.

If you disagree and care to respond, I would appreciate a post explaining why my logic is wrong instead of simply stating it is weird.

That helps no one and is a perfect example of why people have an intense dislike of psychiatry.

Speaking of not tolerating standard drug doses, the medical professionals on this blog were so busy criticizing the 10% rule, that is hasn't occurred to any of you that this method could be used for your patient who might benefit from drug therapy but are sensitive to the standard doses.

Talk about a one size fits all philosophy.

AA

Anonymous said...

Maggie,

My brain thanks you for your suggestion on reducing caffeine:)

AA

Dinah said...

Very strange: These comments came through on email as being posted, but I don't see them here and they are not in the spam. Blogger, I guess, simply ate them or they will arrive later. For the moment, posting for SG and AA:

SG has left a new comment on your post "The Ten Percent Solution":

Dinah -

At the end of this post are citations for a few journal articles about PSSD (Post-SSRI-Sexual Dysfunction), which is a syndrome in which patients still have persistent sexual dysfunction even after stopping their SSRIs. Sometimes these symptoms last for years and for some, seemingly indefinitely. I have these articles full-text in PDF format if you're interested in reading them. Just post a message here with your interest and I'll email them to you (to the shrinkrap blog email, I presume?).

In fact, the co-author of some of these articles, Audrey Bahrick, currently has a PHD student writing her dissertation on the subject of PSSD.

Also, Italian researcher Giovanni Fava is currently accepting case studies of SSRI patients who are in protracted withdrawal for a study. I can assure you there is growing clinical interest in this issue.

If benzos weren't considered addictive for quite some time, isn't it at least fair to look closer into the possibility that SSRIs may have withdrawal problems of their own?

You may not have seen such withdrawal difficulties with SSRIs in your practice, but that doesn't mean they don't exist. Indeed as you said, "there is no one-size fits all psychiatry."

And I would like to point out that it's not just the patients that are having issues with tone/delivery in this thread.

I guess all I have to say is this: just imagine how much pain people are in who suffer from PSSD and protracted withdrawal. And to have a medical profession who doesn't believe them makes the pain that much greater. In fact, it's terrifying, as hopelessness of ever getting better sets in. Please ask yourself, "What if? What if it IS true for some patients?" I'm not asking this as a patient to a doctor, but as a human being to another human being.

Citations:

-Bahrick, Audrey S., and Mark M. Harris, "Sexual Side Effects of Antidepressant Medications: An Informed Consent Accountability Gap." Journal Of Contemporary Psychotherapy, Vol 39(2), June 2009, pp 135-143.
-Csoka A, Bahrick A, Mehtonen O. Persistent sexual dysfunction after discontinuation of selective serotonin reuptake inhibitors. Journal of Sexual Medicine [serial online]. January 2008;5(1):227-233.
-Farnsworth K, Dinsmore W. Persistent sexual dysfunction in genitourinary medicine clinic attendees induced by selective serotonin reuptake inhibitors. International Journal of STD & AIDS [serial online]. 2009;20(1):68-69.
-Bahrick, Audrey S, "Post-SSRI Sexual Dysfunction." ASAP Tablet, Vol 7(3), Sept 2006, pg 2.
-Kauffman, R., Murdock A. "Prolonged Post-Treatment Genital Anesthesia and Sexual Dysfunction Following Discontinuation of Citalopram and the Atypical Antidepressant Nefazodone." The Open Women Health Journal, 2007 (1), 1-3.
-Bolton J, Sareen J, Reiss J. Genital anaesthesia persisting six years after sertraline discontinuation. Journal of Sex & Marital Therapy [serial online]. July 2006;32(4):327-330.



Posted by SG to Shrink Rap at June 28, 2011

Dinah said...

Anonymous has left a new comment on your post "The Ten Percent Solution":

Dinah,

I have said repeatedly in my comments in various ways that I realize that this 10% method is not for everyone. You obviously did not read my comments very carefully.

Anyway, since my posts were offensive even though I said nothing inflammatory, here is a link to one of your colleagues who talks about medication sensitive folks when putting them on meds.

http://www.medicationsense.com/sideeffects.html

"Are You Sensitive to Medications?
Approximately 10 percent of adults, that is 20 million Americans, are medication sensitive. These individuals are sensitive to just about every medication they receive. As one pharmacist said: "You run into patients all of the time who don't tolerate standard drug doses."

So if this is the case when putting folks on meds, it would seem the same situation applies when taking them off.

If you disagree and care to respond, I would appreciate a post explaining why my logic is wrong instead of simply stating it is weird.

That helps no one and is a perfect example of why people have an intense dislike of psychiatry.

Speaking of not tolerating standard drug doses, the medical professionals on this blog were so busy criticizing the 10% rule, that is hasn't occurred to any of you that this method could be used for your patient who might benefit from drug therapy but are sensitive to the standard doses.

Talk about a one size fits all philosophy.

AA

Dinah said...

AA-- that is an interesting comparison. Clinically, I do see people who are very medication sensitive. I'm not usually people's first stop---I'm often the third or fourth stop when things aren't working, and when I listen to someone's story of past responses and side effects, it is often clear that they don't tolerate medications at the usual doses, and I will just start things slowly and at low doses. Sometimes folks respond well to very low doses of medications and there is no need to go up to the usual therapeutic doses of medications. I find this especially true with lithium, which is often quite helpful at low doses but causes lots of side effects at higher doses, and I think this is why it has such a bad name. Paxil, too, can be helpful at half the lowest dose. Prozac, at the initial lowest dose of 20 mg is also too high for many, especially at the outset. I probably miss a fair number of medication-sensitive people (or labeling them as such) because my tendency is to start with much lower doses of meds then other shrinks and work up slowly, unless there is some reason to be in a huge rush. This way people don't have awful side effects and they tolerate the medicines better, though sometimes it takes a little longer to get better. So, I agree, this is not scientific, but I have not noticed that these same medication-sensitive people also have trouble stopping their medications or are more susceptible to discontinuation syndromes.
When patients enlist my help coming off medications electively (or--- it's actually my idea that they should start coming down), I do this very gradually-- mostly because I worry about relapse, but perhaps my caution here masks the any withdrawal syndromes that would have occurred if I'd told them to just stop.
Most people stop for a reason=== several times in any week someone will casually say "I stopped taking the meds"...I ask why, I ask if they feel better or worse without them, if they stopped because of side effects, I ask if they want to try something else. I'm a big believer in the lowest possible doses, unfortunately it takes high doses of multiple medications to get some people better.

I'm not sure we're saying anything very different. I just find the way it's being said to sound accusatory. Do the other shrinks here feel that way, too, or is it just me? I've said your way sounds like One-size fits all because my take is that whatever I'm doing works for most people, so I'm not going to insist that everyone have a slow taper when they want to come off meds (especially if there are side effects, a need to try another med, cost issues, or the patient is saying "I dont want to be on meds!!" (very common)...once there is any evidence that a patient needs a slower taper, then we certainly slow down.

To SG: the idea that SSRI's might cause longer term sexual dysfunction in some people does not sound shocking.

What are the other shrinks seeing?

I still think the folks out here who don't like our views should start their own blog.

moviedoc said...

"Do the other shrinks here feel that way, too, or is it just me?"

It appears to me that some of the hostility toward psychiatrists may be explained by the appearance that we decide how much of what the patient will take. In my practice I educate the patient about the choices, and we decide together, but ultimately it's the patient who swallows the pill, and it's the patient who decides whether the benefits outweigh the risks and how and how fast to taper to switch or discontinue.

jesse said...

Dinah, I'm hearing the same thing you are. AA, many of your points are thoughtful and my impression is that they have been well received by the Shrinks here. Yet frequently you "paint with a broad brush" making sweeping assertions, but then look at even the most carefully stated comment by the psychiatrists with a fine tooth comb. Many of your points are thoughtful and my impression is that they have been well received by the Shrinks here.

An example of the broad brush is in your last comment. In responding to Dinah you said "That helps no one and is a perfect example of why people have an intense dislike of psychiatry." Was Dinah a bit testy there? Perhaps. But if your response is not a broad brush bashing psychiatry it would be hard to find a broader one.

jesse said...

Yes, Moviedoc, I agree with you. It is clear you are very careful, as I know Dinah is. But there is a tone that Dinah correctly (in my view) picks up. If I write that I carefully taper medications I get a reply questioning whether it is carefully enough, bringing up 10% without any qualifications. If one reason to keep a patient on a medication is concern of relapse the reply is that withdrawal looks like relapse. No acknowledgement that there is such a thing as relapse!

So I get the impression that there is an agenda, which is that medication is not good and that patients should taper off of them according to the 10% method, which is not explained.

Anonymous said...

Thanks for the feedback.

Movie Doc, it is very frustrating to delete many posts in the name of wording things carefully only to still be told that my posts are hostile. I think that is why I reacted the way I did.

If Dinah is allowed to be testy, why am I supposed to be perfect? Yeah, maybe I shouldn't have made the remark about why people hate psychiatry but aren't you now doing that you claim I doing in searching remarks with a fine tooth comb?

Jesse, as I said to anonymous, I am always amazed at the assumptions that people make on the Internet.

The only agenda I have is to make sure that people are fully informed. If that means medication as was the choice for one of my friends, that is great. I have never said one word to this person by the way that she is a moron for being on it.

If that means that they are suffering horribly from tapering according to the standard protocol and that their psychiatrist doesn't have a clue unlike you folks, that there is another way which is the 10% method.

Finally, I would ask that you ask yourself this question. I don't expect a response unless you are compelled to provide one.

If I has raised these same arguments on an alternative practitioner blog about how they prescribe way too many supplements for people in withdrawal, would you still feel I was being disrespectful? Assume I used the exact same tone as I have on this board with the same type of arguments.

AA

jesse said...
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jesse said...

AA, I don't find you disrespectful at all and your voice has been, for me, valuable and respected. You ask how might we Shrinks respond if the argument were in regard to supplements for people in withdrawal.

Perhaps the difference is that we Shrinks here have practices in which we work closely with our patients and carefully follow their reactions to any medications we prescribe. Further, they are prescribed carefully taking into account the reactions of other patients as well as the findings of psychiatrists: publishing, peer reviewed, scientifically studied, careful comparisons of one to another, and with serious consequences for misuse. This is not true always, of course, but it is vastly more true than for the use of supplements, which while they might have some scientific and anecdotal bases their use is not subject to the same scrutiny.

I know Dinah, and know that she is extremely careful and thoughtful about medication use. She does not prescribe as you see in Saturday Night Live skits where a doctor just picks handfuls of different pills out of a barrel. From what I read here all of us are careful and know that medications need to be used thoughtfully, and not used if possible. Who among us would not agree that if a patient can achieve what is needed without medication, considering all factors, that is not better?

While the other Shrinks and I have been open about learning from others, and in particular from those on Shrink Rap who have had negative experiences with either medication or their psychiatrists, it is harder to find comments from former patients that show they are learning anything from the psychiatrists. This blog is a great opportunity!

So I would just ask you to be restrained in painting with that broad brush. The remark about why "people have an intense dislike of psychiatry" fits in with this. We listen best when spoken to in a soft voice.

The Alienist said...

Interesting conversation. I have rarely had a patient who had trouble coming off of antidepressants (I would guess <1%). Still, those that have had problems were in great distress and warranted care and support as they struggled with their tapers. One patient took a very long time getting off of paroxetine.

One brief branch of the conversation I disagree with, however, was the reaction against benzodiazepines. I rare prescribe them on an as needed basis, because this reinforces their use as an escape mechanism from anxiety. I prefer to prescribe them to be taken at intervals throughout the day (basing the frequency on their half-lives). In this way, we can prevent excessive anxiety and promote engagement with the fears circumstances in a comprehensive plan to address anxiety.

The vast majority of my patients appear to use their benzodiazepines responsibly and can be maintained on low steady doses of medication while they re-engage the situations they had been avoiding. The biggest struggle with discontinuation usually comes from "taking the training wheels off" as the patient switches from engaging their feared stimulus with benzos to engaging the feared stimulus without benzos.

True, I have had some patients misuse their benzodiazepines. Some have gotten supplies from several different doctors. Some supplement with alcohol. I inform them of the risks, benefits, and alternative treatments prior to starting their medications and the steps I will take if I find that they are unable to use the benzodiazepines appropriately (recreational use, unsafe use, failure to work on re-engaging the feared situations). Most of my patients who agree with these terms have been able to comply with them and be treated successfully).

Overall, I know that benzodiazepines are not for everyone, but please resist making blanket recommendations against them for everyone as well.

Gianna said...

these are my observations on withdrawal...

10% is only a place to start...everyone has to feel their way through from there...sometimes people must go much slower...other times it can be sped up.

http://bipolarblast.wordpress.com/withdrawal-101/

it's an article I wrote based on coming off of all classes of psych meds over a 6 year period. I witnessed thousands of others do it in that time as well.

glad people are talking about this.

cheers.

Anonymous said...

Roy,

I had decided to stop commenting on this thread. But I felt compelled to post after reading your comment on the Soulful Sepulcher blog concerning SR commentators here with negative, antagonistic tones.

In my opinion, that isn't very helpful at all. I feel if you have a problem with what a commentator has done whether it is me or someone else, you should be posting it on your own blog.

In spite of my being upset about that comment, I do appreciate you doing the blog entry which allowed for this discussion.

I have been wanting to see this issue discussed on a psychiatry blog for months and you did provide the opportunity for which I am grateful for.

Jesse, thank you for your last comment. And Dinah, thank you for your last response regarding medication sensitive people.

AA

Anonymous said...

Jesse,

Sorry, one more comment regarding learning from psychiatrists.

I have learned quite a bit from this blog, Evolutionary Psychiatrist, by Emily Deans.

http://evolutionarypsychiatry.blogspot.com/

For those of you not familiar with her, she has looked into the role of how nutrition has effected mental health. Also, she has done a great job of analyzing various studies.

I think what I have learned from being on her blog is the thought processes that a medical professional like herself goes through in analyzing non drug studies and whether they can be helpful as far as mental health.

She also has a great sense of humor which I love.

AA

Anonymous said...

AA, you said:

"I feel if you have a problem with what a commentator has done whether it is me or someone else, you should be posting it on your own blog."

I disagree with you. If there is a problem with another commentator (they have written an accusatory piece on their blog, say) then the issue should be taken up with that commentator on his/her blog. Anyone reading that piece on the other blog should be able to read the responses to it -- on that blog.

And that goes along nicely with how I feel about anyone who uses this blog as their own personal soapbox, changing the subject of every post to suit their own ends. If s/he has so much to say s/he should be saying it on a blog of his/her own, and anyone who wants to comment on it can do so -- on his/her blog.

RH

Altostrata said...

Shrinkrappers -- You're very welcome for the links I left in my posts, which lead to the Pubmed abstract and full text of the articles.

If Roy has any interest any more in this subject, Peter Breggin, author of many books about psychiatric drug dangers, is publishing a new handbook for clinicians called Psychiatric Drug Withdrawal.

More to your taste might be 2005's The Antidepressant Solution, in which Harvard psychiatrist Joseph Glenmullen painstakingly describes techniques of monitoring and gradually tapering patients off psychiatric drugs so as to preserve the integrity of their nervous systems.

A rationale of the 10% reduction from the patient perspective is posted here http://tinyurl.com/7f6b8dx

Rather than posting hundreds of words into this comment box, I've posted links for your convenience. I don't need any additional traffic on my site or increased Google standing.

Every day, new members find it and post tales of horrendous withdrawal and pervasive medical ignorance about gradual tapering. You can read their stories here http://tinyurl.com/3o4k3j5

And you're very welcome for this information, too, which as caring doctors I'm sure you will find important.

PS Alternating dosages is a terrible way to taper people off psychiatric drugs, second only to cold turkey in provoking withdrawal symptoms. How could fluctuating blood levels of short-acting drugs possibly fulfill the objective of smooth, gradual reduction?