“I’ve spent a lot of my life feeling sick with no real diagnosis. I have always been small, and was as a kid. My stomach always ached. I had diarrhea constantly. But it wasn’t until my episode in college that everything went downhill.” Reilly, now a 42 year old woman, is on disability and spends most of her time at home, in bed, watching tv. The “episode” in college was precipitated by a romantic breakup and use of alcohol and marijuana that led to several days of visual hallucinations and paranoia. Because of her long history of low mood, she was labeled with Bipolar disorder and started on 7 medications (yes, 7) during her first hospitalization. Since that time, she has cycled through most mood stabilizers and antipsychotics on the market and earned the new diagnosis of Schizoaffective disorder. She has slowly slipped off the ledge of her formerly functional existence, has gained 60 pounds, and has few social contacts.
And meet Sara:
Sara lost her pregnancy weight in three weeks and felt like she could take on the world. It wasn’t until she was about nine months postpartum that she felt like she’d been hit by a truck. She was sluggish, forgetful, started to gain weight, lose hair – and not just the typical postpartum strands – and struggled to have a bowel movement even twice a week. She felt so overwhelmed that she knew something was wrong with her. In a 15 minute visit, a psychiatrist assured her he knew just what that was. He told her she has postpartum depression and gave her a prescription for Paxil. Within two weeks, she describes planning a suicide attempt. She drafted a letter, and planned to jump out of her window. She had never experienced these feelings before, and she stated, “It just suddenly made sense. I felt calm and certain about it.”
A thwarted attempt, two medication changes, and three years later, she is told that she can never live life without Lexapro and Klonopin.
Entering the Mill
These and millions of other patients find themselves caught in the web of psychiatric sorcery – a spell cast, hexed, potentially for life. They are told that they have chemical imbalances. They are told that the most important thing they can do for themselves is to “take their medication,” and that they will have to do so “for life.”
A Dr. Joanna Moncreiff states:
Symbolically, medication suggests that the problem is within the brain and well-being is dependent upon maintaining ‘chemical balance’ by artificial means. This message encourages patients to view themselves as flawed and vulnerable and may explain the poor outcomes of treated depression in naturalistic studies.”
These patients have suffered a crisis of resiliency.
The stress of their life experience outpaced what their biopsychosocial resources could support. Providers are not asking WHY they became sick when they did. They are not exploring root causes. They are not discussing evidence-based alternatives to medication treatment. And they are not disclosing the long-term risks of psychotropics, including worse functional outcome and increased risk of relapse. Let alone the poor integrity, industry-funded and manipulated data that supports the approval for efficacy of these medications.
Most egregiously, patients are sold the belief that medication is treating their disease rather than inducing a drug effect, no different than alcohol or cocaine. That antidepressants and antipsychotics, for example, have effects like sedation or blunting of affect is not a question. That these effects are reversible after long-term exposure is.
Where’s the Exit Door?
If a single dose of an antidepressant can change the architecture of the brain in ways we have no science to appreciate, what are the results of chronic, long-term use?
What happens when patients want out? When they are not happy with treatment? When they make sufficient changes in their lives to support a new approach?
As psychiatrist and activist Peter Breggin has stated, drug withdrawal programs are the most urgently needed intervention in the field of psychiatry.
I have no mentors. I have few like-minded colleagues. Most of what I have learned about psychiatric drug withdrawal, I have learned from patients and from clinical experience.
I was taught to dismiss patients concerned about becoming “addicted” to psych meds, and to deny the possibility of protracted withdrawal, describing it only as evidence of that patient’s clear “need” for permanent medication treatment.
I was never taught how to taper.
In the first systematized review of SSRI withdrawals, Fava et al. examined 23 studies and 38 case reports leading them to conclude that the euphemistic term “discontinuation syndrome” must be abandoned in lieu of a more accurate depiction of the habit-forming qualities of antidepressants – withdrawal. Yes, just like Xanax, Valium, alcohol, and heroin.
Relatedly, Chouinard and Chouinard state:
Patients can experience classic new withdrawal symptoms, rebound and/or persistent postwithdrawal disorders, or relapse/recurrence of the original illness
[6, 9, 14]
. New and rebound symptoms can occur for up to 6 weeks after drug withdrawal, depending on the drug elimination half-life
, while persistent postwithdrawal or tardive disorders associated with longlasting receptor changes may persist for more than 6 weeks after drug discontinuation.”
They provide a handy chart of the horrors that can befall unsuspecting patients ranging from those who miss a dosage to those who taper carefully.
In a rare instance of clinical documentation around approaches to tapering patients, Dr. Jonathan Prousky, compiles case examples of tapers that resulted in varied outcomes. Titled “Tapering off of psychotropic drugs: Using patient cases to understand reasons for success and failure,” he describes, in detail, his approach to these complex cases. He supports the patients’ reframing of their experience of mental illness, their self-care, and a careful dosage schedule that involves decreasing medication and the use of natural agents such as nicotinamide (B3), botanicals like rhodiola rosea, melatonin, and amino acids like GABA and l-theanine.
We concur that there is no magic supplement bullet, and that agents with evidence for their promotion of the parasympathetic or relaxation nervous system and modulation of excitatory brain ports called NMDA receptors is the goal. Magnesium, N-acetylcysteine, taurine, and glycine are all natural modulators.
Coming Off Psych Meds
First, Reverse the Cause
The best way to promote resiliency is to bring back a signal of safety to the mind and body. The premise of “paleo-deficiency” is making its way into the literature, and the relevance of diet*, green exposure, light cycle throughout the day and night, and movement are amassing a literature that supports the efficacy and relevance of lifestyle.
With my patients, we don’t touch medications until we have initiated 30 days of dietary change . This diet minimizes antigenic foods like gluten and diary, increases natural fats critical for blood sugar stability, and puts a premium on the sourcing of food and elimination of GMOs and carcinogenic, endocrine-disrupting pesticides.
Dietary change is a powerful – if not the most powerful – means of effecting the microbiome and gut-brain signaling. In fact, in Reilly’s case there is compelling evidence in support of the role of gluten intolerance in psychotic illness. Early elimination of gluten and cross-reactants like dairy might have, without exaggeration, changed the course of Reilly’s life.
I often fantasize about an inpatient psychiatric ward where organic ancestral foods are served, meditation and relaxation response are taught, sleep is supported, and exercise encouraged. I’d love a randomized trial of outcomes as a means of deconstructing the one ill – one pill model.
And what about Sara? Cases like Sara’s are near and dear to my heart because of my personal experience with postpartum thyroiditis as a psychiatric pretender. Yes, when psychiatrists don’t know about psychoneuroimmunology they don’t test for biomarkers, and they don’t treat it. Sara had classic symptoms of this common autoimmune disease brought on by immune shifts and environmental triggers after delivery. She also was potentially fatally victimized by the known suicide-promoting effects of antidepressants, particularly in this population.This has only been the subject of three placebo-controlled, randomized trials in the history of time, the analysis of which does not support efficacy.
In these and most cases, psychiatric symptoms are just that – symptoms. They are evidence that the body and mind are struggling. To my mind, medicating these symptoms is the equivalent of seeing that someone is limping slowly down the road and tying them to the front of a race car to get them moving faster. There has GOT to be a better way.
Then, Initiate the Taper
I have learned that the treatment team partnership is critical, and that the most optimal results come from lifestyle change, careful management of dosage decreases, and strategic physiologic support through nutraceuticals. This video by Will Hall describes important steps in the framing of the medication taper experience.
Most patients and supportive practitioners know that the dosages made available by pharmaceutical companies are, unsurprisingly, not conducive to a successful taper. Liquid preparations, compounding pharmacies, and even meticulous removal of beads from capsules are indispensable work-around tools.
One helpful barometer of potential success involves the length of PD use. In one report, patients taking PDs for less than six months were more successful at tapering (81%), compared to patients on PDs for more than 5 years (44%), and patients on PDs between six months and 5 years (a little over 50%).32
To improve the odds of a successful outcome, the tapering plan should involve one PD at a time and reduce the PD with the longest elimination half-life first.3 PDs with longer elimination half-lives (i.e., more than 24 hours) are easier to taper since their withdrawal reactions tend to be less severe than drugs with shorter elimination half-lives (i.e., less than 24 hours).”
I will often do a slightly larger, initial “test-dose” decrease to assess for sensitivity to withdrawal effects, which if tolerated can accelerate the process, sometimes by years.
The risk of relapse is often related to the nature of the effects that medication has on the brain and body. In my experience, agitation, anxiety, and insomnia are the most common symptoms of withdrawal that can crop up within hours of a dose change, or sometimes several months after the final dose. They can resolve spontaneously, or they can remit. Long-term damage from these medications is a real phenomenon, and one that is poorly understood outside of patient accounts and peer support groups. Patients are rarely wrong.
Finally, Change Your Mind
Fear is the enemy of health. Fear is what brings people to psychiatrists, pushes the 911 buttons on the phone, and drives an urgent feeling of hopeless overwhelm. As healers, we have the opportunity to meet this fear with compassion and equanimity. We can put aside our obsessive preoccupation with reactive intervention and liability-driven care, and just tolerate what is uncomfortable about a patient’s distress. We must do this because the data supports the emanant fact that the current paradigm of medication-based intervention is failing, and that it is dangerous.
I believe in transferring a sense of empowerment to my patients. In helping them to access a vital enthusiasm for this opportunity to learn about their own agency and efficacy in their health journey. I talk to them about this process as being one of rebirth. Of a rising from the ash, and a deliberate step in the direction of wholeness and radiant life.
Because health is so much more than the absence of pills or the fading of a laundry list of diagnoses. Health is liberation. I believe this is a basic human right.
The author acknowledges, with great compassion, that this is a challenging topic for the many individuals who make the difficult decision to begin treatment with psychiatric medication. All patients must be given the most complete and accurate information about these medications, including side effects (risk for dependence, violence, impulsivity, etc), the importance of properly tapering off medication, the institutional incentives for medical doctors, educators, and others to advocate for their use, and the availability of effective non-pharmaceutical avenues of treatment that can address root causes of mental illness and behavioral problems. What follows herein is a discussion of steps that the author believes should be taken in anticipation of any medication taper, and the subsequent taper should be handled by an experienced professional. Despite these considerations, some patients may be unable to taper which, in the author’s opinion, speaks to the important of true informed consent prior to medication initiation. This blog is not medical advice and does not replace consultation with a qualified medical professional of your choosing.
*The latest in nutritional psychiatry publications: