Withdrawal

There are many reasons that one might chose to withdraw from a psychiatric medication, ranging from health concerns to drug ineffectiveness.  Such a decision is complicated, can occur with or without the introduction of another treatment, and is highly personal.  The goal of this post is not to discuss the reasons for choosing to withdrawal but rather to discuss the process of successful withdrawal.

The process of withdrawing from a psych drug is not to be taken lightly.  Some people who have been through it say that it is more difficult by far than withdrawal from many legal and illegal drugs, including alcohol, cannabis, and tobacco.  Some people compare withdrawing from psych drugs to withdrawal from cocaine or meth which are both psychoactive drugs.  The difficulty in the process is further complicated by the lack of social support for, resources for, and understanding of psych drug withdrawal.  Most of the support and information that exists is anecdotal and found in the experiences of consumers who have experienced withdrawal.

Withdrawal can include anxiety, depersonalization, brain flashes, seizures, psychosis, pain, fatigue, mania, depression, and drug sensitivities, some of which can be worse that anything previously experienced.  Sometimes withdrawal is precipitated by health problems which only makes the experience more difficult.  For example, people who abruptly withdraw from Lithium due to kidney failure are at greatly increased risk of mania.  Furthermore, the negative withdrawal experiences can go on literally for years if a person experiences protracted withdrawal.  Some people think they have recovered, only to experience withdrawal-like issues ten years after they chose to abstain.

The previous paragraphs are meant to scare and (ironically) to comfort.  If you are thinking of withdrawing, please take care and beware of what you might confront.  If you are having an agonizing withdrawal, please know that you are not alone.  There are people who have lived through it and who can support you.  On the other hand, some people are able to easily withdraw, and they are to be envied.

Knowing all this, let us proceed with our eyes wide open to discuss a single drug: Zyprexa.  I choose this one due to my personal experience with it.  Again, I will not discuss my reasons for choosing to withdraw, nor will I say that other people must make the same choice.  It is often said that the higher the starting dose and the longer one took the drug, the harder the withdrawal may be.

A reasonable approach to withdrawal from Zyprexa is as follows:

1. Reduce the dosage slowly over many months.
2. Hold each dose for a week to a month before further reductions in dose (rule of thumb: reduce dose by about 10% of starting dose, for 30mg starting dose, reduce by 2.5-3mg per step).
3. The last few reductions are often the hardest, e.g. 5 mg to 2.5mg to 0mg.
4. If necessary, use a compound pharmacist to make specialized doses.
5. Zyprexa has a 1-2 day half-life depending on ones metabolism, making a difficult proposition out of dose averaging by alternating doses.  For a four day example, one might take 2.5mg, 0mg, 2.5mg, 0mg, to obtain an average dose of 1.75mg.  However, the drug has to remain in the body long enough for the doses to average, and for some people the Zyprexa half-life might be too short.

It should be noted that some people may need a long slow tail to the reductions before getting completely off.  Some people advise to only make reductions after a time period in which all the withdrawal symptoms have been absent for 2 weeks.  This can make for long hold times between reductions, and is easier to do if the withdrawal symptoms are physical or otherwise very obvious.

Things to know about Zyprexa withdrawal:

1. Target is 6-10 months abstinence.
2. Withdrawal can include: nausea, insomnia, anxiety, lack of self-confidence, paranoia, psychosis, weight loss, appetite changes, neuroleptic malignant syndrome, tardive dyskinesia (TD), tardive akathisia (TA), etc.
3. Reinstating, or increasing the dose to a previous level, can provide relief from withdrawal symptoms (indeed, the definition of a withdrawal symptom is one that almost always disappears upon reinstatement and that usually slowly disappears without reinstatement).
4. If one is switching to a new medication, drug interactions might also cause temporary side-effects.
5. Although some people find that they cannot withdrawal completely, there are options such as specialized dosing from a compound pharmacist that can ease withdrawal symptoms at the tail of the withdrawal

(The caveat, for antipsychotics, is that TD and TA can be permanent--existing after successful withdrawal--or transitory, but we have no way of predicting this.  The mechanisms involved in making TD and TA permanent are not known.)

While some of the withdrawal symptoms can feel like illness, it is important to recognize them as drug-related.  This recognition usually provides quick path to relief (reinstatement) and hope for decreased symptoms over time.  It may be tempting to try treating the withdrawal symptoms with yet another antipsychotic.  This may or may not work, while true withdrawal symptoms can usually be fixed by reinstating the original drug.  (The caveat is that it is possible for a withdrawal symptom to be resistant to reinstatement, but this seems to be rare.)  In my experience, an attempt to treat a Zyprexa withdrawal psychosis with Abilify failed, and the symptoms only responded to the reinstatement of Zyprexa.  On the other hand, some people have a much easier withdrawal if they are switching medications.  Indeed, switching medications can be a successful way to withdrawal, for example some people progressively switch from short-half-life benzodiazepine (benzo) to longer-half-life benzos before withdrawing completely.

There should be absolutely no shame in reinstating.  It is not failure.  It also does not preclude a later successful withdrawal.  Sometimes people have their hearts so set on being free of a drug that they forget to consider all their options.  Since reinstatement can reduce withdrawal symptoms, it can mitigate agony.  If one is withdrawing due to health reasons, the decision to reinstate must be carefully considered and the potential harms weighed.

There is also no shame in using another drug as a crutch to get through the hard parts.  For example, a person might take Benadryl or even a benzodiazepine to help ease insomnia.  While one should consider the risks of becoming dependent on yet another drug, short-term usage of even a highly-addictive benzo can be less risky than courting sleep-deprivation psychosis.

Of course, if you are one of those unlucky people who have multiple drug sensitivity, an extremely sensitive to all drugs, adding even a safe-seeming additional drug at low dose may not be wise.  Such a sensitivity could be transitory and limited to the withdrawal process or could be permanent.  Indeed, some people find that their withdrawal symptoms are better if they do not even use supplements (vitamins, minerals, etc.).  So, if you find your withdrawal experience worsening or becoming increasingly chaotic, you might look into multiple drug sensitivity and even supplement sensitivity as an explanation.

If only I had known all this before I first tried to withdraw from Zyprexa.
After many failed withdrawals (always followed by reinstatement), the keys to my successful withdrawal from Zyprexa were:

1. the insight of my psychiatrist who insisted that I taper slowly
2. the recognition that my reinstatement threshold was psychosis and that I could tough out the insomnia, the anxiety, the crashes in self-esteem, and the arbitrary suspicious thoughts that came and went for the first few months of abstinence.

I can happily say that I have passed the 6-month mark and believe that I have passed the dangerous portion of withdrawal.


It should be clear that while withdrawal from psychiatric drugs can be quite difficult for some people, there are also people who come through the process with little trouble.  There is little science to guide the process, and a person cannot know their likely situation before experiencing it.  Due to the degree of problems that can arise, many people who have experience with this process suggest proceeding slowly.  Slow can mean different things to different people, so it is important for each person to stay within their comfort level.  It is also important to research the particular drug from which you are withdrawing, in order to discover how slow other people take it, what the likely problems, and what other people's experiences are.  The resource, below, Coming Off Psychiatric Drugs is a basic reference that discusses many different drugs.


Resources:

Coming Off Psychiatric Drugs 

Beyond Meds