Before outlining some key strategies therapists can use to support clients through withdrawal in section 6, it will be useful to first provide some background information regarding the medical management of the withdrawal process.
5.4.1 Some background on tapering
Tapering is defined here as the slow reduction over time of a prescribed drug. It should be managed by a knowledgeable prescriber. There are various successful recommended protocols for tapering. All agree that people should never stop taking psychiatric drugs abruptly or use a rushed tapering schedule.
Schedules should be flexible and the reduction rate based on the individual’s withdrawal reactions, intensity of reactions, their ability to cope and whether there is sufficient support available.1 A knowledgeable prescriber will be mindful of such factors when supporting a person through tapering. People’s experience can vary significantly, with some experiencing no withdrawal reactions whilst others can experience severe and protracted withdrawal.
Whilst it is beyond the remit of the psychological therapist to give specific tapering advice, there are some helpful rules of thumb and practical considerations with which it is useful to become familiar, especially with respect to those who do experience severe and protracted withdrawal:
- Schedules: there are multiple online resources that anyone can consult for information on tapering. One such resource distils wide experiential knowledge shared by individuals with lived experience of tapering and withdrawal into clear information about tapering schedules. For example, it states that:
‘… most people most of the time have the least-disruptive, least-disabling, and most successful outcomes by reducing their psychiatric drugs at a rate between 5–10%per month, recalculated each month based on the most recent, previous month’s dose.’2
Recent research in the Lancet Psychiatry also supports the vital need for long tapering for some people.3
- Given the need to taper slowly, two years to complete withdrawal is not exceptional.4
- Tapering strips can help facilitate a successful withdrawal. These strips comprise a roll of small pouches that each contain a daily dose of antidepressant. Each strip contains 28 pouches, with the dose in each pouch getting successively lower over a 28-day period. In a recent study of 895 individuals wishing to discontinue their antidepressants, 71% were able to withdraw successfully with the use of one to three strips.5 These are not currently available on the NHS but can be ordered by a prescriber from the Netherlands. See the resources section for links for further information.
- Some prescribed psychiatric drugs are available in liquid form, which can make reducing dosage easier.
- It is helpful to also be aware that some psychiatric drugs, such as antidepressants, may interact with other prescribed medical drugs. It would clearly be part of the role of the prescriber to decide if any readjustment is needed if a client decides to withdraw.6
5.4.2 Clarifying the language of withdrawal
In order to support clients who have decided to withdraw from psychiatric drugs, it is important to become familiar with the language used to describe withdrawal. Some of the key terms are:
‘Withdrawal’, ‘withdrawal reaction’ or ‘symptom’ or ‘discontinuation syndrome’
All these terms refer to the various adverse reactions that result from reducing or discontinuing a drug. While the first three terms are non-contentious, ‘discontinuation syndrome’ is controversial. Its current meaning was first defined at the ‘Discontinuation Consensus Panel’ funded by Eli Lilly in 19967 and has been criticised for obscuring and minimising withdrawal (perhaps for commercial reasons).8 It is advised that it be replaced with one of the less problematic terms such as ‘withdrawal reaction’ or ‘withdrawal symptom’ or just simply ‘withdrawal’.
This term refers to the gradual return of the original issue, at the same intensity, for which the drug was initially taken.9,6
This refers to one’s pre-drug problems returning with greater intensity after the drug is withdrawn and is directly linked to withdrawal from the drug.10
This term is used to denote a new episode of distress (as opposed to the return of the original ‘episode’). This new ‘episode’, following withdrawal, may be induced by the withdrawal itself.10
‘Persistent postwithdrawal disorder’
This refers to the return of the original symptoms at greater intensity and/or additional symptoms related to a supposed new emerging ‘disorder’, which have persisted for at least six weeks after drug withdrawal.6,10 This term is controversial, however, given that it can be used to ascribe wrongly the responsibility for an adverse withdrawal reaction to an unspecified, unidentified ‘disorder’ within the individual – thus medicalising a drug-induced reaction.
Withdrawal reactions can be experienced at any stage during the prescription course and not just during tapering or after discontinuation. For instance, withdrawal reactions can be experienced when there is a marked decrease in the drug’s effect (which may lead to higher drug doses being prescribed to maintain a said effect). This experience is termed ‘tolerance withdrawal’ – an experience that, if not properly acknowledged, is susceptible to being either denied or misdiagnosed (e.g. as failure to respond to treatment).
Clients who take their antidepressants or other drugs only sporadically, can experience what is known as ‘inter-dose withdrawal’. This refers to withdrawal reactions that are caused by the drug’s effects wearing off before the next scheduled dose is taken. Inter-dose withdrawal is more likely to be encountered with benzodiazepines or drugs with a short half-life (see 5.1).
In some cases, withdrawal reactions resulting from tolerance or inter-dose withdrawal can be as disabling as those experienced during and after tapering, and so should not be overlooked as reasons why a client may start displaying debilitating reactions.1
5.4.3 How withdrawal can be misinterpreted or misdiagnosed
When these different types of experience are either overlooked or confused, withdrawal can be misunderstood or misdiagnosed, with detrimental effects for the client.
In 2007, and with respect to antidepressants, Haddad and Anderson11 provided an instructive list of the various ways in which withdrawal can be misdiagnosed:
i. as relapse (i.e. the original problem returning) with drugs being reinstated as a consequence. For example, as antidepressants are now widely prescribed for anxiety-related problems, and as increased anxiety is a common withdrawal reaction, ignorance of withdrawal reactions could have led, in the past, to relapse being overestimated when antidepressants were withdrawn.12 This could still be leading, in the present, to genuine withdrawal being misread as relapse with drugs being reinstated.13
ii. as failure to respond to treatment (e.g. patients not taking prescribed drugs as directed, leading to withdrawal reactions which are then mistaken for the condition worsening, leading to dose increase or drug switching).
iii. as a new mental health ‘condition’ such as ‘bipolar I or II’ (e.g. with ‘manic’ of ‘hypomanic’ withdrawal reactions being misdiagnosed as the early onset of ‘bipolar’).
iv. as side effects of a new drug e.g. withdrawal reactions can also be experienced when ‘switching’ between antidepressants. If this is not correctly recognised, such reactions are liable to being misdiagnosed as side effects of the new drug to which the person has now switched.11
v. as new physiological conditions such as ‘functional/somatic system disorders’ or ‘medically unexplained symptoms’.14
While we do not currently possess any clear evidence as to how common the misdiagnosis of withdrawal by doctors may be, we do know from anecdotal reports and qualitative survey data that it may be more common than traditionally supposed.
For this reason, some general rules of thumb have been devised to help safeguard against, or identify, such misdiagnosis:
- When did the experience arise? One prevailing view has been that it is possible to distinguish antidepressant withdrawal from relapse as the former usually commences within a few days of stopping the drugs and resolves quickly if the drug is reinstated, whereas relapse is uncommon in the first weeks after stopping treatment.12,15 While this view on timing makes intuitive sense, it has limitations as many withdrawal variations are possible, including late onset of withdrawal and/or longer persistence of disturbances.16 Also, the evidence is unclear as to whether relapse is uncommon in the first weeks after stopping treatment.
- Are emotional and physical reactions occurring at the same time? e.g. if unattributed feelings of anxiety or depression are present alongside physical reactions this increases the likelihood of their being related to withdrawal.17,15
- Is there any evidence of other medical problems? If physical reactions cannot be attributed to other identifiable medical problems they may well indicate withdrawal.18
- How does the experience ‘feel’? many people say that withdrawal related reactions feel qualitatively different to the client’s original presenting issue, with some describing withdrawal reactions as having a ‘chemical’ feel.18
- Fuller lists of commonly experienced withdrawal reactions can be found online, a good example being that given by the Withdrawal Project2 (see resources section).
Guidance on how a psychological therapist might ethically consider using this information to assist both prescriber and client can be found in section 3. As mentioned previously, tapering should ideally be performed under the supervision of a knowledgeable medical professional although the current reality is sometimes the right support is not offered leaving people to withdraw on their own or with the support of online information and communities.19
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2. The Withdrawal Project (2018). TWP’s companion guide to psychiatric drug withdrawal part 2: Taper. Retrieved October 1, 2018, from https://withdrawal.theinnercompass.org/taper
3. Horowitz, M.A. & Taylor, D. (2019). Tapering of SSRI treatment to mitigate withdrawal symptoms. Lancet Psychiatry. Mar 5. doi: 10.1016/S2215-0366(19)30032-X
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16. Fava, G.A., Gatti, A., Belaise, C., Guidi, J. & Offidani, E. (2015). Withdrawal symptoms after selective serotonin reuptake inhibitor discontinuation: A systematic review. Psychotherapy and Psychosomatics, 84(2), 72–81. doi:10.1159/000370338
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19. Guy, A. & Davis, J. (2018). An analysis of four current UK service models for prescribed medication withdrawal support (an APPG for PDD publication). Available online: http://prescribeddrug.org/wp-content/uploads/2018/11/APPG-Service-Model-Report.pdf