Psychiatric Drug Withdrawal
A Guide for Prescribers, Therapists, Patients, and Their Families
Introduction: Hazards of Psychiatric Drug Withdrawal
Why are psychiatric drug withdrawal problems so common and often so difficult to overcome? Because the brain adapts to all psychoactive substances, the abrupt withdrawal from any psychiatric drug can produce distressing and dangerous withdrawal reactions. Even medications commonly thought to be free of withdrawal problems, such as lithium, can produce potentially dangerous reactions when they are stopped.
By means of a variety of biochemical reactions, the brain attempts to overcome the primary effects of any psychoactive substance. For example, many antidepressant drugs have been tailored in the laboratory to suppress the removal of the neurotransmitter serotonin from the synapse in the brain. This impact was expected to increase the amount of serotonin in the synapse and perhaps in the overall brain. But the brain quickly compensates through several biochemical mechanisms that can dampen and even reverse this intended drug effect (Breggin 2008a). Similarly, many antianxiety drugs enhance the activity of the neurotransmitter gamma-aminobutyric acid (
When these antidepressants or antianxiety drugs are stopped, the brain can be slow to recover from its own biochemical adjustments or compensatory effects. In effect, the brain cannot immediately keep up with the removal of the drug. This can produce distressing and dangerous withdrawal effects.
When a patient has been taking a psychiatric medication for several months or more—or even for a mere few weeks in the case of benzodiazepines—the brain becomes especially slow to react to the withdrawal of the drug, causing potentially more long-lasting, hazardous, and even life-threatening adverse reactions.
Psychiatric drugs also cause directly damaging effects. As several chapters of this book will document, all psychiatric drugs that have been examined have proven to be toxic to neurons or severely disruptive of normal brain function. These harmful effects may be partially masked by the blunting of emotions and judgment and medication spellbinding (see Chapter 9) that is associated with all psychiatric drugs. When the drug dose is reduced or the drug is stopped, the individual becomes more aware of the deficits, and others may notice them as well. At times, it may be difficult to distinguish withdrawal effects from direct toxic effects, even after the medication has been stopped for many months. It becomes difficult to determine if the individual is experiencing a lasting withdrawal effect because of the brain’s own compensatory mechanisms or a more direct toxic effect.
Unique Problems Associated with Drug Withdrawal
Withdrawal from psychiatric drugs commonly causes emotionally jarring biochemical changes in the brain. The physical disruption of mental processes during withdrawal can severely impair the patient’s judgment and self-control. In the extreme, severe depression, mania, psychosis, violence, and suicidality can occur during drug withdrawal. The withdrawal process can also elicit many psychological fears about managing life with fewer drugs, lower doses of drugs, or no drugs at all. In addition, concerned or fearful friends and relatives may complicate the drug withdrawal process by directly interfering or by the contagion of their anxiety and other negative emotions. Although the person-centered collaborative approach emphasizes the positive involvement of families in helping the patient withdraw, families can also generate many painful emotions and fears that can stymie the patient’s withdrawal attempts.
In addition, psychiatric drugs commonly cause chronic brain impairment (
These, and other factors that will be discussed, produce a more complex situation than routine medication treatment. In routine treatment, when the brain is exposed to the same dose of a psychoactive substance on a daily basis for a considerable period, the individual tends to stabilize—that is, to settle into a steadier biochemical and emotional state. The prescriber and the client can be lulled into a sense of safety regarding taking the medication. But if doses are skipped or changed, the brain may be unable to adjust in sufficient time to prevent a withdrawal reaction. Drug withdrawal is therefore more complex and more acutely dangerous than the routine prescription and use of psychiatric drugs. More care, more attention, and more specialized knowledge are required than during the routine administration of the same drug.
These cautionary observations are not intended to discourage withdrawal from psychiatric drugs. The long-term effects of psychiatric drugs on the brain and mind present the most serious hazards of all.
The Reluctance to Withdraw Patients from Psychiatric Drugs
Because it is complicated, time consuming, risky, or contrary to their philosophy or training—many healthcare providers do not feel comfortable withdrawing their clients or patients from psychiatric drugs. Very few have the experience to feel confident in how to go about withdrawing from psychoactive medications. As a result, many potential patients have difficulty finding professional supervision and support when they wish or need to reduce the dose or number of their psychiatric medications or to stop them entirely. These individuals may feel compelled to stop their medications on their own without professional help, sometimes with tragic results. Others continue to use their medications despite increasing adverse effects, often with equally or more tragic results.
Because withdrawal from psychiatric drugs can be so difficult, the safest and more effective approach requires a team effort—a person-centered collaborative approach that includes the prescriber, therapist, patient, and the patient’s family or support network. This person-centered approach focuses on the client’s mental status, needs, feelings, and wishes during the withdrawal process. This person-centered approach is consistent with the practice of contemporary medicine and also provides the safest and most effective approach.
Most prescribers are usually limited in the amount of time they can spend with each patient. These prescribers can provide better services if they work with a therapist who sees the patient more often and can develop more understanding and rapport with the patient and family. Because psychiatric drug withdrawal is so potentially hazardous, the patient’s family or social network also needs to be involved to support and to help monitor the patient. The therapist rather than the prescriber will usually be in the best position to coordinate the prescriber, the patient, and the patient’s family or friends.
Because it uses a person-centered collaborative approach, Psychiatric Drug Withdrawal can and should be read by the entire team. This includes prescribers, such as nurse practitioners, primary care physicians, pediatricians, internists, physicians’ assistants, and psychiatrists. It includes therapists, such as nonprescribing nurses, clinical social workers, clinical psychologists, counselors, marriage and family therapists, and occupational and recreational therapists. And finally, it includes patients and their social network of family and friends. All these potential members of the collaborative treatment team effort should find this book useful regarding understanding and assessing medication effects, observing and reporting adverse effects during treatment or withdrawal, informing or reminding patients and their families about the risks associated with these drugs and the benefits of withdrawing from them, and providing guidance and support during difficult medication withdrawals.