The long-term use of benzodiazepines causes severe cognitive and neurological impairments, atrophy of the brain, and dementia, and the newer sleep aids should be considered a potential but unproven risk in this regard. Some of the most severe cases of chronic brain impairment (CBI) occur after years of exposure to benzodiazepines. This chapter examines the risk of increased mortality associated with benzodiazepines and closely-related sleep aids when given in relatively small doses for short periods of time in the treatment of insomnia. All of the benzodiazepines and the more common prescribed sleep aids are addictive. Opiate and opioid withdrawal tends to be more predictable than psychiatric drug withdrawal. Like the abuse of stimulants and benzodiazepines, abuse of opiates and opioids can result in unlawful acts. The chapter addresses legally used opioids, involving mild-to-moderate abuse or dependence as found in patients who can often be safely withdrawn in an outpatient setting.

The syndrome of chronic brain impairment (CBI) can be caused by any trauma to the brain, including months or years of exposure to one or more psychiatric medications. Although all psychiatric drugs have specific initial biochemical effects, over time other neurotransmitter systems then react to the initial drug effects and, as a result, broader changes begin to take place in the brain and in mental functioning. Psychiatric drug CBI, like all CBI, is associated with generalized brain dysfunction and/or damage, and therefore manifests itself in an overall compromise of mental function. The concept of CBI also resembles the concept of organic brain syndrome (OBS). The only effective treatment for CBI is a carefully conducted withdrawal from all psychiatric drugs, as well as all other psychoactive substances. A variety of stressors and trauma can cause chronic brain impairment or CBI. Long-term exposure to psychiatric drugs frequently results in CBI.

This chapter addresses the initial evaluation of patients who have been on psychiatric drugs for months or years. A person-centered approach is one of the most important decisions the clinician must make in the initial evaluation in collaboration with the patient. Many people who seek help from mental health professionals can be treated as autonomous individuals without the necessity of communicating with other professionals or family members. Patients receiving routine psychiatric medication are also likely to suffer from medication spellbinding and/or chronic brain impairment (CBI) and should often be treated in a collaborative fashion. For patients who do not have a desire to limit or stop their medications, the history remains important. Based on the clinician’s understanding of the hazards of the patient’s particular drug regimen-including polydrug therapy or long-term drug exposure the medication history should always examine the possibilities of drug reduction and withdrawal.

Children and teens can usually be withdrawn from psychiatric drugs with relative ease and safety, provided that their parents or caregivers are responsible and cooperative. Children who meet the criteria for attention deficit hyperactivity disorder (ADHD) are particularly easy to withdraw from stimulants when their parents are willing to improve their child-rearing approaches and when the child’s educational environment is improved or changed. Children who meet the criteria for ADHD are not severely emotionally disturbed, or they would carry other diagnoses, such as generalized anxiety disorder, major depressive disorder, or schizophrenia. As a result of pharmaceutical industry efforts conducted hand in hand with paid psychiatric consults, great numbers of children are being diagnosed with bipolar disorder. Children diagnosed with autism spectrum disorders suffer from difficulties relating to and communicating with other people. All psychiatric drugs will exacerbate a child or teen’s underlying lack of development in empathic relationships.

Antipsychotic drugs work by producing indifference and apathy without any specific effect on psychotic symptoms. The antipsychotic drugs have many short-term adverse effects that may lead the clinician, patient, or family to consider medication reduction or withdrawal, including Parkinsonism, dystonias, akathisia, sedation, and apathy. Tardive dyskinesia-often called TD-is a movement disorder caused by antipsychotic drugs that can impair any muscle functions that are partially or wholly under voluntary control, such as the face, eyes, tongue, neck, back, abdomen, extremities, diaphragm and respiration, swallowing reflex, and vocal cords and voice control. Antipsychotic drugs, including the newer ones, can cause neuroleptic malignant syndrome (NMS), which can be fatal in 20” of untreated cases. Long-term exposure to any antipsychotic drug carries severe risks, and a plan for eventual withdrawal should always be part of the treatment. Patients on antipsychotic drugs should be regularly evaluated and physically examined for symptoms of TD.

This chapter examines lithium and other drugs used for mood stabilization. Lithium directly interferes with neurotransmission, causing it to slow down. Neonates and nursing infants of mothers taking lithium develop neurological impairments, including flaccidity, hypotonia, and lethargy. Patients on lithium will inevitably become more apathetic and emotionally subdued. Exposure to lithium for many months and years is common and leads to cognitive deficits as well as a generalized deterioration of central nervous system function. As the results of clinical reports and studies suggest, lithium is highly toxic to nerve cells. Almost any drug that causes sedation and/or suppression of central nervous system activity has been used in psychiatry as “mood stabilizer”. All of these drugs, in fact, flatten emotional responsiveness. The mood stabilizers include carbamazepine, lamotrigine, and valproic acid. These drugs suppress global mental function and can cause chronic brain impairment (CBI).

Every psychiatric drug can produce withdrawal reactions. Patients exposed long-term to psychiatric drugs are likely to experience intense emotional reactions that may at times be frightening and even dangerous. Each class of psychiatric drug, as well as individual drugs, tends to have its own characteristic withdrawal reaction. Too often, clinicians assume that any psychiatric symptom is related to an inherent disorder within the patient rather than related to a direct drug effect or a withdrawal effect. Clinicians and researchers have developed symptom lists for antidepressant withdrawal. The tricyclic antidepressants can cause severe withdrawal reactions frequently in the form of cholinergic rebound. Inpatient programs for withdrawal from benzodiazepines are relatively available compared to programs for withdrawing from other psychiatric drugs. Stimulant drugs, such as methylphenidate and amphetamine, can cause rebound after only one dose, and they can cause serious withdrawal problems after protracted use at higher doses.

The era of patient compliance has been replaced by the era of patient choice. Prescribers and therapists have much to teach each other and the collaborative team, and they have a lot to learn from patients and their families. In the patient-centered model, the patient is viewed and treated as an autonomous, independent person who has the right to participate fully in all treatment decisions and to veto any of them. Modern healthcare requires the patient to take ultimate responsibility for all treatment decisions. The person-centered collaborative approach involving the family is consistent with FDA recommendations in general for antidepressants. Therapists often worry that they will be sued for malpractice if they do not refer patients for medication treatment. The therapist is the glue in the collaborative effort and the leader in creating an optimal healing environment for patients and the support network of family and significant others.

It is critical to distinguish between how to approach medical crises and how to approach emotional crises. By contrast, emotional crises during drug withdrawal are best handled with supportive psychotherapy or family therapy, without resorting to medication, so that the individual’s opportunity for medication-free mastery and growth are maximized. A medical crisis often stirs up an emotional crisis. In addition, many physical illnesses can cause cognitive and emotional dysfunction by directly impairing brain function or by producing physical exhaustion. An evaluation is likely to disclose stressors or conflicts that have caused or contributed to the acute emotional distress. The Non-Emergency Principle or nonviolent communication requires the clinician to be self-confident and self-controlled, and react in an empathic manner, despite provocations or emotional turmoil emanating from the other person. During acute withdrawal, psychotherapeutic interventions should usually be limited to reassurance and guidance.

Prescribers and therapists who embrace a person-centered collaborative approach to therapy and to medication withdrawal will find it professionally gratifying and will help many patients and their families. Any time a prescriber determines that a patient is suffering from sufficient emotional distress to benefit from medication, that same patient should be encouraged to try counseling or psychotherapy. Prescribers can no longer assume the role of medical doctors or nurse practitioners working in isolation prescribing for patients who then depart the office to dutifully take their drugs. All psychiatric drugs have serious long-term adverse effects and tend to produce chronic brain impairment (CBI). The modern prescriber will best serve patients by working together with therapists, patients, and their significant others or families, especially during difficult drug withdrawals. Many patients and families feel wounded by their experience with prescribers and therapists. They feel they have been pushed into taking psychiatric drugs.