Rapid dosage drops can trigger bipolar episodes. Learn one expert’s method for minimizing risk and withdrawing safely.
We recently asked the bpHope community to fill out a short questionnaire about their experiences with antidepressants. The results offer a revealing glimpse into the challenges many of you face.
In fact, your survey results are astonishing. Among the 274 people who answered our questionnaire, 267 (97 percent) reported having taken an antidepressant at some point. Nearly everyone.
Proceed With Caution
So let’s start with a caution. If you’re taking an antidepressant and doing well, don’t stop. It’s great that things are going okay, because that point can be hard to reach. You might consider tapering off later after discussing the idea with your treatment team and significant others.
If you’re taking an antidepressant and not doing well — sorry — you shouldn’t stop either. Talk with your treatment team about next steps. For some people, tapering the antidepressant is one option. This is because antidepressants can help for a while and then seem to stop working; they can help with depression, but increase cycling; and they can cause mixed states, as discussed in previous essays here at bpHope.
Survey Results: The Reality of Antidepressant Withdrawal
Only about 15 percent of survey respondents said they had “no major problems” when stopping. All the rest had at least some trouble:
- Fourteen percent found it difficult but managed to get through it.
- For 15 percent, it was terrible.
- And the rest went back on their antidepressant.
About 1 in 7 people who went back on their antidepressant did so because of withdrawal symptoms. For the other 6 out of 7 who resumed their antidepressant, well, that’s tricky. Symptoms worsened. But was that their bipolar coming back, or withdrawal?
Withdrawal symptoms can include anxiety, anger, agitation, and insomnia — all symptoms of mixed states. So it’s hard to know, impossible sometimes, whether worsening is “old symptoms coming back” or withdrawal.
But one thing is certain: A too-rapid taper makes withdrawal more likely. Let’s see how people did it.
The Risks of Rapid Tapering
In the question about how people stopped (where respondents could select more than one option), only about one-quarter said they gradually lowered the dose. Over 40 percent did not taper at all! And most people who stopped — including many who tapered — did so over just a few weeks to a month.
So overall, a very small percentage of people actually tapered slowly off their antidepressant. No wonder there was so much trouble.
Some people can stop without tapering at all. And some can taper quickly without getting worse. But your survey results suggest that most people need a taper — and that it should take more than two to four weeks.
Some will be okay with the four simple steps outlined below. Even so, smaller steps can make a huge difference and protect you against rough withdrawal or mistakenly thinking you need the antidepressant because symptoms seem to be coming back.
A Safer Approach: The Four-Step Tapering Method
You can improve your odds of stopping smoothly by taking at least four steps, cutting your dose by a quarter of your current dose at each step down.
Here’s an example, for sertraline (Zoloft), starting from a 100-milligram (mg) daily dose. Someone starting at a higher dose should take additional steps to reach 100 mg, then these four to reach zero.
Notice that step 4, down to 12.5 mg, is only half the size of the previous steps. But it’s a 50 percent decrease — half! — from the previous dose. And from there to zero, that’s a 100 percent decrease. These reductions need to be smaller because they represent a large percentage drop from the previous dose.
Notice also that step 1 is only 25 mg. More on the importance of taking a small first step in a moment.
Timing: How Long Should a Taper Take?
The slower, the better, especially if you’ve been taking your antidepressant for longer than six months. Take at least two weeks for each of the above steps. That’s fast, but if they go okay, great. If you get any withdrawal symptoms, take a smaller step down next time and wait longer between steps.
Let any weird changes that started with your last step down settle for at least a week before you take another step, unless you and your provider decide to push through minor worsening to try to get off an antidepressant quickly because it’s causing bigger trouble.
The ‘Smallest First Step’ Strategy
This is not a standard recommendation, but it might be my best. Many people starting a taper worry that it will go badly: Either they’ll get depressed without the antidepressant, or they’ll have withdrawal symptoms. Or they might remember how much the antidepressant helped, and be afraid they’ll go back to where they were before.
For these people, the first step down has to go well. If it doesn’t, they may conclude, “Oh, see, I need this antidepressant.” Or, “these withdrawal symptoms are not worth going through, I’ll just stay on it.” Either way, now they’re really stuck on that medication.
By contrast, if the first step is very small, that can build confidence. For example, consider someone who’s hesitant to taper off sertraline 100 mg/day because they’re worried about worsening during tapering. If I propose decreasing by just 6 mg, to 94 mg daily, I hope they’ll say, “Oh, that? Surely that wouldn’t make much difference. I can do that.”
Practical Tips: Splitting Pills and Dosing
This approach requires some fussing with pill-chopping, yes. For example, the smallest sertraline pill is 25 mg. Decreasing to 94 mg requires quartering a small pill. We could switch to a liquid version (some but not all antidepressants have one), but that’s actually more of a hassle, measuring out the right amount every day with an eye dropper.
Pill choppers are cheap, so I say “Get one, you’ll need it at the end of the taper anyway. And your insurance will fuss over taking more than one small pill, so you’ll have to chop some 100s to make 50s.”
Using this approach, here’s the first step down from sertraline 100 mg.
Yes, it’s tedious. But remember, the first step must go well. A person who has no problems with early steps can speed up, taking larger steps in the middle of the taper. If they then start having difficulty, they need to use smaller steps and will definitely need to do so as they near zero.
Specific Considerations: SSRIs vs. Effexor
This “small first step” logic and how to construct it by chopping pills applies to the SSRIs citalopram (Celexa), escitalopram (Lexapro), and paroxetine (Paxil). Fluoxetine (Prozac) takes much longer to leave the bloodstream, so it usually can be tapered more easily.
Unfortunately, venlafaxine extended-release (Effexor XR) is available only as capsules (the immediate-release version comes in pills, but it is so immediate that it cannot be tapered smoothly). The smallest venlafaxine XR capsule, 37.5 mg, is too big for “small steps.” Here’s my wepbage for more on tapering venlafaxine.
Building Your Support System
However you taper, your treatment team and significant others should be on board: aware and supportive, and able to help you evaluate any weird shifts. Some people will do better staying on their antidepressant until a long period of stability opens the window for cautiously making treatment changes.
For a few people (we really don’t know the percentages; they’re hotly debated), even the small steps I’ve described can be too big. This doesn’t mean you’re stuck. There’s another approach, as outlined on DepressionEducation.org. And the medical team at Outro offers personalized tapers of any antidepressant, using custom small doses if you’re lucky to live in a state they serve and can afford $300 a month. (Get it? Intro … Outro?)
Okay then: If you begin a taper, I hope you’ll consider making the first step small. And that it goes well!
The Takeaway
- Always discuss changes to your medication regimen with your healthcare provider before starting; never attempt to taper without professional supervision.
- Stopping antidepressants abruptly can trigger severe withdrawal symptoms or mimic a return of mood episodes, such as mixed states.
- A gradual tapering process, often taking longer than two to four weeks, gives your brain time to adjust and reduces the likelihood of adverse effects.
- Taking a very small first step in reducing your dose can help gauge your tolerance and build confidence for the rest of the tapering process.