Tapering antidepressants . . . more art than science
I get numerous inquiries about how to stop antidepressants. I get the impression that most people want to stop on their own, and not in collaboration with their psychiatrist. As always, I recommend that you change medicine only after consultation with your doctor. If you don’t feel like your doctor will listen to you, then you need to consider changing doctors . . . or, perhaps, listening to them about what their advice is (they may be right, you know).
There are no hard and fast rules for stopping medication. The factors that I consider when I decide on a taper schedule include the following: 1) how well is the patient doing, 2) how difficult are the side effects, 3) how long the patient has been on the medicine, 4) the ultimate goal.
1) How well is the patient doing? If a patient is not doing well, I tend to get them off the medicine more quickly, presumably to get started on a new medicine. For example, if someone is not doing well on Celexa (citalopram) 40 mg, I might bring them down quickly to start another antidepressant, such as Cymbalta. I might have them take 20 mg for 5 days, 10 mg for 5 days, then switch over to Cymbalta. If someone is doing well and we are really trying to get them off medicine and keep them off medicine, I will taper slowly–sometimes infuriatingly slowly. For example, if someone has done very well on 40mg of Celexa and we are trying to get them medication free, I might lower it by 10 mg every month or two until they are off. Now that means a 3-6 month taper, but if there is no reason to hurry, don’t hurry. Going slowly increases the chances for success. Going to quickly increases the chances for a need to restart the medicine–and recurrent relapses of symptoms may indicate a need for lifelong treatment (something most people want to avoid).
2) How difficult are the side effects? Can you guess my answer? If the side effects are difficult, taper quickly. If the side effects are not so difficult, taper more slowly.
3) How long has the patient been on the medicine? If you have been on an antidepressant for a long time and are getting off, it makes sense to taper slowly. If you have been on it only for a short time, I will tend to go more quickly.
4) The ultimate goal. If the plan is to get someone off medicine completely, I will go very slowly (as outlined above). If I am switching to another medicine, I will go more quickly.
So you see, there are multiple factors involved, but only two options. I will tend to go more quickly on a taper if someone is not doing well, if they have lots of side effects, if they have only been on the medicine for a brief period of time, and if I am switching to another medicine. I will go more slowly if the have done well, have minimal side effects, been on the medicine for a while, and if the ultimate goal is to get off medicine entirely. The other factor that ties in here for a few of the medicines is discontinuation syndrome. If the actual taper causes discomfort, I will switch more quickly if the ultimate goal is a medication change (the new medicine should reduce or eliminate the discontinuation syndrome). Conversely, if there are discontinuation syndrome symptoms and I am trying to stop medicine entirely, I will go very, very, VERY slowly. It is important to remember that when you stop an antidepressant, there is the risk of a return of symptoms (depression/anxiety) and the possibility of suicidal thoughts. For that reason, it is best done in consultation with your doctor.
–Dan Hartman, MD
