Is This the Right Time to Stop Psychiatric Medication?

The COVID-19 pandemic has led to massive upheaval in our lives, leaving in its wake rampant unemployment and financial duress, social isolation, the traumatic loss of family members and friends, and now evidence that at least 10 percent of people who have been infected with COVID-19 are “long haulers.” ¹ This syndrome is associated with chronic fatigue, chills and sweats, body aches, headaches, brain fog, gastrointestinal issues, shortness of breath, and loss of taste and smell. ²

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In several recent studies, it was found that over 30 percent of patients hospitalized with severe COVID-19 (especially those that required ICU treatment) may exhibit long term cognitive impairment such as the loss of memory and concentration as well as possible psychosis, depression, anxiety, insomnia, and symptoms of PTSD (post-traumatic stress disorder).^3,4,5 In addition, patients with a mood disorder appear to be more likely to contract the virus and twice as likely to die from COVID-19.⁶

Consequently, more and more Americans require mental health services, straining an already overwhelmed system. In one CDC survey from June 2020, 31 percent of adults reported anxiety or depression, 13 percent reported substance abuse, 26 percent reported stress-related symptoms, and 11 percent reported serious suicidal thoughts. This was twice the rate reported as compared to before the pandemic for all of the above.⁷

There has been a huge uptick in the prescribing of psychiatric medications. In a July 2020 CDC study, nearly 65 million Americans (1 in 5) were currently taking prescription psychiatric medication. This had gone up nearly 6.5 percent over the previous eight months.⁸

In a large study conducted by Express Scripts, which analyzed 31 million prescriptions over one week in February 2020, there was a 34 percent increase in prescriptions for anti-anxiety meds, a 19 percent increase in antidepressants, and a 15 percent increase in anti-insomnia meds.⁹

Where Primary Care Falls Short

Given the stigma still associated with mental illness—combined with the shortage of psychiatric prescribers, including psychiatrists and psychiatric nurse practitioners–79 percent of antidepressant medications are prescribed by a primary care physician (PCP), either a family practitioner, internist, OB-GYN, or pediatrician. Making matters worse, in several studies, it was found that 50 percent of patients referred by their PCP to a mental health professional never make it to the appointment.¹⁰

Twenty-five to 50 percent of patients did not receive an adequate diagnosis of depression by their PCPs, and 50 percent were placed on inadequate doses of antidepressant medication. Only 10 percent received an adequate course of psychotherapy for their condition. According to these studies, more than two-thirds of people on antidepressants in the U.S. have been taking them for at least two years, while a quarter has been on them for more than ten.^8,10 The fact is that most psychiatric conditions like insomnia, anxiety, substance abuse, PTSD, dementia, and depression wind up being inadequately treated by PCPs.¹⁰

Common issues that arise when PCPs prescribe psychiatric medications include:

1. Lack of a comprehensive psychiatric evaluation and informed consent where adverse effects, withdrawal reactions, and alternative strategies are fully discussed.
2. Lack of monitoring and collaboration with therapists and family.
3. Inappropriate management of adverse effects and withdrawal reactions.
4. Patients not being referred enough for evidenced-based therapies, like cognitive behavioral therapy (CBT), which work as well as medication and with lower relapse rates for most anxiety disorders and mild to moderate depression.
5. Patients being unnecessarily medicated for conditions such as grief, trauma, marital or work stress, insomnia, and mild depression, which will often resolve on their own with time and can be treated with safer alternatives like exercise, brief therapy, meditation/yoga, or stress management apps.

The American Psychiatric Association (APA)¹¹ recommends strict guidelines when prescribing antidepressant and anti-anxiety meds. Following these guidelines ensures that the above issues will be addressed and that patients know the risks/benefits before undergoing treatment.

Unfortunately, given the shortage of psychiatric providers and how overwhelmed most PCPs are today, these guidelines are not being followed. Patients typically leave the office with a prescription that includes refills and a follow-up appointment in 3-6 months.

Withdrawal and Discontinuation Syndrome

Over half of all patients taking either a selective serotonin reuptake inhibitor (SSRI), serotonin-norepinephrine reuptake inhibitor (SNRI), or benzodiazepine (BZD) will experience withdrawal or a “discontinuation syndrome” when trying to come off these. This is especially the case as many patients stop the meds abruptly on their own without consulting either their therapist, PCP, or psychiatrist. This only increases the odds of developing a withdrawal syndrome.^12-14

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Common withdrawal reactions to an SSRI or SNRI can include nausea, increased anxiety and moodiness, insomnia, “brain zaps,” muscle twitches, and in the case of BZDs, more rare severe reactions such as elevated blood pressure, seizures, and even psychosis.

Typically, when a patient tries to come off independently without a proper taper schedule, they experience a serious withdrawal reaction and assume that they are having a relapse of their underlying condition. They may avoid ever trying to stop again. The PCP often misadvises the patient to restart the medication, which leads to the patient believing, “I’m not ready or capable of coming off my meds.”

Tapering should be done using the following strategies and only under careful and ongoing medical supervision. Certainly, when and if problems arise, patients need to be seen ASAP by a psychiatrist or psychiatric nurse practitioner to determine the best course of action in collaboration with the therapist and PCP. Using the Collaborative Care Model, which ensures integrative treatment, has improved the delivery of mental health services within primary care.^10,11,15

Sadly, because patients are often not getting the information they require about tapering and withdrawal, many have turned to social media platforms instead for guidance.^13-14

How to Successfully Taper Off Psychiatric Medications

During this confusing and challenging time, many people on psychiatric medications will be wondering how and when they should come off of their meds. This complicated question should only be addressed by looking at the following factors that play a role in determining the likely prognosis:

1. The severity of the original disorder, including the level of impairment, the current symptom status, and degree of recovery.
2. The past and present history of other concurrent mental illnesses, substance abuse, suicidal behavior/attempts, and the current degree of danger to self/others.
3. The current level of support that exists within the family, work environment, and (if applicable) in therapy.
4. History of adverse effects from meds, adherence to the treatment plan, and overall response to treatment.
5. Level of self-care, including exercise, diet, sleep, stress management, and the motivation to continue a regular practice.
6. Presence of a general medical condition and its impact.
7. Any signs of a switch into mania or psychosis.

These factors will help predict whether or not a patient will be successful in coming off psychiatric medications and requires a careful psychiatric evaluation. The American Psychiatric Association (APA)¹¹ general guideline is for patients treated with medication for moderate to severe major depression to remain on a maintenance dose for four to nine months after being stabilized before a careful taper is begun. However, some patients with severe, repeated episodes of major depression, especially with a history of suicidal attempts, will need to be on medication for longer periods of time.

The following strategies should be employed to ensure a successful taper, and they should be administered and supervised ideally by either a psychiatrist or psychiatric NP.

1. Slow down the taper schedule over several weeks and sometimes months.
2. Avoid alcohol, excessive caffeine, and all substances.
3. Increase exercise and ensure adequate sleep, a healthy diet, and adequate hydration.
4. If there is a severe withdrawal syndrome, consider switching to another longer-acting antidepressant or anti-anxiety agent that is easier to come off of. Effexor (Venlafaxine), Xanax (Alprazolam), Ativan (Lorazepam), Diazepam (Valium), and Paroxetine (Paxil), for example, are noted to have more severe withdrawal reactions, whereas Prozac (Fluoxetine), Klonopin (Clonazepam), Cymbalta (Duloxetine) and Zoloft (Sertraline) tend to be easier to come off of.
5. Start psychotherapy—or increase the frequency if already engaged in therapy—to work through the tapering process. Your therapist can act as a bridge between you and your PCP. CBT has been well tested and found to work as well, if not better than meds for mild to moderate depression so consider adding this effective therapy if not already doing so.
6. Consider CAM (complementary/alternative) therapies while undergoing the taper—including mind/body exercises such as mindfulness meditation, yoga, tai chi, acupuncture, massage, and herbal/nutritional strategies, ideally with expert guidance.

Most of the time, patients can successfully come off their psychiatric medications with proper guidance and support. Occasionally, though, ongoing chronic problems arise, and these need to be addressed only by a psychiatric prescriber and mental health team in collaboration with the medical provider.¹³ This is especially true if you have a neuropsychiatric syndrome associated with being a "long hauler" from COVID-19.