Tapering Meds: When and How to Do It?

“Doctor, the medicine you prescribed has really worked well, and I’m feeling so much better. Also, that period of terrible stress and anxiety I was experiencing when I first came to see you has resolved now that the tumult my company was undergoing is over and my job is secure. I’d really like to see how I might do without the medication.”

Alan Schatzberg, M.D.

The situation described above by a hypothetical patient is relatively common, but can present a challenge for clinicians and patients alike. What should you do if your patient tells you he or she wants to go off medication?

Clinicians who spoke with Psychiatric News emphasized two points when considering tapering and terminating medication: any tapering plan should begin with a candid and thorough discussion with the patient about risks of going off the medication, and clinicians should offer the patient a sense of when he or she can expect to be medication-free.

Define Length of Treatment Early

“Patients wanting to come off medication is an issue clinicians deal with all the time,” said past APA President Alan Schatzberg, M.D., who is the Kenneth T. Norris Jr. Professor of Psychiatry and Behavioral Sciences at Stanford University. “You have patients who are treated for acute episodes who may want to stop medications when they feel better, and patients who have been taking medications longer term who may eventually want to go off or change medication.”

Philip Muskin, M.D., M.A., a professor of psychiatry at Columbia University Medical Center, chief of the Consultation-Liaison Psychiatry Service, and editor of Psychiatric News PsychoPharm, noted that discussing the length of time a patient should expect to be on treatment should recur during therapy.

“All treatments should have a general frame of length of treatment, though that length might be several years or forever in order to maintain the wellness of the patient,” he said. “No treatment should be left vague, and reassessment of symptoms and side effects should be a regular part of the patient-physician interaction.”

Beth Salcedo, M.D., medical director for the Ross Center for Anxiety and member of the Psychiatric News PsychoPharm editorial board, agreed. “I always try to bring the subject up on the first visit so that patients understand before they start a medication what kind of effect we are looking for before they go off the medicine.

“Generally, I don’t feel all people should stay on meds indefinitely, and for someone who has depressive or anxiety symptoms in the context of short-lived life stressors, it makes sense to consider tapering medications over a period of six to 12 months.”

However, she added, “Clinicians should also be sure that patients have been on the medication long enough to both have a beneficial clinical effect and be well long enough to reduce the probability of a relapse—that usually means a minimum of nine months to a year.”

Discuss Risks, Rule Out Big Life Changes

For those who do want to taper off their medications, timing is essential, Salcedo said. “I always tell people the time needs to be right. If you are taking a new job or making a major life change, that’s not the time to stop your medications. And always—the slower the better. Plan on a three-month tapering period for each new lower dose so that the patient can get used to it before tapering further.”

“The half-life of drugs can play an important role in what the patient will feel coming off medication,” Schatzberg said. “Generally, the longer the half-life of the drug, the less likely the patient will experience rebound symptoms, because the drug will stay around [in the bloodstream] for a longer period.”

He added, “In certain situations, you may have the emergence of new side effects. The patient needs to be warned about any potential changes that might occur when they terminate.”

Tapering May Carry Greater Risks for Some Patients

While the experts who talked with Psychiatric News were in agreement that tapering medications in patients with an acute history of depression or anxiety can be performed with success, they warned that tapering medications in patients with a long history of depression, anxiety, or other symptoms can be more complicated.

For instance, most clinicians agree that maintenance therapy is almost always advised for patients experiencing a first episode of psychosis. However, a 2013 study in JAMA Psychiatry by Lex Wunderink, M.D., Ph.D., and colleagues at the University of Groningen, Netherlands, caught the attention of clinicians and researchers: first-episode patients enrolled in an antipsychotic dose reduction/discontinuation strategy had better functional outcomes at seven years than patients receiving maintenance antipsychotic therapy.

Clinicians responding to the study who spoke to Psychiatric News said it has been known that there is a small group of first-episode patients who may not need maintenance therapy—but that it is all but impossible to know which patients fall into that small group.

Beth Salcedo, M.D.

“It’s well established that some patients will never have a relapse after a first episode, and some may not need to be treated with antipsychotics—but there is no way to tell which patients fall into that category,” said John Davis, M.D., a professor of psychiatry at the University of Illinois at Chicago. “On the other hand, it’s clear that most patients will relapse if they are not on maintenance therapy.” (Psychiatric News, August 18, 2015).

Tapering medications for psychiatric disorders during pregnancy also creates a challenging situation. A significant body of research has shown that untreated maternal depression can have long-term consequences for the fetus. There have also been studies that raise questions about rare risks of in utero exposure to selective serotonin reuptake inhibitors.

“The message in the media that many patients hear is that psychiatric medications are really bad during pregnancy,” Salcedo said. “That’s not necessarily true, but we don’t actually have clear evidence on long-term effects for the fetus. By the way, no one objects to staying on blood pressure medicines during pregnancy, but depression is just as dangerous a condition, and I believe it is really important that it be treated.

“Having said that, there are women who could be tapered,” she said. “The decision needs to be made very carefully and ideally prior to the pregnancy. Ideally, I would try to do the taper eight months before [the couple] conceive, so the woman can see how she feels.”

Muskin added, “The data in terms of the need to treat psychiatric symptoms in a pregnant patient do not indicate it is dangerous, but it does not indicate treatment with medications is without any concern. If the woman can be maintained with psychotherapy, that is an option that should be considered.”

There can be no blanket recommendation, however. “Some women suffer tremendously during their pregnancy, and for some their symptoms put both them and their fetus at risk,” Muskin said. “A discussion with the woman, with her partner if the patient consents, and possibly with her obstetrician may be of great use to review the benefits and risks of treatment with medication.” ■