Mark Horowitz was in a unique position when he decided to stop taking Lexapro for depression about a decade ago. The London-based training psychiatrist was working on his Ph.D. at the time, so he had been extensively researching the effects of antidepressants on the brain and body.
“I had been on the medication for about 15 years and wondered if it was contributing to the daytime tiredness and problems with memory and concentration I was dealing with,” he says of his reasons for coming off the drug.
Armed with his scientific knowledge, Horowitz progressed slowly. He stepped down from 20 mg of Lexapro (the maximum recommended dose) to 10 mg, and then to 5. He continued to cut his dosage in half until, after four months, he was done. From there, Horowitz says, “things completely fell apart.”
Although he had attempted to pace himself, his taper proved to be too fast. Especially considering how long he had been on Lexapro and how high his dose was. As a result, he got hit with withdrawal symptoms—including things he had never experienced before.
“I had trouble sleeping; I would wake up in pure panic like I was being chased by a wild animal,” he says. “I took up running to get a bit of relief, and I ran until my feet bled. I couldn’t get a single moment of calm the entire day. I felt dizzy, things around me felt dreamlike. It was really scary.”
After a couple of weeks, Horowitz wasn’t feeling any better, and the situation was becoming untenable. “It completely upended my world,” he says. He decided to go back on the drug temporarily to get some relief.
Trading Side Effects for Withdrawal Symptoms
Why do people decide to go off mental health meds in the first place? Many medications have unpleasant side effects, like the tiredness and concentration issues Horowitz dealt with. And that’s often what drives people to get off their meds. Another big factor is cost. But the reason could also simply be that the person is feeling better and doesn’t want to take meds for long-term maintenance.
Of course, not everyone who stops popping pills will go through what Horowitz did. You might have only minor symptoms that resolve within a few weeks. “Some people seem to be much more sensitive to changes in blood and brain levels of medications than others,” says Julia R. Frew, M.D., assistant professor of psychiatry and vice chair of education in the department of psychiatry at the Geisel School of Medicine at Dartmouth Hitchcock Medical Center. “It probably relates to genetic variations, but we’re not at a point where we can predict that for a specific individual.”
What Horowitz’s experience shows is that it can sometimes take a long time for the brain to adjust to changes in mental health meds. “When I was working on my Ph.D., the literature that I was reading from experts in my field all said it’s no big deal coming off antidepressants—give it two to four weeks. If you have trouble, it must mean you need the drug and you should go back on it,” he says.
Turns out, it ain’t that basic. In recent years, a clearer and more nuanced picture has emerged. We now understand that mental health meds can absolutely cause withdrawal symptoms. And some of them can be severe, including dizziness, headaches, brain zaps, low mood, panic attacks, and suicidal thoughts.
“These symptoms can be mistaken for the return of an underlying condition like anxiety,” Horowitz says. “But if you feel terrible when you stop, that doesn’t mean that you need the drug. It may just be a sign that you need to come off it more slowly and carefully.”
So why can it take so much longer than expected to come off a drug? The prevailing theory is that the adjustments your brain made while you were taking the drug persist long after the drug has left your system. Mental health meds alter levels of brain chemicals like serotonin. These chemicals are involved in everything from sleep to sex drive to hunger.
Your brain becomes accustomed to these changes—and then, “when you stop the drug, your brain scrambles to adapt,” Horowitz says. While your brain is struggling to readjust, “that’s what we think causes withdrawal symptoms,” Horowitz says.
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Although no two people will respond the same, there’s evidence that the higher your dosage and the longer you’ve been on the medication, the greater your chances of having withdrawal symptoms.
Horowitz has continued to study this topic: He has published several studies about tapering and withdrawal symptoms, and co-authored a textbook about how to safely discontinue a variety of psychiatric medications—a process that’s also known as “deprescribing.” He also runs a deprescribing clinic in London. He has found that “it can take months or even years for a person’s brain to fully adjust.”
It’s a bit easier to taper off of some medications than others. For example, “Within antidepressants, Effexor is generally harder to come off of than Prozac for a variety of reasons,” explains Horowitz. But there isn’t one whole class of mental health meds that’s considered the easiest. So you may experience issues whether you’re coming off antidepressants, mood stabilizers, ADHD stimulants, antipsychotics, or benzodiazepines.
Coming Off Your Meds: How to Start
If you’re considering coming off a mental health prescription, where does all this leave you? First, know that it’s not just a decision; it’s a process. While everyone’s situation is personal, these four things are important for everyone.
Speak to a mental health professional first.
You might think it’s no biggie to come off your meds. But please, don’t do anything on your own. First, some people shouldn’t be coming off the meds at all. You might think you no longer need your meds because you’re feeling better, but it’s possible you’re feeling better because of your meds. Speak to a medical pro!
“My number one most important piece of advice is to talk through the decision with a provider,” says Dr. Frew. Together, the two of you can weigh the pros and cons and map out a plan of action. There are a number of reasons why it’s so important not to go it alone.
For one, certain medications, including benzodiazepines—which are typically prescribed for anxiety disorders and insomnia—can cause potentially dangerous withdrawal symptoms like seizures, Dr. Frew says. “The same is true of some anticonvulsants used as mood stabilizers for people with bipolar disorder,” she continues. “Stopping them abruptly can sometimes increase the risk of seizures, even if the person doesn’t have a seizure disorder.”
Then you gotta think about what else is happening at your life at the moment. Are you under a lot of stress? Dealing with a major career or relationship transition? If so, it may not be the best time to taper. “I also tend to recommend that people not taper off antidepressants in the winter months, because cold, dark days can affect your mood and energy levels,” Dr. Frew says.
Do your research.
So here’s the catch: Tapering is a very particular science, and it’s hardly common knowledge even among the M.D. set, according to Horowitz. Most doctors still aren’t knowledgeable about the subject of tapering and withdrawal symptoms, he says.
Depending on how knowledgeable your healthcare provider is, you may need to gather some info on your own, so you’re prepared. It’s hard to believe we’re telling you to go hit up Google but… Hit up Google. Specifically, online communities that offer peer support, which can be game-changing for many people going through the tapering process.
“It’s ironic: Normally, online forums are full of nonsense, and doctors know what they’re talking about,” Horowitz believes. “But in this case, it’s the opposite: Most doctors are uninformed, and online forums are very helpful.”
Occasionally, online forums can get things wrong, but in general, Horowitz says he wouldn’t hesitate to recommend them to people (with the caveat that they shouldn’t take the place of professional medical advice). “Online peer support forums have been the most helpful source of information to me,” he says. “I learned how to come off my drugs from a retired software engineer online.”
The first time Horowitz tried to wean off of Lexapro, forums helped connect him to “thousands of people who had the exact same experience as me. They had the extreme symptoms that I did—I instantly recognized myself in their stories.”
A few years ago, he decided to try tapering again. This time, he incorporated things he’d learned from those forums into his plan. “I was guided by what they had done,” says Horowitz.
For example, remember how he’d packed the tapering process into a few months? On his second go-round, he let the process unfold over several years. He’s currently on a very low dose and plans to be done by the end of this year. (He utilized the online forum Surviving Antidepressants, though says it is now under new ownership and will be undergoing changes.)
One option is The Withdrawal Project, an informational website and online support group devoted to the topic of reducing or discontinuing psychiatric medications. It was created by Laura Delano, who has firsthand experience coming off a variety of mental health meds (her backstory was the subject of a 2019 New Yorker profile).
It’s worth noting that this site is geared toward people who have been on mental health medications for a very long time and have had serious issues trying to come off of them in the past. So just be aware that the advice tends to be more conservative than would be necessary for most people who are tapering down, says Horowitz.
And, of course, we need to drop in the requisite disclaimer about doing your due diligence when crowd-sourcing medical advice. But if your doctor doesn’t seem well-informed about tapering and withdrawal symptoms—or makes it seem overly simplified—you may find online forums to be a useful resource.
Come up with a tapering schedule—then adjust it based on your symptoms.
The rate at which you taper will depend on a few things:
- The medication you’re on
- How long you’ve been taking it
- The dosage
- How your brain and body react to the process
Generally, Horowitz recommends people start by reducing their current dosage by 10 percent per month. But there’s lots of variation here. Some people may be able to keep cutting their dosage by half and be fine.
Others may need to go slower than 10 percent. If it turns out you’re super sensitive to any reduction in dosage, you might consider going a couple of months without making any changes to give your system time to stabilize. Pay attention to how you’re feeling and adjust accordingly. “It’s not just numbers on a sheet of paper—everyone responds differently to withdrawal effects, and you have to be guided by your symptoms,” Horowitz says.
If you do have symptoms, one of the challenges is determining whether they are withdrawal symptoms or signs that your mental health condition is ticking back up. A slow taper makes it easier for you to tell the difference. Often (but not always), withdrawal symptoms will come on faster and be accompanied by physical complaints like dizziness, according to Harvard Health. Stay in touch with your doc throughout the tapering process—“this could be through phone calls, in-person appointments, or patient portal messages,” Dr. Frew says—and share any details about your symptoms.
Be aware that the final stages of a taper can be the hardest.
You’d be makin’ logical sense for assuming that lowering your dosage by 1 mg or less wouldn’t be a big deal. But Horowitz says the opposite is true. “You actually have to go slowest at the end, and edge down those last few milligrams very carefully,” he says, “because very small changes in dosage can have much larger effects than you’d expect.”
This process of making increasingly small dosage reductions at the end of a taper even has its own name, says Horowitz. It’s called hyperbolic tapering.
Depending on the drugs you’re taking, this can be really hard to do with typical tablets from a pharmacy. While splitting pills in half is common, it can be difficult to cut them up much smaller than that. Not only that, but research has found that chopping pills isn’t super accurate and can lead to inconsistent dosing.
Say you’re experiencing withdrawal symptoms and want to do a hyperbolic taper. Talk to your doctor about your options. Some drugs are available in liquid form, which makes measuring out tiny doses much easier. (This is what Horowitz did the second time around.) Your doctor may also be able to order you custom-dosed pills or liquids via a compounding pharmacy.
Remember: NO COLD TURKEY! Not at Thanksgiving. And not when weaning off medication. If you’re careful and plan things out, most people can avoid super negative effects. Medication is supposed to help—so let’s mitigate the harm.