Tapering Off Meds

When Carole, a 39-year-old therapist, first came to see me, she was taking fluoxetine (Prozac) during the day and alprazolam (Xanax) at night. She was an engaging, compassionate, and psychologically savvy woman, who worked at a local agency as a social worker and volunteered at an animal shelter fostering dogs. Over many years, clinicians had diagnosed her with PTSD, ADHD, major depression, and bipolar disorder. She’d been on a variety of mood stabilizers and antipsychotic medications since she was 14, including Lamictal, Abilify, and Risperdal. “I’ve been a patient with so many labels attached to me for so long,” she said. “But I don’t feel like those labels define me, and I wonder what life would be like without all the medications.”

I listened to Carole’s history, which included sexual abuse by her grandfather between the ages of 10–13 and watching her father physically abuse her mother. Given her symptoms—mood swings, interpersonal challenges with coworkers, insomnia, and nightmares, as well as chronic use of opiates for pelvic pain and inflammatory bowel disorder—I told her I believed she fit the criteria for complex trauma, rather than the host of other diagnoses she’d been given. I felt sure she could build on her previous therapies and make good progress with a correct diagnosis and treatment plan.

Trained in bodywork yoga, meditation, and nutrition, I’ve been in clinical practice for more than 40 years as a psychotherapist specializing in trauma recovery. In the 25 years that I’ve worked with people who want to taper their psychotropic medications, I’ve had many clients like Carole, who’ve been medicated for so long that they don’t know how—or whether it’s even possible—to go about their everyday lives without prescribed drugs.

Early on in my work, I discovered that people who survive trauma often have ongoing digestive problems, headaches, chronic pain, fatigue, and autoimmune illnesses, which respond exceptionally well to concrete, holistic interventions, especially ones centered around nutrition. These might include eliminating pro-inflammatory foods like refined sugar and soda; adding good-quality protein and fats to enhance neuronal function; and taking B vitamins, essential fatty acids, and amino acids to improve brain chemistry. In fact, improving their diets helped my clients so much that over time, my referrals increasingly came from therapists whose clients wanted a robust nutritional plan for their mental health. Often, these clients also wanted to taper meds for various reasons, including adverse side effects, lack of efficacy, and pregnancy and breastfeeding concerns. Many of these clients have been on medications for five, 10, or even 30 years. Frequently, tapering meds is the final stage of their healing process after years of therapy.

Although psychotropic drugs have helped many people, the risks of some meds may outweigh the benefits. Treatment-emergent suicidality, for instance, remains a significant concern. And SSRIs inhibit mitochondrial function. Mitochondria are like little engines in our cells, and the latest research sheds light on the importance of the role they play in mood, energy, and focus.

For people who either don’t want to take meds in the first place or want to taper off them, nutritional therapies and integrative methods provide a promising alternative. A caveat that requires honest assessment is that changing one’s diet and lifestyle is self-care intensive: it takes motivation and often considerable time, particularly at first, as new habits and routines are created. Not every client has the time, bandwidth, or other resources required to engage in self-care at this level.

Is the Client Ready?

When I meet with clients who want to taper their meds, I start by conducting a comprehensive intake that helps us identify strengths and plan for challenges. The assessment includes detailed questions about medication use, history of trauma, social supports, cultural and spiritual practices, exercise, diet and nutrition, and supplement and herb use. I also ask about past experiences in psychotherapy.

Carole had discussed her childhood traumas with a counselor early on. Later, she’d completed a full year of CBT treatment, and she’d seen an EMDR therapist for six months. She’d experienced notable benefits from both of these therapy experiences, which gave her a solid foundation for medication withdrawal. Plus, since healing may be a lifelong process for complex trauma survivors, she didn’t need to be sold on continued therapy.

Psychotropic medicines have become such a cornerstone of mental health care that many people can’t imagine life without them, but Carole was clear that she could. Still, she had two persistent worries. One, she’d been told repeatedly by practitioners over the years that she’d always be on medications, and as a result, she saw herself as dependent on them and was now afraid to stop taking them. Two, her family often expressed fears about her stopping meds, so she worried they wouldn’t support her. In many ways, taking psychotropic medicines had become part of her identity. So over the course of treatment, Carole and I would spend several sessions addressing her long-held beliefs and fears about living without meds. We’d collaborate with her prescriber, invite family members in for a group session to get them on board, and come up with a detailed nutrition and exercise plan—all before the actual tapering of meds would begin.

Many clinicians, including prescribers, are afraid of people coming off meds, mainly because of the amount of support it requires. I believe this is the fundamental reason prescribers don’t encourage it. Additionally, providers worry that the client will relapse or experience discontinuation syndrome—with symptoms like insomnia and anxiety. Often, they’re unsure how to differentiate relapse from temporary tapering symptoms.

We therapists can help clients determine whether tapering is the right choice and, if so, develop a holistic, wraparound plan for success. Successful tapering requires education about the medication’s discontinuation process, opportunities to build coping skills and explore one’s sense of identity, a robust self-care routine, support in the form of a taper team, and the patience to tolerate going slowly. The most crucial element is the pace, which is often much slower than the pharmacist or prescriber suggests. Of course, the intersection of everyone’s unique biology, beliefs, and readiness, along with the specific medications they’re taking and the benefits of therapy, will affect the process.

In my practice, we collaborate with the prescriber and plan a taper schedule together, identifying the order of the taper if the client takes more than one medication. Before the process begins, we start a self-care program that includes nutrient-dense foods, low sugar intake, high levels of good-quality fats, at least 50 percent of self-prepared foods at home, and a daily exercise routine. I tailor a core set of nutritional supplements for each client to address their unique biochemistry and ease withdrawal of the medications. These may include essential fatty acids, B complex with additional folate and B-6, amino acids, and the fat-soluble vitamins A, D, E, and K.

Carole was eager to engage in this plan, saying she felt she had options that put her in control for the first time.

Mood Follows Food

Initially, Carole described several side effects from her medications, including weight gain and mental fogginess in the mornings. She also said she was ready for a close relationship with a partner, but that the meds had decreased her libido. They made her feel numb, physically and emotionally—a common reaction, often called the pancake effect. She said she used alprazolam to sleep because fluoxetine seemed to overstimulate her. She also told me of ongoing digestive problems, including acid reflux.

Before starting her program, I asked Carole to keep a three-day food–mood diary, which can help clients see how foods can be used as physical and emotional fuel. Food patterns, including gathering, preparing, and eating, are essential for self-care and health recovery. The diary helps clients enhance their self-awareness around the relationship between food and mood.

When I present the idea of the diary, I address the shame many people feel about their diets by telling clients, “There’s no right diet for everyone.” I advise them that this practice is not about losing weight and that our focus is health at every size. Then, I ask them to start the diary by writing down their answers to these basic questions: What kind of foods do you eat? At what time of day? Do they satisfy you? Is there something you can’t stop eating? Are there some foods that you’d never eat? If you were going to make any changes in your diet, what might they be?

Clients can go on to explore the quality of food they eat. For example, are the fats they eat brain-healthy fats, like olive oil and butter? Or are they eating harmful fats, like margarine? They can list when and how much they use stimulants like coffee or sugar. The diary provides an opportunity for therapists to educate, make recommendations, and engage in motivational interviewing about which foods to consider reducing, eliminating, or increasing, and in what order.

I emphasize the idea that there’s a healthier, mood-supporting alternative for every poor-quality food. Butter makes a good substitute for margarine, raw honey or stevia for refined sugar, natural cream or nut-milk substitutes for artificial creamer. Virgin olive oil replaces canola oil, and freshly prepared foods take precedence over packaged or fast foods.

Carole had written that she drank coffee in the morning with artificial creamer and sugar. She ate pastries mid-morning with more coffee because she usually felt fatigued. By lunch, which was a fast taco or burger, she often felt grumpy. She had a soda and an apple with nuts most afternoons. Dinner was usually pasta with some vegetables.

My first goal was to help Carole make the connection between what she ate and how it made her feel. Then we’d identify foods she enjoyed that wouldn’t disrupt her energy and mood. It was essential for her to feel nourished by new food choices, not deprived. We started by substituting natural, organic whole cream for the fake creamer. Next, I gave her a few recipes to try that were naturally sweet and delicious but made without refined sugar, which contributes to inflammation and depression. I applauded her for eating protein at midday and explained that she could get even more benefits if she ate it without the refined flour (or corn), which made her sleepy after lunch. Since she loved french fries, I gave her a recipe for healthy baked fries and dip, and suggested she bring a baked potato to work with all the fixings when she ordered her burger or chicken fajitas.

I made sure what we discussed wasn’t shaming or linked to attitudes about body size. I emphasized that Carole already had deep intuition about her needs, based on how certain foods made her feel. Still, people tapering psychotropic medicines benefit from plenty of good-quality plant and animal proteins. I suggest eating all the colors of the “brainbow,” from blue, purple, and red berries and orange yams and carrots to raw green leaves like kale or spinach. These are best lightly steamed and topped with butter to provide antioxidants and polyphenols to help the liver detoxify.

In a balanced circadian rhythm, our energy and hormone cortisol are highest in the morning and wind down throughout the course of the day; however, in Carole’s case, as is common with people who experience depression and complex trauma, this cycle can be reversed, with lower levels of cortisol and energy in the morning and higher levels at night, leading to insomnia. When this happens, I recommend engaging in CBT for insomnia, reducing stimulants, using blue-light-blocking glasses and melatonin supplements at night, and incorporating stress-relieving foods and herbs, like licorice-root tea in the morning and ashwagandha tea in the evening.

I told her that fermented foods support the vagus nerve, and that grains like oatmeal are relaxing to the nervous system and, along with fats and some protein, make a good evening meal. I also recommended a mocha matcha smoothie I developed to help wake up, increase focus, and boost mood, which would sustain her until mid-morning.

Engage the Prescriber

At this point, before Carole started tapering, I needed to engage her prescriber, the one who’d told her she’d always require medications. Carole had let him know we were working together, and he was expecting my call. He’d told her that although he doubted she’d be successful at tapering, he was glad she was focusing on healthy lifestyle activities and wanted to support her choices. I find this to be the most common response among prescribers. Frequently, they’ll ask for literature to read more about the process I propose, which I provide. When the occasional prescriber is unwilling or unable to support the changes the client requests, I recommend changing prescribers.

After I shared my assessment and recommendations with Carole’s psychiatrist, I let him know the ways Carole and I planned to manage her anxiety during the day, so we could reduce the occasional daytime use of alprazolam and the consistent use at night, thereby stabilizing her sleep. I suggested that Carole might reduce fluoxetine because it could stimulate her at night and counteract the alprazolam taper. Fluoxetine is available as a liquid, making it easier to taper in small amounts. In the end, I suggested we be in touch if anything changed and assured him I’d consult him for advice and support along the way.

After thoroughly discussing the plan with him, he cautiously agreed to support the integrative program I’d developed. In fact, he’d grown concerned about Carole’s increased use of alprazolam, a short-acting benzodiazepine, and agreed that a longer-acting benzodiazepine could benefit Carole as she reduced the dose.

None of this meant the process would be easy. Mainly, Carole worried about becoming emotionally overwhelmed—a concern her prescriber shared, so we talked about the specifics of her self-care plan and how she’d reach out to her taper team—a network of supportive friends, family, and other providers.

Beyond Chemical Withdrawal

We often think coming off medication simply means stopping the drug and coping with the side effects or hoping to avoid returning symptoms. But this process involves much more than the physical element. Many of our clients have used medications for years, even decades, beginning in childhood. Learning to live without medication, or to live with a reduced dose, is a process that includes forging a new sense of self without medication.

To help Carole initiate that change, we explored how she imagined her identity would shift and reflected on how her new diagnosis of complex trauma might help—not because it would redefine her, but because it could help explain many previously unexplained aspects of her distress. After all, while she’d been told that her chronic digestive pain, anxiety, and insomnia were due to conversion disorder and somatization bipolar disorder, no one had helped her understand how these symptoms fit together as a response to a nervous system that had been perpetually on high alert, ready to defend and protect, since she was a child.

“Let’s recognize and honor the extraordinary courage and resilience it took to survive your early trauma,” I said to her, “and the compassion you share with others through your work. The next step of your journey is a chance to walk further along the path of self-care and discover all the types of nourishment you need.”

The program Carole and I developed had clear guidelines about how she’d care for herself, including healthy eating, exercising, seeing friends, and using the breathing and self-massage techniques I’d taught her to help decrease anxiety. To start, she planned a week off from work and then saw clients part-time from home for a week to “find her groove” in her self-care and stress reduction regimen. She was fortunate that this was an option for her.

The experience of another client, Jon, shows how crucial it is for us to take a more holistic view of our clients’ lives, addressing their social supports and physical health before they begin their taper. Jon wanted to stop taking quetiapine, an antipsychotic often prescribed for depression, bipolar disorder, and chronic sleep disruption. We created a plan for him to exercise, eat healthy foods, and take some specific vitamins and minerals. Within weeks, his mood had improved, and he said he was ready to taper. But his siblings and mother, who’d always been critical of him, made fun of his self-care program. Slowly, without therapy to address the family dynamics, his motivation to stay with the program waned. First, he stopped exercising, and then his diet gradually changed to include lots of sweets. In the end, he recognized the need to incorporate his family and support systems into his taper plan, but he said he wasn’t ready.

Unlike Jon, Carole was aware of the importance of her social-support system in changing her medications. Just as she’d have to see herself differently to leap into living without medicine, her friends and family would have to see her differently to support her in that process. For that to happen, I asked her if she’d like to invite some family members to one of our sessions to discuss her plans. Together, we could give them a chance to express their concerns and ask questions.

Before the meeting took place, Carole anticipated what she thought certain family members would say, and we role-played dialogues so she could be ready with language she knew expressed why she was tapering and what she wanted for her life. She practiced being assertive rather than defensive, her default position.

She was closest with her older brother, Gary, and he attended the meeting, along with her mother, aunt, and older sister. Because she knew Gary disapproved of her going off medications, she started by addressing him. “Gary,” she said, taking a breath, “I’ve discovered that the cause of nearly all my health problems is the trauma we experienced as children. I realize this is why all the medications haven’t helped my symptoms, and in some ways, they’ve made me feel worse. With my therapist and doctor’s support, I’ll taper the meds slowly and stay on a self-care plan I’ve already started. But I’ll need your support.”

“I’m concerned for you, Carole,” Gary admitted. He was tall and jovial and had a clear older-brother vibe. “You’ve tried things before that haven’t worked, and I don’t want to see you institutionalized again.”

Carole leaned toward him and took his hand. “I have a lot of help I didn’t have before, and there’s a science to tapering that I’ll follow. Before, I did this too quickly, but now I know I need more time. Will you support me in this? Maybe you can be my walking buddy as part of my exercise plan. Can we make a date?”

Gary smiled and gave her hand a squeeze. By the end of the session, her three other family members asked if they could be part of her taper team too.

Just before she started the tapering process, Carole said, “I’m excited! I feel positive about my next steps and a little scared.”

“That’s totally normal,” I replied. “Remember, you’re in control of the process. I have no attachment to the outcome. I’ll support you in whatever you need each step of the way. It doesn’t matter how long this takes or if you change your mind at any point.” In the early days of tapering, clients may be hypervigilant for signs of returning symptoms. But it’s important to distinguish between relapse and discontinuation syndrome, which many people experience when they taper psychotropics. Symptoms of this syndrome can include lethargy, fatigue, headaches, achiness, and sweating, as well as insomnia, vivid dreams or nightmares, unusual sensory experiences, electric shock-like sensations, anxiety, irritability, agitation, aggression, and mania.

Discontinuation symptoms emerge within days to weeks of stopping the medication or lowering the dose, whereas relapse symptoms develop later and more gradually. SSRIs and SNRI medications that are processed quickly, like paroxetine and venlafaxine, cause more intense withdrawal symptoms. More slowly processed medications, such as fluoxetine and sertraline, may cause fewer problems. Strategies for mitigating withdrawal symptoms include switching to medications with a longer half-life before the taper and obtaining medications in liquid form to allow for tapering smaller amounts at a time.

With Carole, we reduced each medication milligram by milligram, every two weeks, waiting for her to stabilize at each stage. Her first challenge was sleep. As we reduced her nighttime medication, we ensured that she had nutrients, herbs, and sleep hygiene in place to stave off disruption. She didn’t experience discontinuation symptoms, but if she had, I would’ve supported her and reassured her that this was a process and the symptoms wouldn’t persist.

Carole engaged in each aspect of her program with enthusiasm and adherence. She walked around a local lake with Gary or her friends a few days a week and went to the gym. Over time, she followed my suggestion to explore yoga, Pilates, and tai chi, so that she had a robust exercise plan in place six days a week. She explored bodywork: first, foot reflexology, then, cranial sacral therapy. We worked together on her relationships and career goals. She took a wellness vacation at a spa and enjoyed attending cooking classes, where she made new friends.

Two years after our work began, she was pain free and off all her medications. She had an occasional sleepless night and was sensitive to feelings that others could trigger. But she had numerous tools now to find her center and reach out for the supports that nourished her mind and body.

Carole’s experience is a common one in my practice. Many clients who come to me have improved via therapy, yet their medication status has remained unchanged. With the advent of integrative mental health and natural medicine, therapy clients are increasingly educating themselves about alternatives and turn to integrative therapists for help.

Whether or not we specialize in psychopharmacology, we should be able to help clients explore their concerns about the medications they take. Sometimes they’ll want us to advocate alongside them and coordinate care with other health providers. As therapists, we have a pulse on their resources and supports; if they embark on the reducing or tapering path, we can walk with them as knowledgeable and compassionate guides.

Mocha Matcha Mood Smoothie

(makes 1–2 servings)

This is my favorite morning or early afternoon pick-me-up. It provides delicious anti-inflammatory brain food. The coffee and chocolate boost mood, and the coconut fat improves synaptic plasticity. Green tea is rich in theanine, a relaxing amino acid, and epicatechins, which are antioxidants. If you prefer, you can substitute organic decaffeinated coffee or just use cocoa, replacing the liquid from the coffee with extra coconut milk. When taking nutrients or liquid fish oil, open the capsule or add the teaspoon of oil.

Ingredients

4 oz. fresh brewed organic coffee, hot, or 1–2 shots of espresso

4 oz. full-fat, unsweetened coconut milk (almond or hemp milk are substitutes)

1/2 tsp. organic matcha powder (or 4 oz. strong tea from 3 matcha tea bags)

2 tbsp. unsweetened organic cocoa powder

2–5 drops liquid stevia, monk fruit, or raw honey to taste

Vanilla extract (optional)

Directions

Combine all ingredients in a blender at medium speed for a few minutes until frothy. Pour into a mug and top with a dollop of organic whipped cream or coconut cream, if desired.

PHOTO © ISTOCK / LYNDON STRATFORD