How user knowledge of psychotropic drug withdrawal resulted in the development of person-specific tapering medication

Abstract

<jats:p> Coming off psychotropic drugs can cause physical as well as mental withdrawal, resulting in failed withdrawal attempts and unnecessary long-term drug use. The first reports about withdrawal appeared in the 1950s, but although patients have been complaining about psychotropic withdrawal problems for decades, the first tentative acknowledgement by psychiatry only came in 1997 with the introduction of the ‘antidepressant-discontinuation syndrome’. It was not until 2019 that the UK Royal College of Psychiatrists, for the first time, acknowledged that withdrawal can be severe and persistent. Given the lack of a systematic professional response, over the years, patients who were experiencing withdrawal started to work out practical ways to safely come off medications themselves. This resulted in an experience-based knowledge base about withdrawal which ultimately, in The Netherlands, gave rise to the development of person-specific tapering medication (so-called tapering strips). Tapering medication enables doctors, for the first time, to flexibly prescribe and adapt the medication required for responsible and person-specific tapering, based on shared decision making and in full agreement with recommendations in existing guidelines. Looking back, it is obvious that the simple practical solution of tapering strips could have been introduced much earlier, and that the traditional academic strategy of comparisons from randomised trials is not the logical first step to help individual patients. While randomised controlled trials (RCTs) are the gold standard for evaluating interventions, they are unable to accommodate the heterogeneity of individual responses. Thus, a more individualised approach, building on RCT knowledge, is required. We propose a roadmap for a more productive way forward, in which patients and academic psychiatry work together to improve the recognition and person-specific management of psychotropic drug withdrawal. </jats:p>

The ‘patient voice’: patients who experience antidepressant withdrawal symptoms are often dismissed, or misdiagnosed with relapse, or a new medical condition

“…28,51 This suggests that the NICE guidance on how to discontinue antidepressants needs to be updated, and new guidance on Safe Prescribing and Withdrawal from prescribed drugs associated with dependence will hopefully contribute to best practice in this area. 52 Overall, there has been scant attention paid to the issue of antidepressant tapering previously in the academic literature, 48,[53][54][55][56] which has been focused primarily on starting medication. 57 The ANTLER and REDUCE trials are ongoing, but further trials will be required in order to provide detailed advice to GPs on how to taper medications.…”

Outcome of antidepressant drug discontinuation with taperingstrips after 1–5 years

“…Dose and day information printed on each pouch allow patients to precisely record and monitor the progress of their reduction. 8,10 In a previous study, we reported that 71% of patients using a taperingstrip, mainly for venlafaxine and paroxetine, were able to come off their drug in the short term, reporting the outcome after a 2-3 month course with taperingstrips, using a median of two 28-day taperingstrips. 11 Here, we report on the longer term, 1-5 year outcome of antidepressant taperingstrips in a sample of 483 users of psychotropic drugs in the Netherlands, of whom 408 used an antidepressant.…”

“…In recent years, in response to users of antidepressant medication trying to come off, the not-for-profit organisation Cinderella Therapeutics in the Netherlands oversaw the development of personal taperingstrips for hyperbolic reduction of antidepressant medication in those suffering withdrawal or deemed at risk. 8 , 10 A taperingstrip consists of antidepressant medication, packaged in a roll or strip of small daily pouches. Each pouch is numbered and has the same, or slightly lower, dose than the one before it.…”

“…Dose and day information printed on each pouch allow patients to precisely record and monitor the progress of their reduction. 8 , 10…”

“…7 It remains difficult to implement for antidepressants, however, given that virtually all medications come in dosages that do not allow for flexible and personal tapering. 8 The Horowitz-Taylor method recognises that antidepressant tapering should be ‘hyperbolic’, meaning the dose needs to be reduced by half, then by half of that, and so on. 7 Although some antidepressants can be cut or come in fluid form, these methods are cumbersome and imprecise, 9 and not developed specifically for tapering.…”