Depression

I recently had the absolute pleasure of interviewing Dr. Kelly Brogan, holistic women’s health psychiatrist and author of the new bestseller, A Mind of Your Own. I’ve had the section on medication tapering and withdrawal effects transcribed because it’s so valuable.

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Kelly: Now much of my practice is devoted to psychiatric medications tapers. Guess what? I didn’t learn that in my training. There wasn’t a single hour of education on this subject. I have learned how to do this from patients, and really from patients globally who are educating each other and frankly educating physicians about how to engage in a safe and responsible psychiatric medication tapers……

…when you try to taper off a medication after long-term exposure, either because you’re no longer deriving that initial benefit from it, or because something has changes about your life circumstance and you want to try a different kind of healthcare maybe, they you might learn that these are some of the most habit forming medications, I would say habit forming substances, on the planet.

I wouldn’t believe this if I haven’t seen it with my very own eyes, but this is what actually compelled me to put down my prescription pad for good. After I read that book, I began to take patients, or at least offer them the opportunity to taper them off of medication. Even when we did it responsibly, I was essentially running an outpatient rehab. I mean from neurologic symptoms to psychiatric symptoms, physical symptoms, autoimmune diseases flaring, patients developing impulsive behavior and even violence. It was beyond description.

Then I began to see that actually a lot of patients around the world are talking about this. They’re talking about withdrawal from anti-depressant specifically, but of course other medications as well. Their doctors are totally ill-equipped to help them because we don’t learn about how to do this in our training. We actually in fact dismiss patients when they talk about these being addictive medications. Of course, now finally Fava is a group of researchers who have finally begun to publish the reality of this withdrawal syndrome, and how disabling it can be.

Since I have 4 grounded lifestyle interventions, and actually begun with nutrition such that I don’t even begin a medication taper until about 2 months into lifestyle change, everything is different now in my practice. I feel that once you can optimize your physiology, you really put yourself in a much, much better position to safely and strategically taper. Wow. Isn’t that something you would want to know before taking your first prescription? I certainly never told any patients that it could be like a horror show and you might never be able come off of a psychiatric medication if you’re taking it for longer than a year or so. I never informed patients of that.

A lot of what I discuss and describe in this book is in service of presenting people with a full picture of what the science has to say before they make a decision. I think we really wish that there was a magic pill. We really wish there was a safe effective quick fix. Unfortunately, what is available is really anything but that.

Trudy: Yeah. We want that quick fix. I’ve got a few follow on questions, because this is a lot of good information here. The fact that you see all these problems when people are coming off the meds, is there a time frame, or is that really dependent on each person?

Kelly: It’s very, very dependent on each person. That ends up being the take home that we are talking about. What I like to call end of one medicine. We’re talking about the fact that our levels of biochemical individuality have ever been more relevant than when we’re exploring how we interact with chemicals in our environment, in our pharmaceuticals. We really need to understand that every single person is an individual.

When I taper patients off of meds, I normally do what’s called a test dose decrease, which often is around 20% to 25% of the dose. We come down by that. Again, this is after we’ve done the initial months at least of fairly strict dietary compliance working with relaxation response, doing 20 minutes or more of movement, working on sleep. All of this has to happen first. Then we begin, and so we start with a test dose. If we see in about 2 to 4 weeks that test dose is completely well-tolerated, meaning you don’t even notice the difference, then we probably can work in bigger increments. That’s actually a godsend. These tapers, when we’re working in 10% and less doses, could take literally years.

You want to begin to learn about what your body is capable of bouncing back from. We begin with 25%. If that’s not a pretty picture, then we’ll just scale it back to about 10% of the initial dose, and work with that 10% increment at about every 2 to 4 weeks, sometimes unfortunately slower. The increment and then the speed are 2 variables that we have to learn for each patient.

I don’t know what I would do without a compounding pharmacy. While many of these medications are available in liquid form, and some of them, like Effexor for example, have beads inside a capsule, to be able to tailor and personalize the dosage to each individual patient is wonderful and that I have that option through compounding pharmacy. I work with one in Massachusetts named Johnson Compounding, and they’ve just been a wonderful support over the years to my patients.

Trudy: Wonderful. Very slow and then obviously very individualized. Now I’m very familiar with the effects of benzodiazepines and the slow taper process that’s needed for someone on the anti-anxiety benzodiazepine medication. Would you say that SSRIs can have comparable effects in some people, or are they not as bad as the benzodiazepines?

Kelly: That’s a great question. What we’ve observed in psychiatry is that there’s really been a transition from using benzodiazepine as sort of like a spot treatment to transitioning into using anti-depressants long-term. When I was in my training, the typical gold standard protocol would be to start somebody on both benzodiazepine and anti-depressant, and then taper them off to benzodiazepine and leave on the anti-depressant with the thinking being that benzodiazepine are acknowledged for their habit forming properties and anti-depressants are totally safe.

What we are learning is in fact, that group that Fava runs, with the papers that they’re putting out, they are essentially equating the anti-depressant withdrawal phenomenon to benzodiazepines. In my clinical experience, I would actually argue that SSRIs are worse with long-term exposure. A lot of people at this point, given that it’s been decades since Prozac, have been on these medications for more than 10 years. We’re really talking about a level of habituation that could be challenging to undo. It’s not that I haven’t. I struggled a lot with Klonopin for example. It’s not that I haven’t encountered challenges with benzodiazepines.

A patient in my practice I’m taking off of Lexapro a thousandth of a milligram a month. I’ve never heard of something like that. Heroin, crack, cocaine, oxycontin: show me something that would ever require that. It’s unbelievable. I think it’s at least comparable I would say, and that’s what the literature is beginning to demonstrate, is that there are actually comparable phenomenon, but we really never ever talked about anti-depressants in this way, so it really is a game changing perspective.

Trudy: The fact that you say people are not told that this could be a possibility, and the fact that you’re talking about this and writing about it I think is so important, because people need to know. They would choose not to do this if they did know. I see there is this MA bill going through [correction: being proposed – you can read more here]. It’s about benzodiazepines and people needing to consent to the fact that it’s going to possibly cause them issues. It sounds like we need to do the same with these anti-depressants.

Kelly: Absolutely, 100%.

Trudy: Now, I’ve heard that certain SSRIs are worse than others. I’ve heard that Paxil can be really bad. Have you seen a difference between different medications?

Kelly: Basically we look at half-life of these medications, and we extrapolate from there. Assuming that Prozac would be the easiest, and there are medications like Paxil and Effexor that are more challenging. In my experience, there are 2 ways of discontinuation – the field likes to call it discontinuations issues. The first is acute. It’s within 72 hours of a dose change where you can get brain zaps and headache, and gastrointestinal distress, you feel agitated. The Paxils of the world are much more likely to cause those more immediate withdrawal symptoms.

What I have found is unfortunately there’s no free lunch. There isn’t a medication that actually is effortless to come off for everyone, so that even when you’re on Prozac, for example, for a long period of time, even though it has this long half-life, it should be easy to come off of, in my experience, it can often be challenging as well. These other medications often manifest as second waves. What I have found is almost uncanny – after about 2 months, it’s almost always 6 to 8 weeks after the final dose or after a major dose change. It’s like the other shoe can drop.

You have those immediate withdrawal symptoms, and then about 2 months later, you can begin to have what has historically been categorized as a relapse. This is when your doctor will tell you, “You see, you should have never even tried to go off your medication. You need it for life. Now you know.” That’s what we’re taught to say. In fact, it’s actually a protracted withdrawal phenomenon. Again, this has now been documented that this can occur for unfortunately, I don’t want to scare anyone, it can occur for months and months and even years after the final dose. That being said, there is a medication that spares you from that arm of this problem.

Even I went for years tapering patients off of Wellbutrin and thinking, “Well, this is the easy one. I can even come down by 50% of the dose, and it’s not a problem.” Right now, I have in my practice, a patient who has been completely destabilized coming down by 25 milligrams of Wellbutrin. Again, it’s a very individualized process, and I don’t think that there are any obvious choices in terms of medications that are easier come off of after long-term exposure.

Trudy: Thank you for sharing that. It’s scary, but the good thing is that there are solutions. People on these medications must do the slow taper and make all the changes that you’ve talked about. I’m glad that you mentioned, “Don’t rush into this, make all the food changes.” We’re going to talk about some of the things that you recommend in a second, but get yourself in a better place to start making these changes. If you’re listening to this and you’re thinking, “Oh my gosh. This is terrible.” Don’t go and rush out and just stop. You simply don’t want to stop cold turkey. You want to be working with someone. Then obviously read the book and get resources so you can be in a good place when you’re starting to make these changes.

Kelly: Absolutely. That’s all incredibly important. Yes. Please don’t ever consider just stopping your medication.

Trudy: Absolutely. I have one final question on the medication aspect. You’ve got a small section in the book where you talk about using amino acids are helping people taper, and as you know, my community is very into using the amino acids. I find them very helpful for helping people with mood and anxiety issues. Can you talk a little bit about how you use the aminos and how beneficial you find them when someone is doing this taper?

Kelly: Yes. Absolutely. I am quite certain that there are many, many, many roads to physiologic and psycho spiritual resiliency. I, in no way, intend to position myself as having the answer by any means. I am very much trying to create a space for all of those who are passionate about natural healing, including yourself and our colleagues, because I think that just about everything in the natural health arena offers you the potential for very high yield, very low-risk healthcare.

I certainly don’t consider myself an expert in amino acids and don’t have a fraction of the knowledge that you have about this arena. That being said, I do use them for tapers specifically. If I use supplements I wait after a month of dietary change before introducing any supplements, mostly because I want to, I don’t know, send patients the message of what a single intervention, in terms of lifestyle, what a dietary intervention can do in terms of moving the needle of their health. I often don’t want to cloud the picture with other interventions like even supplements or even detox.

After that period, if it is necessary, I’ll often lead with some of the supplements that I talk about, whether it’s probiotic or glandulars, I use a lot based on my work with the only mentor I’ve ever had, Dr. Nicholas Gonzales. I learned a lot about using glandulars, using specific minerals, using fatty acids, that sort of thing. Well, we’re working with SSRIs. I tend to use tryptophan more often than 5-HTP. I do use tryptophan even in the 3 to 6 gram range before dinner and before bed. I would say that it’s helpful often, not in every case, with a lot of the insomnia specifically. It’s about the worst thing that can happen in the setting of a taper. It’s the kind of insomnia that’s induced by psychiatric medication taper.

I have several tricks up my sleeve, and that’s certainly one of them. Through my own self-education, and again, you may have a more sophisticated perspective on this that when you use 5-HTP or tryptophan for the longest period of time, meaning over a couple of weeks, so you want to balance it out with tyrosine or DL-phenylalanine. If we are using it for a period of time, I might incorporate that. I have found that when I work with Wellbutrin tapers, it’s extremely helpful. Tyrosine and actually an herb called mucuna support dopamine.

Then all of my patients who are tapering – I have them on a blend of amino acids.

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We cover much more than the medication taper and withdrawal and you can listen to the entire interview here:

 

A Mind of Your Own: The Truth about Depression and How Women Can Heal Their Bodies to Reclaim Their Lives is superb, brave, bold, science-based (which I love!) and offers holistic solutions for depression (and anxiety). Get the book from Amazon or better yet, get a copy from your local book store (ask them to get it if they don’t carry it)!

It launched March 16th and there is a grass-roots effort to share this book widely because of the mainstream media blackout.  Join the grassroots effort and help share this valuable message!

Take a picture with the book and post on social media with #amindofyourown and you can have an impact. You’ll also automatically show up in “hall of fame” on the tagboard.

You can go and get the first chapter of the book if you’re on the fence (get it here: http://kellybroganmd.com/amindofyourown/?ref=35). After reading the first chapter, I know you’ll want to get the book and join the grass roots effort.

If you already have the book lets us know in the comments what you think.

Feel free to post questions on the blog and please do share your SSRI or benzodiazepine taper and withdrawal story so we can all be better informed.

PS. Both Kelly Brogan and myself will be presenting at the Mindd Conference in Sydney in May. We’ll also be presenting at IMMH/Integrative Medicine for Mental Health Conference in September in Washington DC. Come along to those events, and you can hear Kelly Brogan speak live, and you can hear me speak live as well.