Tapered Antipsychotic Withdrawal Mitigates Risk of Psychotic Symptoms

Research suggests that slowly tapering off an antipsychotic reduces the risk of withdrawal psychosis compared to abrupt discontinuation.

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In a new article published in Schizophrenia Bulletin, Mark Horowitz and his colleagues argue that discontinuation of antipsychotics may cause dopamine hypersensitivity leading to symptoms including psychosis. The current research presents evidence that slowly tapering antipsychotic use, as opposed to abrupt cessation, could minimize the risk of experiencing psychosis due to withdrawal from these medications.

The authors also explain that while these medications can be useful and minimally harmful for short-term treatment, the risk of adverse effects from long-term use makes discontinuation an attractive option for many. They write:

“In the context of adverse effects of long-term antipsychotic medication (movement disorders, such as tardive dyskinesia (TD), metabolic effects, and effects on brain structure) and, importantly, patient preference, it may be reasonable to attempt reduction or cessation of antipsychotics in people with nonaffective psychotic illnesses who have remitted after treatment, guided by psychiatrists.”

The use of antipsychotic medications has come under increasing scrutiny as their adverse long-term effects have begun to surface in academic literature. Some authors have pointed to the poor long-term outcomes for people experiencing first-episode psychosis with greater exposure to antipsychotics. There is also research suggesting the experience of people using antipsychotics is mostly negative and that as few as 1 in 5 people may experience any benefits beyond placebo.

As the current research suggests, service user choice and shared decision making (as opposed to decisions made by authorities on the part of the service user) have become increasingly important in healthcare. While psychiatry has had some unique issues with service user agency and shared decision making, the current authors are not the first to suggest that antipsychotic use should ultimately be a choice.

Evidence has existed since at least the 1970s that drug-induced dopamine supersensitivity can cause psychosis. In line with the current research, Horowitz has found in past research that sudden discontinuation of antipsychotics could cause a relapse of psychosis not seen in low-dose patients using antipsychotics.

There is also evidence that “treatment-resistant” schizophrenia is strongly linked to dopamine hypersensitivity, and that same supersensitivity can even cause once useful drugs to lose their efficacy over time.

While the current research acknowledges the usefulness of antipsychotics in short-term treatment, the authors are warier of the long-term adverse effects outweighing the benefits. They also point to patient preference as playing an important role in the treatment and note that when psychiatrists ignore patient preference for discontinuation of antipsychotic medications, this may cause an abrupt and dangerous cessation resulting in withdrawal symptoms rather than a steady, expert-assisted tapering.

According to the authors, antipsychotics work by acting as an antagonist for many of our receptors (blocks them from being activated), perhaps dopamine most importantly. If we are exposed to dopamine antagonists over a long enough period of time, our brains react by creating more dopamine receptor sites. This state of heightened dopamine receptors is what they call dopamine hypersensitivity.

When an antipsychotic is abruptly discontinued, the heightened dopamine receptors (that had been blocked by the drug) are flooded with dopamine. A similar process happens with many neurotransmitters and their receptor sites under the influence of antipsychotics. This is correlated with many adverse withdrawal effects.

The authors divide these withdrawal symptoms into three groups: somatic symptoms, motor symptoms, and psychological symptoms. Somatic withdrawal symptoms, such as nausea, sweating, and diarrhea, usually start within a few days and last a few weeks. These symptoms are likely a result of acetylcholine antagonism and the subsequent flood during antipsychotic discontinuation. Motor withdrawal symptoms can include dyskinesia, parkinsonism, and neuroleptic malignant syndrome.

These adverse effects can last for months or years. Psychological withdrawal symptoms include psychosis, persecutory delusions, and other psychotic symptoms (often misunderstood as a return of the initial psychosis rather than a withdrawal symptom).

The authors argue that often the appearance of psychosis after discontinuing antipsychotics is a withdrawal symptom rather than a return of the initial psychosis. They present two pieces of evidence to support this argument.

First are the instances of people that have never experienced psychosis having psychotic symptoms after abrupt withdrawal from dopamine antagonists. In some cases, these symptoms persisted until the dopamine antagonists were readministered. For example, in one case where a dopamine antagonist was not reintroduced, the psychotic symptoms persisted for 10 months.

The authors also point to the timing of relapse psychosis in people diagnosed with schizophrenia. Research has found that 48% of psychotic relapse occurs within 12 months of discontinuing antipsychotics, with 40% of those occurring in the first 6 months. After the initial 12 month period, psychosis relapse was observed at only 2% per year. Additionally, evidence suggests that the longer a patient uses antipsychotics, the greater their risk of psychosis during withdrawal.

Although the current standard guidelines ignore tapering, the current research suggests that the worst of these withdrawal symptoms can be avoided by slowly discontinuing these medications rather than stopping them abruptly. This is because when a person gradually tapers down the dose of antipsychotics, the number of dopamine receptors does not change radically, and we do not experience the dopamine hypersensitivity that likely leads to psychotic withdrawal symptoms.

The authors recommend spending months or more likely years coming off of these drugs. Then, to safely discontinue their use, a person would need to reduce the dose by one quarter to one half and maintain that new dose for 3-6 months. They would then repeat the process until they take about 1/40 of the initial dose before complete discontinuation.

 

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Horowitz, M. A., Jauhar, S., Natesan, S., Murray, R. M., & Taylor, D. (2021). A method for tapering antipsychotic treatment that may minimize the risk of relapse. Schizophrenia Bulletin, 47(4), 1116–1129. (Link)

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Richard Sears
Richard Sears teaches psychology at West Georgia Technical College and is studying to receive a PhD in consciousness and society from the University of West Georgia. He has previously worked in crisis stabilization units as an intake assessor and crisis line operator. His current research interests include the delineation between institutions and the individuals that make them up, dehumanization and its relationship to exaltation, and natural substitutes for potentially harmful psychopharmacological interventions.

15 COMMENTS

  1. That’s largely how I was weaned off the antipsychotics – over 2 1/2 years, and only seeing my psychiatrist between 2-4 times a year. But this was due to scheduling difficulties, more so than insight on my psychiatrist’s part.

    I did still experience, actually two, drug withdrawal induced super sensitivity manic psychoses, but they were not bothersome to me.

    I had tons of energy, they functioned as an awakening to my dreams, and they were staggeringly serendipitous. They were kind of like good mushroom trips, that lasted three months each, albeit with a spiritual angle.

    I will say my first super sensitivity manic psychosis happened about 6 months after being weaned off lithium, but a full two years after I’d been taken off the last antipsychotic, which that psychiatrist prescribed.

    And my second super sensitivity manic psychosis happened about 2 years after being weaned from Depakote. And 2 1/2 years after being “snowed” in a hospital, then weaned off an antipsychotic.

    So I would imagine the psychiatrists and psychologists are underestimating how much after being weaned from the psych drugs, one can deal with a drug withdrawal induced super sensitivity manic psychosis.

    I absolutely agree, however, no one should ever be forced or coerced to take the antipsychotics. Especially since the antipsychotics can make a person “psychotic,” but in a really bad way, via anticholinergic toxidrome.

  2. The safest way in my experience to withdraw from Neuroleptics / Major Tranquilizers / ‘Antipsychotics’ is through a very slow drug Taper. But I found that even with a very slow taper I still suffered from nearly disabling High Anxiety – and it was my ability to find effective ways to deal with this High Anxiety that made it possible for me to come off the ‘Antipsychotics’ and to remain long term well.

    Exposure to ‘antipsychotics’ CAN CAUSE ‘schizophrenia’ in the same way that Anti Anxiety drugs can cause Anxiety. My original schizophrenic symptoms were ‘game played’ , but I still ended up in hospital the first time I attempted to withdraw abruptly (with permission) from ‘Antipsychotics’..

  3. One of the things that perplexes me is the expectation that a person can be treated with Major Tranquillisers – come off the Tranquilizers and still remain long term well – without any adjustment.

    Theres a supposed 2% per year, long term relapse rate in this Study. Bearing in mind the cost of ‘Schizophrenia’ are there NO, NON DRUG means available to protect against this relapse rate?

    The approach seems to be along the lines of a person withdrawing from the drugs and then ‘sinking or swimming’.

  4. It’s very good to have all this information from experts like Mark Horowitz Joanna Moncrieff Robin Murray David Taylor.

    But Psychiatry is not a convincing medicine if Doctors have not in 60 years catalogued how these Extremely Dangerous Drugs Function.

    https://www.irishtimes.com/life-and-style/health-family/not-guilty-by-reason-of-insanity-inside-the-central-mental-hospital-1.3544665

    Psychiatrist:- “….The most typical patient is a man suffering from schizophrenia who has stopped taking his medication and has killed a family member – often a parent…”

    Relevant Missing Information from the Psychiatrist is;- “..If a person comes off Psychiatric drugs abruptly they can go “stark raving mad” and do things that they would NEVER previously do. But if they withdraw from drugs very carefully they can often reduce, or come off drugs successfully or ‘relapse without much event’. The Danger is the Drugs NOT The Patient…”

    • You’re not alone, evergreen, but I felt that way too, when I was trying to escape ‘the system.’ I’m glad you found MiA, it didn’t exist back when I was trying to escape.

      I don’t know if this would help you find someone to help wean your son off the Olanzapine, but if you go to the ‘Drugs’ tab at the top of the page. Click on it, and you’ll see a ‘Provider Directory’ option, click that. Maybe you can find a local doctor or organization that may help you get your son weaned from the drug.

      Some of the things that seemed to help convince my psychiatrist to wean me from the drugs – I think – were that I kept very, very busy volunteering, I was ‘prolifically’ working on an art portfolio, I did a lot of journal writing, I refused to stop exercising, I refused to give up on my activities, myself, and my children.

      And as a mom, probably the best thing you can do is to encourage and show love to your son. Get him volunteering somewhere, if he’s not already, encourage him to keep a journal, and calendar notes. In my case, doing art, working in my yard, biking, rehabbing my home. Keeping very busy both helped me, and likely reminded my psychiatrist I was a productive human being, not worthy of being massively neurotoxic poisoned.

      But I will say, complaining about the psych drugs doesn’t win a lot of points with the psychiatrists. Gentle encouragement to wean one off the drugs, works better than demands.

      And I will mention, I was poly drugged, so drugged much worse than your son. Resulting in anticholinergic toxidrome poisoning, which does make one ‘hyperactive,’ as opposed to inactive. But the neuroleptics can also make a person ‘inactive,’ via neuroleptic induced deficit syndrome. And I don’t know your son’s symptoms.

      I hope my sharing my experience and research helps at least a little, reminds you that you’re not alone, and helps you and your son to maintain hope. Your son can heal. Keep the faith and God bless.

  5. On the whole, I was lucky in that I went “cold turkey” on almost every psychiatric drug and survived. In fact, I can not remember tapering. I did taper earlier, but did end up back as “psychiatric patient” taking the same drugs, etc. However, I took these drugs for almost fifteen or so years after that tapering episode. I took up to seven or eight different drugs a day until I basically shut down—I went comatose—I ended up in the hospital. I spent eleven days in the hospital; the first six or so being “comatose.” The doctors first thought I would be a “vegetable” then I got to the point they thought I would “long term care” and then just some “rehab” with a “rehab person” coming to my apartment everyday. But, then the day I got out of the hospital, I called them and cancelled their services. However, it took me two more years until I competely walked away from psychiatry, etc. And they tried this and that pill and I stayed on lithium. I moved, too. But then two years later, my body and brain finally rejected the last pills. By that time, I think I was developing lithium toxicity. The psychiatrist wanted to keep me on lithium as protection. I took the prescription, filled it, took one pill, immediately gagged and threw it up. I then threw away the bottle and have never taken any of these evil psychiatric drugs again. I have no idea if how it happened to me is really good for anyone. However, there is a warning here in that in one is not careful, the body and brain may revolt. However, I did got through an eventual testy withdrawal period. Now, I say I am in my adaptation phase and each day I learn more and more about myself. But I am very highly sensitive to certain foods, smells, textures, etc. My sleep schedule is strange as compared to other people. And, I can not take any drugs, even for pain. I was already allergic to alcohol, now I don’t even go near it not even to cook. I also allergic to odd things like glue and paint, so although I do art, it limits how I can safely express myself. But, to me, that’s quite alright. I am alive and I am in gratitude to Jesus everyday for the gift of my life. Thank you.

  6. Hi Richard,

    FACTUALLY
    A Black person in the UK is about 10 times more likely to be MISDiagnosed ‘Schizophrenic’ (than a white person), but NOT 10 times more likely to completely Recover.

    BUT
    It is possible – to LEARN to recognise the Psychological Withdrawal Effects of the ‘antipsychotics’, and to LEARN to compensate for them – and to regain WELLNESS.

    (Similar techniques CAN be applied by someone in CRISIS seeking CALM, that has never taken Major Tranquilisers aka ‘Antipsychotics’).

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