What Medicine Does Not Yet Recognize in Psychiatric Tapering

I remember he was a very tall man, yet he seemed so small to me at that moment. We were in the nurse’s office, which I couldn’t stand. I’ve never believed fluorescent lights to do anything to calm the nervous system, and it was that type of environment that often feels “too much” for anyone in his condition. The faint scent of medical equipment lingered in the air, mingling with just a hint of nervous sweat. The rolling chair with its old, squeaky wheel brought me to his eye level and allowed me to lean in closer, trying to ground us both.

His hands gripped my shoulders as if they were a lifeline, and I felt every tremor of his muscles, like electric shocks running through his arms. His mouth twisted in the early stages of dyskinesia. I could feel his desperation flow through me. His eyes, almost child-like in their vulnerability, locked onto mine as he begged me to help him. He was experiencing myoclonus (localized, seizure-like muscle jerks) along with heightened mental energy, insomnia, rumination, anxiety, panic attacks, and what we would later recognize as SNRI-induced akathisia. “Help me,” he said so simply, but I could sense how utterly lost he felt. Akathisia is rarely straightforward and almost always complicated to treat, and most people have never heard of it until they have it.

He bombarded me with questions about how he had ended up here. “Why is this happening? Does any psychiatrist know about this? I think I have akathisia, have you heard of it? Does this happen to everyone? Did I take it too long? Why did no one tell me?” A 55-year-old man whose life had suddenly become nothing but coming off his migraine medication. Divorced with three kids, he told me he wanted to get better for them. He seemed caught between gratitude for the relief the drug had once provided and horror at the consequences he had never anticipated. It’s a self-punishment cycle I’ve seen time again where on the surface it seems appropriate to blame the prescriber, but deep down the person blames themself for letting it happen.

Fifteen years earlier, it had been prescribed for migraines, and he told me it did help, especially at first. But over time, for reasons he couldn’t fully explain, he decided he no longer wanted to take it. “I wasn’t getting headaches anymore and I’d been on the drug so long, maybe I didn’t need it anymore so I just stopped…I don’t know.” This was his first experience tapering and his doctor advised him, as so many do, to cut his dose in half. He described that night as “absolute hell,” and came to see me after 10 nights of no sleep and chronic panic because I’m a naturopathic doctor, and his faith in the conventional system was understandably broken.

Every answer I offered felt inadequate, and I could see the frustration building as he tried to make sense of a body that now felt foreign to him. How do you tell a patient that physicians simply aren’t trained in safe deprescribing? It’s just not good enough.

He had been taking Effexor, a medication that, after 1995, was increasingly prescribed off-label for conditions like migraine headaches. At the time, few patients (or even prescribers) fully understood the long-term risks, including chemical dependency and withdrawal challenges. He had trusted the medication, believing it was safe, ordinary, and routine, and naturally, he carried a lot of anger.

His desperation wasn’t simply a personal failing or lapse in judgment, it reflected the problems of a larger system he had relied on. Medications originally developed for psychiatric conditions had quietly found their way into new domains, being prescribed for migraines, insomnia, PTSD, and framed as low-risk solutions. Short-term courses became indefinite without discussion, informed consent, or guidance on how to stop.

In that nurse’s office, it became clear to me that his struggle was not just the result of the medication itself, but also of the gaps and assumptions embedded in a system that had made long-term dependency almost invisible, leaving patients unprepared and largely unsupported when they finally decided to come off it.

To better appreciate my patient’s experience, it’s beneficial to discuss how psychiatric medications came to be prescribed the way they are, the gaps that keep psychiatric withdrawal patients from receiving adequate care and why they exist, and most importantly, the foundational shifts that must take place for lasting change and true healing.

One of the most concerning downstream consequences is the insidious cycle of medication withdrawal followed by reinstatement. Because psychiatric drug trials rarely study long-term use or discontinuation, withdrawal remains significantly under-recognized in the medical literature.

When an individual tapers off or discontinues psychiatric medication, they may experience symptoms that closely mimic psychiatric disorders, including rumination, insomnia, anxiety, paranoia, depression and fatigue. This overlap makes patient testimony easy to dismiss as somatization, personal pathology, catastrophizing, drug seeking or addiction which is profoundly circular logic.

Much of this stems from a binary model embedded in psychiatric training: if a person is on the medication, they are considered treated; if they are off the medications and symptoms emerge, the illness is assumed to have returned. The system is structured to recognize only two states: “medicated and well” or “unmedicated and sick.” Withdrawal doesn’t fit neatly into either category.

Most safety and efficacy trials last only weeks or months, and do not track long-term outcomes. Participants are not followed after discontinuation, and withdrawal symptoms are often mislabeled or excluded. The absence of evidence does not equate to the evidence of absence, but that’s exactly what happens.

Compounding the issue is the lack of ICD diagnostic coding for protracted withdrawal. If it’s not codeable, it’s not billable, and if it’s not billable, it’s not tracked and if it’s not tracked, it doesn’t exist. What does it mean to hold clinical authority over experiences that medicine does not yet recognize as real?

Systemically, the system rewards prescribing, not deprescribing. There is no time compensation for slow tapers, no prestige for withdrawal care, and high medico-legal risk if symptoms worsen. This path of least resistance often leads to the addition of more medications, reinstatement and reframing symptoms as illness. This is why psychiatric medication withdrawal remains an orphan phenomenon… clinically real, yet administratively invisible.

To understand why this gap exists, we must zoom out and look at how medical knowledge is formed in the first place, and how selective experiences come to be seen as credible and others not. Medicine relies deeply on evidence-based practice, but the evidence is not neutral. What gets selected, studied, published and funded shapes our beliefs. Research becomes the gate keeper of truth, promoting that a lack of research equates to a lack of validity and the presence of research equals information you can feel confident trusting. Within this structure, individual experiences become tempting to dismiss. We see this diagnostic overshadowing extensively within the community of those experiencing withdrawal symptoms or akathisia from psychiatric medication, especially if the patient is also female and/or elderly. If patient experiences are routinely discounted and long-term harms remain understudied, how do we know when our understanding is complete? If our understanding is incomplete, then the way we communicate risk is also incomplete (or the uncertainty itself is left unspoken) and informed consent becomes an ethical question.

This concern extends beyond whether risks are mentioned at all. It also includes which risks are emphasized, which are minimized and which remain absent in the conversation. A landmark 2006 study in JAMA Internal Medicine used audio recordings of actual office visits and found that physicians informed patients about adverse effects for only approximately one third of new prescriptions. If the possibility of withdrawal is rarely discussed, if the limitations of our current understanding are left in the dark, or if long term risks are minimized, what does informed consent truly mean?

What happens when medicine mistakes the limits of its knowledge for limits of reality?

We don’t actually need research to tell us that people want to be believed. And yet, across accounts of psychiatric medication withdrawal one of the most consistent themes is about not being gaslit or dismissed. Patients describe wanting their experiences taken seriously enough that the conversation about tapering more slowly becomes a shared clinical consideration rather than a point of conflict. Patients also want their symptoms contextualized. During withdrawal, the brain can feel “on fire,” and in this state interpretation matters as much as intervention. They also don’t need to be told they are “failing treatment” or being “noncompliant” when their experiences don’t match expectations. For medical evaluation to be both humane and precise, it requires less curiosity about protocol adherence and more about the individual.

I return to the patient I described in the beginning. I held his clammy hands, looked in his eyes and told him I believed him. I believed he was experiencing a very real withdrawal in response to a medication he was not given true informed consent about. I told him I would do what I could to help him and all he had to do was hang on to any courage he had, and inform me if treatments felt better or worse. My goal was to nurture the autonomy he had lost in the psychiatry system.

One of the critiques of naturopathic medicine is the lack of standard of care, but I believe it’s our strength. Because prescribing medication is easy, but stopping is another story and each person’s story is unique.

Before we continued tapering, we clarified his goals and ran labs. What helped him become free of medication and feel some inner peace was a whole-body approach. This included reducing inflammation using nutrition and supplements as well as intravenous NAD+. This approach was unique to him and would not be appropriate for every person going through Effexor withdrawal.

Maybe we are closer to a shift in the medical system than we fear. In practical terms one of the easiest and most immediate changes is a move toward slower, individualized tapering. The current guideline parrots “cut it in half,” and replacing that recommendation with an instruction to reduce by 10% is only a partial improvement. An ongoing clinical adjustment is needed based on response, context and patient input. What matters is not the speed alone, but the ability to adapt the process to the person in front of us.

Another shift is the inclusion of nervous system informed approaches alongside medication decisions. Most psychiatric medications affect the whole body (not just neurotransmitters in the brain), as evidenced by the myriad of symptoms seen during withdrawal, so we need whole body support. This may include somatic therapies, breath work and other supportive interventions that help regulate physiological arousal during periods of destabilization such as naturopathic or alternative medicine.

Care must focus more explicitly on collaboration. The current model where the doctor is the one-up and the patient is the one-down doesn’t facilitate a team approach. When the clinician shares their medical knowledge from a place of curiosity, and the patient reports their thoughts and symptoms, we can start to see a true therapeutic alliance. Together, these shifts can create a distinctly new way to support patients tapering psychiatric medications, and the medically orphaned will finally feel welcomed.