Medication Withdrawal Effects

I've been searching the web lately trying to better understand potential adverse health effects from psychiatric drug withdrawal.   Why can one person get off a psych med without hardly an ill effect while another will suffer for months during the process?  Hmmm, this looks interesting.

Each person's brain/body responds differently to drug withdrawal, just as each brain/body reacts differently to a new drug.  In the latter the process can produce adverse reactions we call side effects.  For drug withdrawal, troublesome symptoms are usually called withdrawal effects.  A more fancy term being used is discontinuation syndrome.

Withdrawal Effects.  Withdrawal from psychotropic medications can include flu-like symptoms such as fatigue, lethargy, aches, insomnia, diarrhea, nausea, and dizziness.  Some people become hospitalized because of the withdrawal process.  The experience can be horrible and last months or even years according to those who've been through a bad withdrawal.

In an online web forum one practicing M.D. was quite critical of the withdrawal effects from psych meds.  He lamented that there are some patients who's experiences are so bad that they end up deciding to stay on the drug, even when they have determined it has no therapeutic value for them.  They were stuck on a drug that wasn't working because withdrawal was too excruciating.  What's worse, some unfortunate souls in this situation continue to experience withdrawal effects even after getting back on the drug!

From an article on antidepressant withdrawal, the writer says withdrawal effects are more likely to occur (a) if you have been on the medication for six weeks or longer and (b) if you are within the first two weeks of the tapering off process.

Drug withdrawal symptoms are reported across the psychiatric spectrum.  An article in the journal Medical Hypothesis reports withdrawal effects in antidepressants, antipsychotics, lithium, and benzodiazepines such as Xanax.

I was quite concerned about withdrawal effects from the antipsychotic Abilify (aripiprazole) during my recent tapering off from it (see my last post on 12/12/11 about this).  I didn't do much research before stopping.  I just hoped for the best.  Fortunately things worked out well for me.

Some personal websites were particularly grave about the withdrawal effect.  I bet these folks are the unfortunate ones who have debilitating symtoms that can last for many years.

We certainly need more research in this area.  Without more information it is difficult to compare the risks and benefits of stopping.  Perhaps there are other medications or practices we can do to minimize the withdrawal effect?

One big step in the right direction comes from a new company adverseevents.com.  They are making it possible to readily find information about the toxic effects of medications including psych drugs.  Their process uses a propriety algorithm to extract data from the FDA's Adverse Events Reporting System (AERS) and assemble the information into a useable and understandable format for patients and healthcare professionals.

Paxil. One drug that kept coming up was the SSRI antidepressant Paxil (paroxetine).  According to a the Mayo Clinics Medical Edge Newspaper Column, Paxil is in a group of SSRIs that are the most difficult to quit.  This is because certain SSRIs are metabolized (removed from the body) more rapidly than other SSRIs.

In one blog post the author explains her experience with Paxil withdrawal effects.  Her reaction was so severe that they had to allow seven months for her to taper off.   Withdrawal effects included headaches, lethargy, depression, dizziness, the "zaps" (whatever those are) and nausea.  At the same time she says a close friend withdrew from Paxil with only headaches.

Adverseeffects.com reports withdrawal effect information about Paxil.  Data they have from consumers between 1/1/2004 to 6/30/2011 that shows withdrawal from Paxil has a hospitalization rate between 5 and 7 percent!  Wow, who knew?

I don't remember any withdrawal effects when I got off Paxil about 10 years ago.  Maybe I was too depressed to notice.  I remember I didn't respond well to the drug therapeutically.

Takeaway message.  The symptoms from tapering off vary a lot from person to person and drug to drug.  Trying to determine who will experience withdrawal effects and how severe those effects will be is really anybody's guess at this point.

We need to explore whether the long-term recommendation for bipolar disorder treatment should be indefinite use of psych meds?  Should medication for life really be the presumptive remedy?

Finally, when stopping a medication it is critical to work with your psychiatrist so that the tapering off period is as gradual as necessary to control the withdrawal effects.  You need to start low and go slow.

UPDATE: Meds Change Successful!!

This post is an update to my  ALERT: Meds Change post from the 11/16/11.  At that time I had just seen my psychiatrist the Friday before on 11/11/11.  I could of made it an 11 a.m. appointment and arrived 11 minutes late, but that would be silly.

My appointment was from 2 to 2:20 p.m.  I hate those 20 minute "medication management" type visits.  I feel I don't have enough time to process all the information and make good decisions on how to move my treatment program forward.

30 mg Abilify Tablets

Anyway, I have been working with my pdoc since 11/11/11 to reduce and eliminate Abilify (Aripiprazole) from my medication regime.  The good news is that I was successful, yay.  I'm now Abilify free!

The dose reduction went like this:

1. On 11/11 reduced Aripiprazole from 30 mg to 15 mg each evening.  Just break that tablet in half and swallow.  
2. On 11/23 reduced from 15 mg to 7.5 mg each evening.  You should of seen those pills as I broke them into four pieces using my fingernails.  I don't think they were meant to be broken up like that.  They wanted to stay whole and complete.  But the good doctor said do it so I did. 
3. On 12/7 I stopped taking Abilify completely.

I've been off the drug now for five days and things are going okay.  I still have my moderate depression which can range from mild to severe depending on the brain biochemistry flavor of the day.  I notice that I'm less tired in the morning and find it easier to get out of the darn bed each day.  This is an important daily ritual for me.  If I'm not out of bed by 9 a.m. then it's likely the whole day will be shot.

Most importantly I experienced no withdrawal symptoms.  I am very pleased with my divorce to Abilify.  It's going to save several hundred dollars over the year and I don't have to put up with its whiny, sleepy side effects.

Dopamine Receptors Impacted by Abilify

Now I'm stable with moderate depression taking my three psychotropic meds, including Xanax as needed, up to 2 mg per day.  I'm taking 60 mg Cymbalta, 450 mg Wellbutrin, and 300 mg Lamictal daily.  Each day I also take 300 mg of Omega-3, a multivitamin, and 325 mg of aspirin.

I've been taking the aspirin for the last couple weeks after reading an article by James M. Greenbelt on how inflamation in the brain can make you insane in the membrane.  He says, "It appears that inflammation and the complicated collection of immune system chemical messengers called cytokines play and important role in brain function and may cause psychological symptoms."

Not really a raving review for addressing brain inflammation but the article makes sense.

Another study was more promising, especially for people like me that have treatment resistant depression.  He states, "A study involving depressed patients classified as non-responders supplemented each patients standard antidepressant treatment with the addition of aspirin, an anti-inflammatory.  More than 50% of these patients responded to this combination treatment.  At the end of the study more than 80% of the group responsive to the anti-inflammatory went into remission."

Now that's what I'm talking about.  Remission.  Wouldn't that be awesome.  It's too bad there's not a similar study/trial evaluating aspirin as an add-on med for bipolar depression.

I think I'll keep taking the aspirin each day and see if it makes my brain feels less inflammatory, whatever that feels like.

N-acytelcholine (NAC) molecule

I'm not sure what to do next.  I can try and reduce or eliminate another pharmaceuticals.  I'd go after Cymbalta next.  I know I'd be a fool to get off the Lamictal and I respond well to Wellbutrin.  I can not attest to the effectiveness of the Omega-3 and multivitamin.  I think they make such a small difference in my mood that I can't tell if they are doing anything.

I also want to try the supplement NAC (N-acytelcholine).  I wrote about it here.  I am okay with the unidentified but likely low risks it poses.  Yes, that's it.  I'm going to stay with my current meds mix until my next pdoc appointment in January.  We'll discuss taking NAC at that time.  I think she'll go for it.

In the meantime I will enjoy my new found alertness and wakefulness.  I hope it lasts for awhile.

Bye bye Abilify.  That's one less box car of meds riding on this precarious, crazy train called me.

kNACk for Bipolar Depression

I enjoyed reading Natasha Tracy's blog post on the use of NAC (N-acetylcysteine) as a low cost add-on for treating bipolar depression.  The post got me thinking.  I decided to take a closer look and see if I should use NAC in my own treatment program.

The fundamental problem is there are few choices of medication for effectively managing bipolar depression.  One article states, "Given the failure of almost all modern trials of antidepressants in bipolar disorder to demonstrate efficacy, and the limited efficacy of mood stabilisers in the depressive phase of the disorder, this is a major unmet need."  I never knew we were so hosed.

State-of-the-science

A 2010 comprehensive review of clinical trials and other data was performed to assess NAC effectiveness.  The review's tepid conclusion: "bipolar disorder treatment outcomes may potentially be improved by additional use of [NAC] with conventional [psych meds]."  They also urged caution when interpreting the large effects of several isolated studies, as they have not yet been replicated in larger trials. Okay, so now what.

One article studied NAC efficacy as an add-on for maintenance medication.  The authors studied bipolar individuals with moderate depression.  Results showed a "robust [drop] in depression scores with NAC treatment."  That sounds better.

In another study, NAC was given to 75 depressed bipolar patients at 1 gm twice a day in combination along with their usual bipolar medications.  The results showed a significant improvement in mood, global functioning (whatever that is), and social/occupational functioning.

How it works

NAC is a precursor of glutathione and works to replenish depleted sources of glutathione in the brain.  Low glutathione levels in specific brain areas are linked to mood disorders, particularly schizophrenia and bipolar disorder.

Anything else?

Finally, in regards to risk one journal article concludes:  "While dosages, pharmacological strategies (monotherapy versus augmentation), and long-term risks are not fully evident, NAC appears to be a promising, relatively low-risk intervention."  I can live with that.

Conclusion: Go for it!

The supplement appears safe at the oral doses given in the studies.  And according to Ms. Tracy's blog post NAC is inexpensive at $25 per month and readily available over-the-counter!

Now, how should I go about doing this?  First, I will get buy-in from my mental health team - which consists of my parents, psychiatrist, and a few close friends.

This should be straightforward forward, I hope.

And I need to decide if I'm going to stay at 15 mg/day Abilify (recently reduced from 30 mg/day) or try and get off it completely.  I'm leaning towards just getting off the stuff.  I haven't noticed anything negative since the reduction a couple of weeks ago.

What about the dose?  Well, one study administered a dose of 1 mg of NAC twice per day on moderately depressed bipolar individuals.  I would say I'm mostly moderately depressed so I'll just use that dosage.

So, I'll check-in with my mental health team, dump the Abilify, and start taking NAC. Stay tuned!

Anybody else take supplements for bipolar depression?

DISCLAIMER: I am not a trained mental health professional.  This post is my opinion only.  Do not change or adjust your medications without first consulting your psychiatrist or other mental health professional.

ALERT - Meds Change

I'm making my first medication adjustment for my bipolar in over a year.  I'm reducing the Abilify I take by 50 percent from 30 mg/day to 15 mg/day in the evening.  We'll see soon how this works out, stay tuned.

Abilify was prescribed for my depression - specifically, it is being used as an add-on treatment for treatment resistant depression when an antidepressant alone is inadequate.  The exact way Abilify (or any other psychiatric medication for that matter) works is unknown. It is thought that it may work by affecting the activity of some key brain neurotransmitters — adjusting dopamine, instead of completely blocking it, and adjusting serotonin.  Okay, whatever.

I reported to my psychiatrist last Friday that some depression symptoms were not acceptable.  I was having too much difficulty getting out of bed and starting my day.  She said Abilify can sometimes make people groggy and get the "stuckness" feeling.

So, we decided reducing the Abilify was worth trying.  I was skeptical at first since Abilify was the last drug I added to my medication regime back in October 2010.  It was added at that time to curb an oncoming depression episode.  I do remember it helping some at the time.

With the current adjustment my new medication cocktail is: Morning - 450 mg Wellbutrin, 60 mg Cymbalta; Evening - 15 mg Abilify, 300 mg Lamictal, and 60 mg Cymbalta.  I also take a multivitamin and 300 mg of omega 3 from a fish oil capsule.  I'm glad the fish oil is in a capsule because it tastes pretty nasty.  Is this stuff the extract of fish guts or what?

Here's a mosaic of my current medication cocktail. ==>  ==>  That's all for now.  Join me next time for a look at bipolar disorder and stress!