Author: RxISK Medical Team
20 February 2015
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It is not uncommon for people dependent on and having withdrawal problems from antidepressants, mood stabilizers or other drugs to be referred to, seek out, or encounter therapists who will often have the skills to be helpful. However equally, if these therapists take the wrong approach, in practice they may compound rather than relieve the problems.
Therapists here means anyone from formally accredited psychologists to counsellors to complementary therapists or others with lived experience. Therapies means all supports or therapies that do not in some way use prescription-only drugs to attempt to ameliorate some of the features of withdrawal.
Some of the difficulties stem from therapists thinking they understand what’s going on — that withdrawal is somehow just linked to too much adrenaline, or what the person now has is a reappearance of some failure to resolve the difficulties that were present when the person was originally put on antidepressants or mood stabilizers.
But therapists can’t understand dependence because no one at present understands what gives rise to dependence on and withdrawal from antidepressants, mood stabilizers or antipsychotics, and in particular to the enduring symptoms after stopping that can be so distressing or the instabilities that people can run into on trying to stop that are not mentioned anywhere in any books.
However, perhaps because the terms withdrawal and addiction strongly suggest something “mental” and of course the person coming for help wouldn’t be coming for help if he or she didn’t have something “mental” wrong with them in the first instance, all sorts of therapists feel happy to wade in, not realizing it seems that to do so can seriously undermine the person they are seeing.
The word serotonin may similarly suggest mental treatment to some. There is however vastly more serotonin in the gut and blood stream than in the brain and SSRI withdrawal might have more to do with calcium channels than with serotonin for all we know.
Dependence on and withdrawal from antidepressants maps on to comparable problems with anticonvulsant mood stabilizers and antipsychotics — drugs that have little to do with serotonin.
The experience of difficult tapers on treatment and enduring withdrawal problems is debilitating and can make someone appear “neurotic.” This “neuroticism” is then used often used by doctors to justify continuing with medication and so for this reason it is critically important to attempt to distinguish any neuroticism in response to dependence from difficulties that might have been present in the first instance.
Rather than being “mental,” antidepressant withdrawal is a physical state more like antipsychotic induced post-withdrawal dyskinesia or tardive dyskinesia than like withdrawal syndromes that hinge around cravings for the missing drug. Few if any people crave SSRIs, mood stabilizers or antipsychotics.
These are drugs that can cause significant withdrawal problems even in normal volunteers exposed to drugs for a matter of weeks. In normal volunteers exposed for a few weeks, the after effects can include anxiety, fatigue, malaise, depression and suicide. The drugs cause physiological problems.
The challenge is to help the person live with these problems and not be defined by them, and to keep their family engaged in supporting them.
There is no simple behavioural approach towards withdrawal that will necessarily ensure the withdrawal succeeds. While many regard slow tapering with reductions in medication levels of 10% at each step as the method of choice, and while often successful, even close adherence to such protocols does not guarantee success. Many are left with enduring problems that can last for years. Others run into strange states of instability that have not been described in any textbook.
Having made these points, a good therapist can help and can possibly find the challenges encountered by helping alleviate withdrawal among the most interesting they have. The problem is how to identify those components that can be helped and how to support the problem solving efforts of the patient.
For instance, many patients withdrawing from serotonin reuptake inhibitors develop a food intolerance. There is likely some physiological basis for this but in many cases an understandable phobic element can develop also. There is a real need to attempt to distinguish between the physiological problem and any phobic avoidance and in helping the person nudge forward from whatever position they are in.
Nudging people forward rather than treating a clear disease entity involves helping both extraverts and introverts and this may mean being prepared to use NLP for the former and Cognitive approaches for the latter.
The most important aspects of therapy may be the nonspecific or common factors of therapy that involve validation of the patient’s suffering, confidentiality, support, alliance building, use of collaborative problem solving strategies, exposure to anxiety evoking stimuli, patience, and a willingness to tolerate the patient’s suffering as they go through the withdrawal experience no matter how long it takes or at least as long as the patient is willing to tolerate their own suffering.
Another area of great importance is enhancing a person’s self-management skills. We live in a culture where it would be thought inconceivable that someone with serious epilepsy could manage their condition without medication but in fact they can do so very successfully in many cases by looking after dietary issues, sleep hygiene, taking particular call when burdened by work demands, infections or other physical stresses.
Recognizing the physicality of the problem should not lead a good therapist to abandon their patient as it sometimes does.
Equally important is being able to recognize the right time to attempt certain things – getting the motivation right.
Doctors often panic when the patient exhibits any suffering and increase or add other drugs too rapidly, or switch drugs too rapidly. The NIMH collaborative depression study found therapists who were more patient and expected recovery to take more work and time had better outcomes.
Aside from specific symptomatic interventions, there is a more general need to keep up morale, and a need to view health broadly with an emphasis on keeping the person physically and socially active.
Questions before engaging a therapist
- Do you accept the points made above?
- Do you accept that you may not know any better than me about prescription drug dependence and that progress will need collaboration rather than dictatorship?
- Are you happy for me to consult with others about treatments you might propose?