Doctors have been prescribing tranquilizers and anti-anxiety agents for centuries. Antidepressants are more recent. They weren’t discovered until the 1950s. When a doctor prescribes anxiolytics or antidepressants, does he or she envision the patient taking it forever? Many of these head drugs are hellishly difficult to discontinue. Drug companies have been reluctant to provide physicians or patients guidelines to help in tapering such psych meds. Sertraline withdrawal can be extremely challenging. So can discontinuing drugs like alprazolam, citalopram or duloxetine.
Anxiety and Depression During COVID-19:
Every generation complains about challenging times. But this pandemic certainly deserves top billing when it comes to producing anxiety and depression. We would not be surprised to learn that sales of anti-anxiety agents, antidepressants and sleeping pills are way up.
Face-to-face counseling is much harder when people worry about catching COVID-19. Virtual therapy is now a thing. This tele-mental health remote approach is catching on. But many people in crisis still need chemical assistance.
Pharmaceuticals can help. After all, they have been used for a very long time. Here is a quick history of psych drugs.
From Laudanum to Lexapro in Two Minutes:
Humans have probably experienced anxiety from early days. Predatory animals like tigers or bears, rival tribes or lack of food and shelter would be enough to make anyone nervous.
Ever since the 17th century, doctors have been prescribing medications to calm the nerves. Laudanum, also known as tincture of opium, was popular with Victorian women.
By the end of the 19th century, chloral hydrate was being prescribed for anxiety and insomnia. When this drug was added to alcohol to create a “Mickey Finn” or knockout drops, the sedative effect was powerful, quick and potentially deadly.
Barbiturates Became Extremely Popular:
By the early 20th century, barbiturates had become the tranquilizers of choice. Phenobarbital (Luminal) was one of the most popular. It was followed by secobarbital (Seconal) and pentobarbital (Nembutal). Barbiturates began to fall out of favor by the mid 20th century because they could lead to dependence and death from overdose.
Famous People Who Died of Barbiturate Overdose:
Marilyn Monroe died under mysterious circumstances. What seems clear, though, is that barbiturates were involved in a deadly overdose.
Judy Garland (aka Dorothy in “The Wizard of Oz”) died after an overdose of the sleeping pill secobarbital.
Elvis Presley had barbiturates in his body when he died, including amobarbital, pentobarbital and phenobarbital.
A New Generation of Tranquilizer Is Born:
By the mid 1950s a new tranquilizer was on the rise. Meprobamate (Equanil, Miltown) caught on with physicians and patients. At the end of the decade, this medication was one of the most popular pills in the pharmacy, making up about a third of all prescriptions dispensed. It truly was a blockbuster for the pharmaceutical industry.
Doctors prescribed meprobamate to help people relax, fall asleep and deal with a variety of mental health issues. There was a belief that the drug could help people overcome alcoholism.
The Benzo Bonanza:
When Librium (chlordiazepoxide) was first marketed by the Hoffman-La Roche company in 1960, it was wildly successful. Here was a pill that could calm the jitters, ease feelings of grief and help you get to sleep.
Not long after the success of Librium came the blockbuster Valium (diazepam). It rapidly rose to the number one most prescribed drug in America. Between 1969 and 1982, this benzo topped the doctors’ hit parade of most prescribed drugs. It’s been reported that during Valium’s peak popularity year (1978), approximately 2.3 billion pills were sold (Washington Post, Oct. 1, 2005).
Why Were Benzodiazepines SO Popular?
Benzodiazepines were referred to as anxiolytics (anti-anxiety agents) or hypnotics (sleeping pills). The very names seemed calming: Restoril seemed restful. Tranxene seemed tranquil and Halcion sounded a lot like halcyon, which is defined as a tranquil and peaceful time.
One of the reasons the benzos were so successful was the belief that they were extremely safe. Doctors were told that benzos could not be abused and would not lead to overdose deaths. In the early days there was little, if any, fear of benzodiazepine dependence.
The Rolling Stones Warned Us!
In their famous song “Mother’s Little Helper,” Keith Richards and Mick Jagger wrote about the dangers of downers (there is some question whether this song was about barbiturates, Miltown (meprobamate) or 5 mg yellow Valiums (diazepam).
Here are the famous words:
• “Mother needs something today to calm her down
• And though she’s not really ill, there’s a little yellow pill
• She goes running for the shelter of a mother’s little helper
• And it helps her on her way, gets her through her busy day…”
The song ends on a disturbing note:
• “And if you take more of those, you will get an overdose
• No more running for the shelter of a mother’s little helper
• They just helped you on your way, through your busy dying day”
Antidepressants Take Over:
The medical profession has been slow to recognize that withdrawal symptoms from head drugs are common. Patients were complaining about trouble kicking medications such as chlordiazepoxide (Librium) and diazepam (Valium) in the 1960s.
Fluoxetine (Prozac) was introduced in 1988. This antidepressant was followed by paroxetine (Paxil) and sertraline (Zoloft). Over the intervening years lots more SSRIs and SNRIs came on the market. Escitalopram (Lexapro) was approved in 2002. It would be hard to say one is much more effective or safer than another.
Head Drug Withdrawal:
As already mentioned, benzos were considered super safe. Prescribers did not readily accept the concept of withdrawal difficulties. We once received a live radio call from a listener who reported complaining about Xanax withdrawal symptoms whenever she tried to discontinue the drug.
She reported that the physician who prescribed this anti-anxiety agent attributed her symptoms to a return of the original anxiety. The doctor said she was suffering from a Xanax deficiency syndrome and would need the drug for the rest of her life. There was no thought of gradual tapering.
How Common Is Antidepressant Withdrawal?
It wasn’t until 1997 that doctors started recognizing “antidepressant-discontinuation syndrome” (Therapeutic Advances in Psychopharmacology, online, July 10, 2020). But how common is this problem?
The authors of this article write:
“How many patients who suffer from withdrawal is not clear. In 17 different studies, ranging from small, industry-funded drug trials to large independent online surveys, incidence rates were reported ranging from 5% to 97%. According to the most recent online survey among 867 people from 31 countries who had tried to come off antidepressants, 61% reported withdrawal effects, with 44% describing these as severe. These rough estimates do not tell us what the numbers are for a specific drug. A problem is that not only do we not have enough data but that the incidence, severity and duration of withdrawal and relapse are probably all contingent on how a patient tapers; abrupt withdrawal causes more problems than gradual tapering.”
Symptoms of Withdrawal:
Even after psychiatrists acknowledged that suddenly stopping drugs like alprazolam (Xanax), escitalopram (Lexapro) or citalopram (Celexa) might trigger reactions, they had no clear guidelines for helping patients get off these medicines.
Stopping suddenly can result in dizziness, insomnia or something people call “head in a blender.” Other withdrawal symptoms may include anxiety, fatigue, nausea, headache, irritability, rapid heart rate, confusion, muscle twitches and sweating.
Drug companies have not been enthusiastic about admitting their medicines can cause dependence. They also have been reluctant to come up with ways to help people step off their medications. The FDA has not required studies to determine the best discontinuation strategies.
We often see recommendations for “gradual tapering,” but that advice is too general to be helpful. How rapidly does one taper and over what time frame? Is that days, weeks or months?
Over the years, people have found their own ways to gradually phase off medications so that they minimize unpleasant withdrawal symptoms, with varied success.
Sertraline Withdrawal Problems:
Q. I am weaning myself off of the antidepressant sertraline after having taken it for ten years. This feels like hell! Constant pulses in my head are driving me crazy. I am confused and irritable, laughing one minute and crying the next.
Tonight it is so bad I have been begging God to kill me if this does not stop. I need help.
Gradual Dose Reduction Could Help:
A. Get in touch with your physician immediately to ask for help with antidepressant withdrawal. Gradual tapering of the dose over several weeks or months is critical.
Stopping a drug like sertraline (Zoloft) too quickly can cause terrible side effects such as dizziness, nausea, sweating and “brain zaps” that feel like electric shocks. Suicidal thoughts are not uncommon, but should disappear once you get through the sertraline withdrawal period.
Other Readers’ Sertraline Withdrawal Stories:
DMH described a very unpleasant experience:
“A doctor put me on Effexor several years ago. Although I took it for 4 months, I never had improvement with my depression.
“I quit taking it and the first thing that happened was I got the worst headache that I’d ever had in my life. Ibuprofen, acetaminophen, aspirin–nothing helped. I finally realized that it might be the Effexor withdrawal.
“After taking just one capsule, my headache was gone within 30 minutes. I also had the brain zaps, irritability, etc. and went to several doctors who were unable to help me.
“Basically it took me 3 months to taper myself off of the Effexor. A year later my husband saw something on television about a class action lawsuit against several pharmaceutical companies because of the withdrawal symptoms patients experienced when they stopped (cold turkey), taking the SSRI type of antidepressants.”
OHJ has also had difficulties with antidepressant withdrawal:
“I was in one of the original clinical trials for Cymbalta and continued using it after it was approved by the FDA. After a number of years, I switched to Pristiq. And somehow, I have ended up on Viibryd. All of these drugs cause severe, disabling diarrhea, which I treat with Bentyl and Imodium.
“I tried to withdraw myself from the Pristiq, with my doctor’s knowledge. It is shocking that there is no withdrawal protocol. You cannot cut up the Pristiq tablets into smaller dosages because of the way it is manufactured. You risk Serotonin Syndrome. It is a trap.
“What I discovered on my own is that you need to add an SSRI while reducing the SNRI. Then, you taper off the SSRI. I used Celexa for this process (with my doctor’s help).
Unfortunately, in my search for a brain drug that does not cause absurd diarrhea, I ended up with the last drug available, Viibryd, which is even more addicting than Cymbalta and Pristiq. Viibryd is no better than all the others and now I am addicted again.
“I am seriously considering ECT, in order to be able to quit the brain drugs. ECT, however, requires a two week stay in the hospital, causes memory loss, and has to be repeated periodically. What kind of trade-off is that?
“Anyway, if you are not currently taking Cymbalta and are considering starting it, be aware that it is highly addicting and your doctor will not know how to get you off of it in the event of undesirable side effects. There is no withdrawal protocol. ‘Tapering off’ is wildly unpleasant and takes a long time and interferes with living your life.”
This report is from a health care provider, BNJ:
“Most of my patients are able to change antidepressants without problems. A few however, have had a very difficult time.
“One patient wants to start a support group that will start by saying “my name is Bill and I’m addicted to Cymbalta.”
“Keep trying, the key for most people seems very slow decreases. It is more evidence that these meds are not as safe and innocuous as we once thought-they are changing our brains!”
One reader describes an extremely slow Cymbalta tapering tactic:
“Getting off of Cymbalta was the hardest thing I’ve ever done in my life. Many doctors, like mine, don’t realize how difficult it is or that you have to taper.
“I found help online — my withdrawals were so difficult, I’m not sure I would have survived if I had not found online resources and other people’s stories of their difficulties and the techniques they used.
“What I did, safely and carefully, was actually open the capsules and count the beads in order to taper down. (Cold turkey is horrible, and I simply could not do it!) Counting the beads was detailed in many places online.
“I went down VERY slowly and this greatly minimized the horrors of cold turkey. It took three solid months for me to get off of it completely. Even then, my brain didn’t ‘heal’ completely for nine months. I had bad memory problems, extreme difficulty with logical thinking, exhaustion, physical aches, and more. Eventually I did get better, but it was a long, painful journey. Given how hard this is, it is unbelievable that the manufacturer does not offer a tapering dose-pack.”
Neither the FDA nor the pharmaceutical manufacturers have provided clear guidance about how to discontinue such medications. In our opinion, this is a travesty.
So is the widespread use of the term “discontinuation syndrome.” We agree with the Italian investigators reporting that SSRI antidepressants can cause withdrawal symptoms when they are stopped (Fava et al, Psychotherapy and Psychosomatics, Feb. 2015). This condition should be called “withdrawal syndrome” since that is what it is.
A New Approach from the Netherlands:
In Europe, at least in the Netherlands, a compounding pharmacy apparently makes such medications available in packaging (tapering strips) that offer pills of gradually decreasing dose in pouches organized by month. Patients can record and monitor the progress of their dose reduction, which must be supervised by their physician. If US doctors would prescribe pills through a service like this, it could help a lot of people who otherwise end up suffering horrific withdrawal or counting beads for hours.
To read about other people’s experience with stopping antidepressants and their coping strategies, click here. You may also be interested in our Guide to Dealing with Depression, in which we discuss how to stop such medications.
Please share your own experience with anti-anxiety agents or antidepressants in the comment section below. You can read more about the patient-developed “medication-withdrawal tapering strips” developed in the Netherlands at this link.