Managing side-effects and titrating patients safely off psychiatric medications

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By Carolina Brooks, BA, IFMCP

In my practice, I regularly see patients who are on psychiatric medications and would like to find alternative solutions. Some are experiencing side effects and would like to reduce these naturally rather than going on the additional medications they are being offered. Some patients would like to come off medications completely and find natural solutions instead, some are fearful they are becoming dependent on sleep medications. Some patients are looking to get pregnant and would like to come off medications completely.

Often nutritional deficiencies can cause symptoms of mental illness and I have seen something as simple as depleting B vitamins and supporting digestion relieving symptoms of depression. Mental health issues may also be a consequence of glial priming driven by a traumatic brain injury, in which case, the immune system needs to be regulated. It is also important to understand the reason the patient was put on medication in the first place.

The problem with psychiatric prescribing today is that there are no clear guidelines around how to titrate someone off medications. Little research has been undertaken by pharmaceutical companies in this area, which has led to many physicians feeling confused about how to taper someone off gently and without side-effects, particularly if polypharmacy at present.

Some guidelines even suggest that because depression is a chronic disorder, medications should be continued and the patients left on medications indefinitely, however, this may not be an appropriate outcome as there may be long-term consequences. A 2019 study in JAMA Internal Medicine concluded that use of anticholinergic, antidepressant, antipsychotic, anti-Parkinson’s, epilepsy, and bladder control medications were associated with increases risk of developing dementia.

Discontinuation syndrome has been documented in many classes of psychiatric medications particularly antidepressant and antipsychotics, yet many doctors attribute them to recurrence of the original mood disorder and suggest more medication to manage symptoms. In any case, not all patients experience somatic or psychological withdrawal symptoms or side-effects. The most common symptoms and side-effects I have seen in patients seeking withdrawal support in my clinic include brain zaps, anxiety, severe insomnia, low libido, emotional instability, stomach cramps, dizziness, fatigue, poor concentration, and tardive dyskinesia. Suicide ideation is another side-effect and withdrawal symptom, but not something I have worked with directly as I refer straight back to the primary care provider for urgent care.

A 2019 article in The Lancet recommends serotonin receptor reuptake inhibitor (SSRI) medication is tapered over months or years to doses lower than minimum therapeutic doses to minimize withdrawal symptoms, as minimal benefits have been demonstrated for short tapers of two to four weeks over abrupt discontinuation, with a tapering regime tailored to the individual. The mechanism hypothesized is that inhibition of the serotonin transporter and serotonergic transmission will drop dramatically with a reduction in dosage of the medication, and this is what can cause discontinuation effects.

Before I will agree to support withdrawal from medications, it’s crucial to ensure that underlying physiological processes are optimized to reduce risk of reaction. This includes optimizing digestive function, detoxification pathways, reducing any underlying inflammation and toxic exposures, minimizing exposure to stimulants that can dysregulate cortisol, destabilizing blood sugar balance and circadian rhythm, and optimizing stress management techniques, including regular exercise and positive social interactions. Stimulants do not just encompass sugars, processed foods, cigarettes, and caffeine, but include television, mobile phones, and computer use. It’s important to consider what might be potential triggers for emotional distress. The biggest triggers for one of my patients working in the fitness industry weaning from fluoxetine for disordered eating was scrolling through Instagram.

Many patients are not well informed about depletions caused by their medications. Magnesium is depleted by a number of antidepressants and central nervous system stimulants, and symptoms of hypomagnesia such as depression anxiety, insomnia, pain, arrythmias, and headaches are also listed as side effects for many common medications.

In a 1999 study in the European Journal of Clinical Pharmacology, it is concluded that beta-blockers inhibit production of melatonin, which contributes to insomnia.

Without key nutrients, the nervous system will not have the opportunity for repair. Key foods include leafy green vegetables, brightly pigmented foods, nuts, seeds, and oily fish for omega 3s, and borage or evening primrose oil for gamma linolenic acid (GLA) to provide the nervous system what it needs. I tend to eliminate gluten and dairy as these foods contain peptides, which may interact with opioid receptors in the brain and increase risk of mental disturbance, according to a 2016 article in Frontiers in Human Neuroscience. I often supplement with branch chain amino acids between meals and vitamin B6 to support neurotransmitter synthesis.

When tapering patients off medications, I prefer to use gentle herbal and nutraceutical interventions, including herbal anxiolytic and nervine herbs, which also help to regulate gut motility. I use these in tisanes, tincture blends, and essential oils for topical use in carrier oil.  In my experience, medications, which have a longer half-life, cause fewer withdrawal symptoms and side-effects than medications with a shorter half-life, and it’s important to consider the form of the plant as well as the plant itself when choosing herbs for titration of medications.

Gut irritants should be avoided to reduce solicitation of peripheral serotonin for use in the gut and reduce the impact of serotonergic drug withdrawal on the digestive system. Dopaminergic mechanisms also plays a role in gut motility regulation. When a patient is withdrawing from dopamine receptor agonist medications, I use velvet bean (Mucuna pruriens), a dopaminergic herb widely used in Ayurveda that naturally contains L-dopa and helps to mitigate fatigue, support healthy dopamine levels, and improve symptoms of low libido.

Other key herbs include:

• Agrimony (Agrimonia eupatoria) is a great herb for insomniacs, it helps to calm anxiety, improves blood sugar regulation, improves nutrient assimilation, and exerts anti-inflammatory effects in the gut.
• Damiana (Turnera diffusa) has mood-elevating and anxiolytic effects similar to diazepam and may be useful for low libido and digestive symptoms.
• Skullcap (Scutellaria laterifolia) is a nervine herb and is useful for insomnia, epilepsy, and muscle. It contains flavonoids (baicalein, scutellarin, and wogonin), which interact with the gamma-aminobutyric acid (GABA) receptor. I have found it useful in a tincture blend for a patient suffering tardive dyskinesia who I have tapered off clonazepam alongside GABA supplementation.
• Ginkgo (Ginkgo biloba) is another useful herb for tardive dyskinesia. A 2011 study in the Journal of Clinical Psychiatry demonstrated ginkgo’s efficacy, with no significant adverse effects, and concluded the mode of action was through ginkgo’s antioxidant activity.
• Rhodiola (Rhodiola rosea) is a useful anti-depressant, energizing, and stimulating adaptogen, which can improve focus and reduce anxiety. It is considered as effective as sertraline for mild to moderate depression, with less side effects, supports dopamine activity, and is useful for withdrawal and mitigating addiction reward behaviors.
• Rose (Rosa damascena) is one I use in essential oil, tisane, and hydrolat forms. Rose is well-known in folk medicine as an anti-depressant, anxiolytic, aphrodisiac, and anti-convulsant, euphoric plant.

Other useful herbs include gotu kola (Centalla asiatica), oat straw (Avena sativa), chamomile (Matricaria recutita), lavender (Lavandula angustifolia) , motherwort (Leonorus cardiaca), verbena (Verbena officinalis)  and tusli (Ocimum sanctum), particularly for those looking to taper off SSRIs such as citalopram and sertraline.

It’s important to check timings, pharmacokinetics, and pharmacodynamics to assess potential interactions with medications before prescribing supplements and herbs, particularly if a patient is on multiple medications due to potential impact on the liver’s various cytochrome P450 pathways. There are very few nervine herbs I would consider safe to use during pregnancy due to lack of evidence.

Some examples of potential interactions including ginkgo, theoretically potentiating antipsychotic medications, altering drug levels of benzodiazepines, reducing drug levels of hypotensive drugs, omeprazole and statins, or increasing levels of beta-blockers in the bloodstream. Rhodiola may cause overstimulating effects in large doses, and velvet bean should be avoided alongside monoamine oxidase inhibitors and antipsychotic drugs. I prefer to avoid herbs like St John’s Wort and cannabis while people are titrating off medications as these are known to cause interactions and impact metabolism of medications in the liver.

I use combinations according to patient needs and their specific health complaints and have had great results titrating people off medications safely and slowly. I have seen good results in reversing tardive dyskinesia with this approach, helped patients sleep and regain quality of life without a recurrence of their original symptoms.

References

Bressan P., Kramer P. (2016) Bread and other Edible Agents of Mental Disease. Frontiers in Human Neuroscience. 2016; 10:130. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4809873/ 

Coupland C.A.C., Hill T., Dening T., Morriss R., Moore M., Hippisley-Cox J. (2019) Anticholinergiv Drug Exposure and the Risk of Dementia. Jama Internal Medicine. 2019; 179(8): 1084-1093. Retrieved from: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2736353

Horowitz M.A., Taylor D. (2019) Tapering off SSRI treatment to mitigrate withdrawal symptoms.  The Lancet Psychiatry. Volume 6, Issue 6, p538-546.  Retrieved from: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30032-X/fulltext

Stoschitzky K., Sakontik A., Lercher P., Zweiker R., Maier R., Liebmann P., Lindner W. (1999). Influence of beta-blockers on melatonin release. European Journal of Clinical Pharmacology. 1999 Apr; 55(2):111-5. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/10335905

Zhang W.F., Tan Y.L., Zhang X.Y., Chan R.C., Wu H.R., Zhou D.F. (2011) Extract of Ginkgo biloba treatment for tardive dyskinesia in schizophrenia: a randomized, double-blid, placebo-controlled trial. Journal of Clinical Psychiatry. 2011 May; 72(5): 615-21. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/20868638