When trying to get off drugs leads to more drugs

When people are trying to get off neuroleptic (antipsychotic) medications, they often run into a problem like the following. The medication is reduced, then some kind of scary problem emerges, and then the person finds they must go to an even higher dose of medication than they were previously on in order to bring the problem under control. The possibility of such scenarios is a reason given by many prescribers for never attempting a reduction in the first place.

(Note that scenarios like the above can occur even when people work with their prescriber to reduce doses very slowly, say 10% at a time, and waiting to get back to equilibrium before reducing again: they are even more likely if reductions are made quickly.)

I don’t believe, however, that the risk of this occurring, or even the fact that it has happened to a person in the past, should be interpreted to mean that no one should try to reduce or get off medications. Instead, I think there are ways to prepare to face the difficulties that might emerge when reducing medications, and such preparations can increase the chances that a reduction can work. Each person is unique, and decisions should be made base on that unique situation, but here are some ideas about things that might help. I’d also be interested in hearing about what ideas others may have.

One thing that can be helpful is doing a review, written if possible, of past episodes of problems or “relapses,” and then mapping out step by step how the problems started and got worse, and what, other than more drugs, was first tried to cope with them. Then the person can systematically plan out and imagine how to handle things more effectively next time.

In CBT it’s called “imaginal exposure” when people imagine being in a troubling situation and then imagine themselves either handling it or just tolerating it. That’s also the core of the method that has been found effective for nightmares. Since psychosis is often kind of like a nightmare while awake, it makes sense that a similar method can be helpful.

The nightmare method is about remembering the nightmare while awake, then imagining what resources one would have to have to make the outcome become positive, then re-imagining the nightmare with a positive outcome, and perhaps rehearsing that re-imagining repeatedly until it “sinks in.” Eventually the new way of facing the dream “demon” or whatever it was is available to the mind even when the person is not awake.

One reason why people with nightmares don’t think of practicing with how they might handle scary nightmarish imagery is simply that they are afraid of the imagery, and so they try to cope by avoiding it. The problem with that is that they then don’t get any practice, and when the scary imagery emerges anyway when their defenses are down, it seems really catastrophic. If on the other hand a person consciously chooses to evoke the nightmare imagery (while awake and ready to handle it) then defenses can be developed and the imagery looses its ability to overwhelm. A person trying to withdraw from neuroleptics who is hoping to just “not have” the psychotic types of experience may similarly avoid even reminders of them, till, with the medication reduction, defenses are down and the psychotic types of experience do emerge and become overwhelming. It’s better to seek out reminders of psychotic states and deliberately remember or evoke psychotic thoughts and imagery while in a calm and secure state, before trying the medication reduction, so one can get practice in facing psychotic types of experience and imagining how to overcome them without drugs.

Another angle that might be helpful is learning how to modulate various mental phenomena that one perhaps usually sees as being controlled by medication. Let’s use the example of someone who has noticed that irritability tends to be an early warning sign of relapse, and who notices that medication reductions are usually accompanied by increased irritability. Prior to trying another medication reduction, the person can practice at developing his or her own irritability reduction methods – for example practice facing situations that would usually be irritating, but use things like conscious adjustment of attitude, redirection of attention, etc., until one can choose to be in a non-irritated state even in the presence of usually irritating stimuli. Now, when the next medication reduction is attempted, the person will be less intimidated by emerging irritability and will be able to modulate it to avoid more problems.

One key general skill is that of learning how to have choice over how much to stress over things. Neuroleptics are essentially indifference pills, so if one can learn how to strategically “care less” when necessary, then overstressing and resulting “symptoms” can be avoided even without medication. Of course, this has to be done without going to the opposite extreme of not caring enough, which takes one into negative symptoms.

A common dynamic in relapse when nueroleptics are reduced is that the person starts caring more because of being on less of the drug. That leads to increased stress, which might build up over time, or emerge suddenly when specific obstacles are encountered. This increased stress leads to “symptoms” emerging. Especially if these “symptoms” are seen as “illness” or as something one can’t handle, the person responds with more “caring” or worry about what is happening, then experiences more stress, and so then more of the “symptom” which escalates in a vicious circle. Then, a higher dose of neuroleptics than one was previously on are needed to undo the vicious circle.

But none of this is inevitable. If a person learns more stress management methods, and learns to see the emerging “symptom” as an opportunity to practice skills and as an indication of a need to gently put more energy into stress management, the person can get through the medication reduction without ever going into the vicious circle outlined above.

The process of weaning off neuroleptics can never be made risk free, but there are ways to make it more likely to succeed. And the risks of trying to get off should be weighed against the risks and costs of staying on them. I hope the mental health system gets better at helping people better understand their choices and how to give themselves the best chance of minimizing risks of medication reduction if that is what the person wants to try.