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The reduction or discontinuation of psychiatric medications such as antidepressants, antipsychotics or anxiolytics can cause physical and psychological withdrawal and rebound symptoms. Withdrawal symptoms may be so severe that patients are unable to continue reducing the dose, regardless of the medication’s efficacy.

In 2010, the Tapering Project was started to address these problems through the development of tapered doses of medication provided in strip packaging: tapering strips.

Tapering strips allow patients to regulate the tempo of their dose reduction over time and enable them to taper more gradually, conveniently and safely than is possible using currently available standard medication, thereby preventing withdrawal symptoms.

What

In a tapering strip, medication is packaged in a roll or strip of small daily pouches. Each pouch is numbered and has the same or slightly lower dose than the package before it.p

How

Strips come in series covering 28 days and patients can use one or more strips to regulate the tempo of their dose reduction over time. Dose and day information printed on each pouch allow patients to precisely record and monitor the progress of their reduction.

For whom?

Tapering strips are developed for medication in cases where doing so improves the medical care available and meets an unmet need. See the list with available tapering strips.

In a new article in European Neuropsychopharmacology, researchers Mark Horowitz and David Taylor provide guidance for tapering psychiatric drugs, whether for full discontinuation or to reduce the dose. They suggest a slow, individualized taper to minimize withdrawal effects.

“The general principle when reducing or stopping psychiatric medications is as follows. Make a small reduction, monitor for withdrawal effects or destabilization of the patient, then ensure stability before making further reductions. Reductions should probably be made in smaller and smaller increments because of the pharmacology of the drugs; the final dose before completely stopping will need to be very small.”

Horowitz and Taylor have previously written about this approach for antidepressants in Lancet Psychiatry and for antipsychotics in JAMA Psychiatry (with Sir Robin Murray).

…Some people may require months or even years to slowly decrease their dose before eventually stopping the drug. The researchers write:

“Withdrawal effects (and relapse) might be minimized by stopping psychiatric drugs over a period long enough for underlying adaptations to the drug to resolve.”

According to the researchers, based on studies of the drugs’ effects on the brain, psychiatric drugs impact the brain along with a hyperbolic relationship. That is, at low doses, small adjustments have huge impacts—but at high doses, even large adjustments have less of an impact.

“The relationship between dose of a psychiatric drug and its effects is hyperbolic,” they write. “This is a consequence of the law of mass action: when there are few molecules of a drug present at the site of action, every additional molecule has a large incremental effect, but when higher concentrations are present each additional molecule has less and less effect, as receptors become saturated.”

This means that dose reductions should not be linear (reduced by the same amount each time, e.g., 40, 30, 20, 10, 0 mg). Instead, one strategy is to reduce the current dose by 10% each time, especially ensuring that the last adjustment—to full discontinuation—is very small.