Easy to start, harder to stop: psychiatric medication and tapering

Happy Pills, Jonathon Rolande

I recently had the opportunity to speak with Tobin Richardson on the Save the Therapist Podcast about psychiatric medication tapering. We talked about a movement disorder called akathisia that can happen when starting, stopping, or changing the dose of a drug.

It happens most commonly with neuroleptic medications (also known as anti-psychotics), such as Risperdal or Abilify, but can also occur with other drugs such as SSRIs (anti-depressants) and antiemetics (for nausea). The podcast highlights a theme: it is often much easier to get onto psych medications than to get off of them.

I commonly hear from patients that they went to their primary care doctor, were asked some basic depression screening questions, and left with a prescription for a drug they hadn’t even considered taking before the appointment.

When this happens, or especially if a client is prescribed a higher-risk drug like Haldol, which has extremely high rates of akathisia, I check in with clients about their anxiety level and sense of inner restlessness to assess for akathisia. I observe their movement, and if I suspect akathisia, I’ll perform a BARS (Barnes Akathisia Rating Scale) assessment.

The reason for this is that not only is akathisia extremely uncomfortable, it can exacerbate mental health problems and even increase one’s risk for suicide, or for aggressive and even violent behavior. People who have had akathisia often describe the experience as torture.

The gold standard treatment for akathisia is to reduce or stop the drug that is causing it. However, this needs to be done slowly to prevent withdrawal akathisia, which can happen when stopping or starting a drug.

While the first antipsychotic medication was introduced nearly 75 years ago, we are still only beginning to have honest conversations about how to safely discontinue neuroleptics and other psychiatric medications. In Tobin’s conversations with all of the clinicians interviewed for this episode, a recurring theme was the gap in informed consent and how difficult it can be for patients to find clear guidance, support, or clinical resources when they decide they want to come off these medications.

As more research emerges on these medications, there is increasing support that they are best used at the lowest effective doses and for the shortest duration possible. If we are to take this guidance seriously, it follows that all clinicians, both prescribers and talk therapists, should have at least a basic understanding of how to support clients through tapering and discontinuation when the time comes.

To hear our conversation, check it out here.