This article is not medical advice and does not replace consultation with a qualified medical professional of your choosing.
These days, more and more people are taking antidepressants as part of a regime to help them manage depression. Right now over 10 percent of folks are taking an antidepressant. That figure climbs for certain categories when we consider that 17.5 % of folks 45-64 are taking an antidepressant and 18.9 % of folks 65 and older are taking one. Many people find relief and improvement in symptoms from antidepressants and some feel that they have been a lifesaver for them.
But a good percentage of folks are finding unwanted side effects form taking them and are actively weaning from their use or have stopped them because of this. Just to add, please never make a decision to stop antidepressant usage without working collaboratively with your prescriber. When reducing or stopping antidepressant use, many people are finding that symptoms of withdrawal can be deeply challenging and overwhelming at times. Many people experience symptoms such as sleep disturbances, sensory processing problems (imbalance, vertigo, dizziness, electric ”brain zaps”), mood issues such as anxiety and depression and flu like symptoms such as nausea, headaches and sweating. Some of these symptoms last just for the duration of the taper off of the antidepressant but for some people these experiences can become prolonged and have long lasting effects on people- sometimes lasting years.
The name for the symptoms of antidepressant withdrawal symptoms and prolonged discontinuation symptoms are known as antidepressant discontinuation syndrome.
There is not a lot of literature about how to manage these distressing feelings. In conventional medicine, reinstatement of the same antidepressants, changing to another type of antidepressant such as prozac (with a longer half-life), or increasing dosage back up to a greater level are all ways to manage these symptoms. But for many people reinstatement or switching antidepressants does not feel like an adequate choice or can incur worsening mental health. For that reason, a number of groups of people have banded together to look at ways to manage these symptoms.
Outside of antidepressant discontinuation usage, there have been numerous groups that have developed to work through managing the symptoms of benzodiazapene discontinuation (xanax, valium, klonopin, etc). Really complex and sometimes severe complications are noted with that class of medications and entire protocols developed to manage the symptoms of discontinuation (Benzobuddies). In general these include reducing doses very slowly over a prolonged period of time. This goes against the usual conventional medical wisdom of relatively short tapers of just a couple weeks to a month. People taking antidepressants noted that slow tapers were often helpful for them as well and most communities talking about antidepressant discontinuation advocate for slow tapers- sometimes as little as a ten percent cut every couple weeks to a month, and often even less.
Because of the lack of a great deal of support from the conventional medicine community around alleviating some of these discontinuation symptoms, many of these folks have gone looking for other alternative approaches to managing these symptoms. There is a growing body of anecdotal knowledge around the use of diet, herbs and stress management techniques for alleviating some of the worst of these symptoms. I want to explore some of these interventions in this article.
Understanding the neurology of antidepressant discontinuation
First off, one of the first things to understand about discontinuation of antidepressants is that the body perceives it as a fundamental shock. Serotonergic antidepressants work in part by reducing the reuptake of serotonin into neurons and allowing for a flooding of serotonin between neurons in the synapses.
They also lead to a reduction in actual serotonin receptors- otherwise known as “downregulating” receptors. Because serotonin has been artificially increased the body reacts by reducing the number of serotonin receptors as it is trying to balance out the drugs effect. Now imagine the body loses that artificial boost in serotonin. Now you have neurons with less serotonin receptors and the body has to adjust again to start repopulating receptors— but that takes time. In the mean time, the body perceives a strong reduction in serotonergic transmission and it causes the myriad side effects of discontinuation.
One of the main theories for why people are given antidepressants is because they naturally lack enough serotonin and these medications provide that replacement. However, the theory of a chemical imbalance where some people lack enough serotonin has been proven to be false. Certainly antidepressants provide a boost via the serotonin pathway but they don’t replace a serotonin deficiency just as wine doesn’t cure anxiety because someone lacks an alcohol deficiency. You can read about the myth of chemical imbalance here, here and here.
Antidepressants can be very effective for certain people with moderate to severe depression however. The main reason is they help to flood the brain with a mood altering neurotransmitter that reduces anxiety and improves mood. The problem comes from the numerous side effects that can develop when that medication is taken away and how the body reacts.
Because of the problem of discontinuation, many people avoid the process and simply stay on the meds for fear of mood disregulation. Conventional medicine practitioners will often suggest that discontinuation symptoms are simply expressions of the original depression- but increasingly people are aware that discontinuation symptoms are a separate entity outside of any endogenous depression.
So if discontinuation can be hard, what are some of the interventions that can help? The best intervention is to work with a competent, caring and collaborative prescriber. One of the main techniques for managing the effects of discontinuation was mentioned above and that is encouraging the prescriber to offer a slow pathway to discontinuation. Sometimes this takes a linear course of slowly weaning over a period of many months. But sometimes it means going in fits and starts- decreasing slowly when one feels strong and resilient and “holding” or waiting at other times when one feels stressed and burdened. Working with a good prescriber who will honor the need to go slow and take breaks is key here. There is often a sense of “doctor knows best” but this is not always the case with discontinuation. The best judge of how quickly to taper is usually the patient themself who can sense how discontinuation affects their mood, physiology and behavior.
Outside of working with a good prescriber who will listen and work collaboratively, the other key is to honor what is needed for helping an individual through a taper and afterwards.
The first thing to understand is that there is no evidence based research or literature about the best alternative interventions for managing the effects of am antidepressant taper. That means that people have to really examine what works best for them without a body of evidence to support it. Essentially that means for most people it is a guessing game of trial and error. For that reason, the best interventions are the ones that are gentle with the least possibility of exacerbating symptoms.
As an herbalist I am often looking for interventions that are gentle, simple, and effective. This is really heterogenous and what works great for one individual doesn’t always work great for others. Some basic ideas do apply though and here they are…
1- Having good supports. I mentioned the key importance of working with a collaborative prescriber. But its also often key to have a network of supports to help through this time. This can include a good therapist as well as friends and peers. Relying on a group of people to help through this time can improve the process of recovery.
2- Reduce Stress. Yup it is fairly obvious but needs to be said. As you discontinue and afterwards, reduce stress as much as possible. If possible, reduce work at stressful jobs, try and reduce connections to unhealthy and toxic people. Essentially you are trying to reduce the possible triggers of increased anxiety and stress until your body recalibrates and becomes more resilient.
3- Reduce Stimulation. So many of things in our lives are stimulating- from our phones, social media, games, florescent lights, etc. Some of these can feel like good stress busting diversions- but some of them act to increase our stress. If we are staying up too late gaming, or getting obsessed with the status of our friends on social media- this can feel like an increased load on our nervous system and can impair healing from discontinuation.
4- Nutrient dense foods and herbs. This is really key here and often overlooked. The nervous system will be happy when you bathe it in a steady diet of concentrated vitamins and minerals. The nervous system needs a variety of minerals and vitamins in order to stay healthy and repair itself. For example, potassium is key for regulating nerve impulses, calcium aids nervous system development and B-12 helps maintain the myelin sheathing of neurons. Vitamins and minerals are better absorbed from proper nutrition than any vitamin or mineral supplement. That means concentrating on eating foods that are nutrient dense. There is a strong focus these days on Paleo/Ancestral/Ketogenic diets for helping people with various ailments, including neurological disfunction. Certainly eating a diet devoid of processed food and rich in fats and nutrient rich vegetables is often very healing for people. The problem is that most people can’t stick to such strict diets. It also isn’t culturally normative around the world where most people’s traditional diets include grains and legumes. I’d also say that eating a diet rich in grass-fed meats and organic produce is often far too expensive for the average consumer.
That is why I primarily look at the “art of the possible.” Making some healthy changes in diet is better than trying to adhere to a diet that is often impossible for most people. I generally steer people to traditional whole foods diets- I’m not going to say a lot here as there are loads of books and articles on the subject but I’ll add a couple things. I am a big fan of Sally Fallon’s books on the subjects here and recommend “Nourishing Traditions” and a number of her other books such as “Nourishing Broth” for in depth explorations of the subject and some good recipes.
5- Avoiding gut irritants. This is somewhat overlooked when talking about discontinuation Because we are talking about serotonergic changes, we need to honor that the vast majority of serotonin is located in the gut and is produced there. That means that serotonergic drugs have a strong effect on gut health. Many people who take antidepressants for a long period complain of gut health issues from poor digestion to bloating, cramping, constipation, gastritis and more complex forms of digestive upset including GERD, gastritis and Chron’s. That means that special care and attention should be paid to the health of the gut.
Outside of eating a nutrient dense diet its important to reduce gut irritants. The low hanging fruit are tobacco, alcohol, heavy coffee consumption, processed foods and especially sugar and high fructose corn syrup. Heavy sugar intake can lead to blood sugar imbalances that further exacerbate discontinuation symptoms. Beyond that there are numerous foods that can cause reactions in people. Many people notice that gluten and dairy can upset their digestion, lead to inflammation and these are often really helpful for people to avoid. Some people have noticed its best to really strip the diet down and eat more ancestrally (Paleo) and avoid legumes and grains as well. It can be stressful to radically change one’s diet during this time and I emphasize the importance of making any healthy changes, even if they are small. Working with diet to help reduce the stress and load on the gut is often really helpful here and can help people recover more easily.
6- Movement. In this process of healing and rebuilding, its key to engage in movement that moves the blood and lymph, remove waste product and circulates nutrients to help heal the nervous system. The key here is to engage in movement that does not tax the body excessively and lead to an exacerbation of symptoms. For some people heavy exercise that induces a great deal of sweating can feel helpful- while for others hitting aerobics and spin classes only makes the discontinuation process worse. Generally I have seen gentle outdoor movement as one of the best options- walks, biking, gardening, hiking, etc.
7- Sacred Care. When dealing with ongoing anxiety and distress from discontinuation it can be helpful to build in a physical and energetic practice that reduces stress. Gentle forms of yoga, tai qi and qi gong can also be deeply helpful for building resiliency and strength. I have seen forms of sitting meditation be counterproductive as the discontinuation can cause anxiety and dark thoughts to circulate and meditation just makes a person focus on those sensations more- instead of moving through them, shaking them off and releasing that tension.
8- Herbal nutritives. Just as taking in a nutrient dense diet is key, taking in herbs that are filled with vitamins and minerals can be key to the healing process. Some of the best herbs to integrate include nettles, oatstraw, alfalfa, seaweeds, and gently bitter roots such as dandelion and burdock root. See below for resources on this.
9- Herbal relaxants. In terms of symptomatic relief, many people complain of anxiety, insomnia and challenges in managing stress. Though herbal anxiolytics are essentially a form of symptomatic relief, that can be essential when working through discontinuation. In this first category, I would stress the importance of gentle anxiolytic “nervines”. Thats an herbalist term for herbs that will help calm anxiety and strengthen the nervous system. These are often best taken in tea form with a blend of herbs. Finding a good blend of herbs to make into regular tea can be really helpful here.
So for example, a simple and tasty combination of skullcap, oatstraw, rose and lemon verbena can act as a nice aromatic tea to help reduce anxiety but also improve gut motility and thereby improve intestinal function which is key as well. Needless to say this also helps with hydration as well. There are a number of formulas that are possible but in general these herbs should be gentle, relatively tasty (so you will drink cup after cup) and easy to duplicate by going to your local herb store or looking on line. (See resources below.)
10- Herbal relaxants- strong. This next category include herbs that are stronger in effect and will help reduce the anxiety associated with discontinuation. Many of these herbs have a very strong taste and therefore don’t go very well in teas so people often take them as tinctures (alcoholic preparations.) People going through discontinuation will have different experiences with stronger nervines. For some people they will be helpful and effective but for others they can actually add a layer of fuzziness and sleepiness without really changing the underlying distress from discontinuation. This is where it only works by trial and error. One can try a tincture or two and see the effect and its it is helpful. Each plant has slightly different effects so I will list a few:
Kava- anxiolytic, muscle relaxant, strong.
Valerian- anxiolytic, hypnotic, sometimes energizing to certain people.
California Poppy: Relaxant, pain relieving.
Motherwort: Gently relaxant, cardiotonic
Generally its best to take a formula of herbs and in the resource section I mention a couple.
11- Aromatherapy. Herbs don’t have to just be taken internally and many people are sensitive to taking in anything during discontinuation. That means working with the other senses (smell, touch) can be useful for helping a person to destress and heal. Baths infused with herbal salts and massaging in infused herbal oils to the skin can help bring relaxation and a reduction win discontinuation symptoms. See below for resources.
12- Cannabis. In a number of states cannabis has become legal and many people are using it as a plant to help them with tapering off of psychiatric drugs such as antidepressants. Needless to say that cannabis is illegal in many places so this doesn’t represent an option for many people. The legalization of cannabis has allowed for consumers to become very knowledgable and picky about the particular strains of cannabis they want to buy. That means they can focus on relaxant, calmative and analgesic strains. Perhaps the largest change outside of legalization is the production of strains that are high in CBD (Cannabidiol). This is a constituent in cannabis that has relaxant and pain relieving qualities. Strains high in CBD are often helpful for people in distress. While some people find relief from strains that essentially only contain CBD, others find relief with varietals that contain some THC- the main psychoactive constituent in cannabis. Others can find relief in cannabis high in THC as long as it comes from Indica varietals.
So for example, some people may choose a purely CBD strain such as ACDC while others may find relief from strains that are more balanced such as Harlequin (with a 5:2 CBD/THC ratio.) Others may do well with a THC dominant strain such as Graddaddy Purps because it is an Indica that tend to be relaxing for many people.
While some people can find relief with cannabis, for many others it can feel dissociative or anxiety provoking so this is really particular to the individual. In general it is not a great answer for many people but for a select few it really helps. And of course dosage matters quite a bit. An edible dose of cannabis is far more potentially challenging to the nervous system than smoking a couple hits. All of this is really trial and error for most of folks- and If you are untrained in cannabis use, please do far more research before engaging in this option. Leafly has a good article on the subject of anxiety reducing cannabis with some examination of the different strains. Take a look here.
12- OTC. Other options for help with the withdrawal symptoms are the occasional use of over the counter aids. The two main ones that are available are melatonin and benadryl as sleep aids. If antidepressant withdrawal is leading to prolonged insomnia it can be helpful to have an intermittent aid that can help. Long term use of benadryl is not a good option as it leads to long term health risks such as alzheimers and dementia. Melatonin is a hormone and can help some people with sleep issues and is less risky than regular benadryl use.
OK – so for herbal resources I thought I’d look to my local herb store here in Portland store known as The Herb Shoppe for some options in helping people herbally. There are no interventions that are going to magically speed up the time before the body can readjust and recalibate. But certain herbs can help people manage the distressing feelings associated with discontinuation. The main thing to consider in discontinuation is what herbs to avoid while in discontinuation.
Saint John’s Wort is probably the most prominent example of an herb to avoid. While often offered by doctors in places like Germany for mild to moderate depression, SJW interacts with the liver in a way that can affect the metabolism of drugs. With serotonergic antidepressants this can cause an exacerbation of negative symptoms and theoretically something known as serotonin syndrome- a nasty set of symptoms due to serotonin toxicity. I have heard of only a handful of cases where this poor interaction has caused serotonin syndrome but why test it?
Outside of SJW, the other herbs to be careful around are those that are very strong in effect, affect hepatic metabolism or act as strong diuretics- thus causing a change in the effect of medications. Herbs that I tend to avoid include strong plants such as kratom and kanna, tryptamine entheogens like Psilocybe mushroom and ephedra. Even common “herbs” such as coffee and chocolate can exacerbate withdrawal symptoms as they both are stimulants as well as diuretics that could affect medication metabolism.
Many herbs have a diuretic property but do not cause diuresis enough to affect SSRI metabolism unless taken in copious amounts. Frankly one of the strongest herbal diuretics out there (coffee) is consumed by millions of people who are also taking psychiatric drugs but does not seem to cause excessively poor side effects and I have yet to hear of a doctor saying one should not drink coffee who is taking antidepressants.
So that being said here are some suggestions for some good options that one can purchase directly or on line from the Herb Shoppe.
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Nutritive Beginnings Tea Blend Nutrient dense tea blend.
Here and Now Anxiety Tea Blend Just how it sounds.
Sweet Slumber Tea blend For sleep aid.
Five Flower Formula This is often given to people who are in a place of shock or triggered into severe anxiety . Flower essences are often helpful because there is no risk of contraindication because flower essences are essentially homeopathic (containing no gross medicinal constituents) and act very gently on the system.
Unplug – Relaxing Bath Soak When all else fails, add this to a warm bath and find relief through a good herbal soak.
Serenity Oil Blend A good aromatic oil blend can be really helpful. Apply some to the temples or massage it into the forehead, hands or feet to help find some relief from anxiety and stress.
Orbits of the Heart for modest, gentle relief from anxiety.
Soul Shine to bring greater resiliency and strengthen the nervous system to manage stress more easily.
The process of coming off antidepressants can be a long and slow one. Even after discontinuation, people can feel a sense of lingering distress that is attributed to the discontinuation instead of the original depression. Some of the ideas here can be useful for long term self-care when managing distress and discontinuation effects. And to repeat, all of this should be done under the care of a physician. If a doctor does not appear to be amenable to collaboration, I would recommend finding one that is more able to listen well to a patient’s needs. Naturopaths, functional and integrative doctors are often more understanding of the complexities of antidepressant discontinuation and generally more open to holistic supports.
survivingantidepressants.org A forum devoted to assisting people in their process of coming off antidepressants.
MadinAmerica.com A website critical of the overprescription of medications with resources and numerous articles on the subject.
Dr. Kelly Brogan A leading integrative physician specializing in women health and mental health. You can google her name and find numerous articles by her on the subject of antidepressant use and discontinuation.
Icarus Facebook page This is an organization dedicating to helping people work through mental health issues while not being centered primarily in conventional medicine approaches. They have a website and also a great Facebook group where people discuss issues such as antidepressant use and discontinuation.
Pub Med literature
This article written by Jon Keyes, Licensed Professional Counselor and herbalist. If you are interested in a consultation with Jon, please contact him at firstname.lastname@example.org
You can also find me at the Facebook group Herbs for Mental Health.