When the taper is nearly complete, maintain the reduced benzodiazepine dosage several months before the final taper.23 Carbamazepine, imipramine, valproate, or trazodone may help alleviate benzodiazepine discontinuation symptoms in select patients.21
When discontinuation occurs
Medical comorbidity. Common medical conditions, including pregnancy or acute surgical procedures, may necessitate abrupt psychotropic discontinuation (Table 4).
Because up to 30% of medical patients have a psychiatric disorder,30 primary care physicians often start psychotropics to manage anxiety and depressive symptoms and may seek psychiatric advice when switching or stopping medications. Moreover, 10% to 15% of hospitalized medically ill patients require dosage reduction or discontinuation of psychotropics that are contributing to the clinical presentation.31
Table 4
Common conditions requiring abrupt psychotropic discontinuation
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Switching. When switching psychotropics, effects from the first psychotropic may appear to be adverse effects of the new psychotropic. Thus, unrecognized discontinuation syndromes may lead to unnecessary treatment changes.
In our experience, a general rule is to cross-taper and decrease the psychotropic being discontinued by 10% every 1 to 2 weeks. Prescribe adequate dosages of the new psychotropic, closely monitor vital signs, and watch for emerging discontinuation symptoms.
Pregnancy. For women who become pregnant while taking psychotropics, consider the patient’s psychiatric stability, week of pregnancy, psychotropic agent, and treatment preferences when adjusting the treatment plan. In one study of 34 women who stopped psychotropics abruptly for fear of harming the fetus:
- 26 (70%) reported physical and psychological adverse effects
- 11 (30%) reported suicidal ideation, and 4 were hospitalized.32
Patient education. In the study described above, some of the pregnant women’s physicians were unaware of the risks associated with abrupt psychotropic discontinuation and others were aware but failed to inform their patients.32 Thus, patient and family/caregiver education is important. When stopping psychotropics, discuss their risks/benefits, address unrealistic expectations, and individualize therapy by tapering and providing adequate dosing. Watch for suicidality; a weekly telephone call might be useful.
Related resource
- Hardman JG, Limbird LE, Gilman AG. Goodman & Gilman’s the pharmacological basis of therapeutics (10th ed). New York: McGraw-Hill, 2001.
Drug Brand Names
- Alprazolam • Xanax
- Aripiprazole • Abilify
- Bupropion • Wellbutrin
- Carbamazepine • Equetro, Tegretol
- Chlordiazepoxide • Librium
- Citalopram • Celexa
- Clonazepam • Klonopin
- Clozapine • Clozaril
- Diazepam • Valium
- Duloxetine • Cymbalta
- Fluoxetine • Prozac
- Fluvoxamine • Luvox
- Imipramine • Tofranil
- Lorazepam • Ativan
- Mirtazapine • Remeron
- Oxazepam • Serax
- Paroxetine • Paxil
- Phenelzine • Nardil
- Quetiapine • Seroquel
- Risperidone • Risperdal
- Tranylcypromine • Parnate
- Trazodone • Desyrel
- Sertraline • Zoloft
- Valproate • Depakene
- Venlafaxine • Effexor
- Ziprasidone • Geodon
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.