Adjusting Medicine Over The Summer Part I–Antidepressants

A common question as we head into the summer months is what to do about medications.  Most parents (and some kids) are very reluctant to change medications over the school year since a return of symptoms covered by the medicine can be very, very disruptive. Summertime is the logical time to consider some changes.  Antidepressants are prescribed for a variety of conditions that are based in serotonin and norepinephrine dysfunction of the brain.  These conditions include depression (obviously) and anxiety disorders, but they are also used for the irritability that comes with other psychiatric syndromes.  In any case, people often look to decrease or stop the medicine in the summertime in the hopes that they can get off and stay off.  There are factors that make this a possibility . . . and some factors that make this less likely.

Some factors that make summer a good time for change:

1.  The Sun:  While not everyone is enamored of the sun and what it can do for you, most people feel better when they have the opportunity to hang out and soak up some rays.  I always feel more confident decreasing medicine as we head into spring and summer.

2.  Decrease in Stress:  Again . . . not always true.  School is out (great for kids) . . . School is out (sometimes not so great for parents).  It really depends on the persons position and circumstance.  If stress level tends to drop over the summer, it CAN be a good time to consider a decrease in dose of medicine.

3.  Decrease in consequences for decompensation:  This is especially true for kids who are out of school for the summer.  Any worsening of symptoms of anxiety or depression might mess up camp, the vacation to the shore or home life in general . . . but it won’t cause long lasting difficulties with school.  Since school is a high priority for most people, taking concerns about academic decline out of the mix can be helpful in the decision process.

Some factors that make summer NOT a good time for change:

1.  None really . . .

The factors that complicate medication decreases tend to be independent of season of the year.  These include the following:

1.  Many of the conditions these medicines are prescribed for are chronic conditions, and, hence, benefit from chronic use of medicine.  It is my firmest belief that everyone who is prescribed antidepressants for depression deserve a try off the medicine.  This is especially true for kids, but it is true for adults as well.  If depression has returned after the first trial off medicine, you STILL deserve a second try off the medicine.  If depression returns after the second trial off medicine . . . I start to be less enthusiastic about additional trials off medicine.  With each subsequent return of symptoms, the likelihood of return of symptoms off medicine goes up.

2.  Anxiety is a funny thing . . . not funny haha . . . but funny quirky.  Anxiety can be even more of a trait than depression.  Some folks are just the anxious kind.  The good news is that you can learn to be less anxious, and changing your circumstances or how you think about or respond to stress can make a huge impact on your overall level of anxiety.  Some people are chronically anxious and don’t do well no matter when a taper is attempted.  Not in the summer . . . not the winter . . . never.  For people who are chronically anxious, there may never be a good time to be off the medicine.

So . . . you have consulted with your doctor and you have decided to try to go off the medicine.  How do you proceed?

In my experience, the most important feature of a successful taper (no matter what time of year) is to go slowly.  Very slowly.  Sometimes infuriatingly slowly.  The longer someone has been on the medicine, the more slowly the taper should be.  That almost ensures that you will NOT be off the medicine by the end of summer.  But you will be on less.  In my experience, it is less likely that the symptoms that the antidepressant treated will come back.  It also allows for the accumulation of emotional data as the dose goes down.  If you have a bad day . . . or a string of bad days . . . right after decreasing your dose, it may not be from the decrease in dose.  You might just be having a bad day (it happens sometimes).  Decreasing slowly allows you to not over react to a few bad days and go back on the medicine (and feel stuck on it).

People are very tuned into the risk of “discontinuation syndrome” . . . the nice name for the nasty effects some people feel when they come off antidepressants.  Most people do not experience them.  For others, it is pure hell.  The likelihood of discontinuation syndrome is greatest for antidepressants the body gets rid of quickly (called a short half-life in doctor-speak).  The biggest offenders are Paxil and Effexor, but it can occur with any antidepressant.  The one exception is Prozac which as a reported rate of discontinuation of 0% . . . but never say never . . . there is ALWAYS someone out there who will have difficulties.  The best way to avoid discontinuation syndrome is to taper the medicine very slowly.  The initial decreases tend to be easier than the later decreases.  It is always that last . . . few . . . milligrams . . . that are the hardest to stop.  I have had to use liquid forms of medicines at times.  I even had one patient count out the beads inside a capsule of Cymbalta and go down by one milligram every few weeks (as an FYI . . . 1 mg of Cymbalta equals nine beads!).  The other trick for getting off a difficult medicine is to do a substitution of Prozac for the original medicine and taper off the Prozac.  Its long half-life allows the body to clear it very very slowly and makes the risk of discontinuation much less.

Hope the above is helpful . . . I’ll be back next week to talk about ADHD medicine!

–Dan Hartman, MD