A Psychiatrist on SSRIs and Tapering Off of Antidepressants
Written by: the Editors of goop
Published on: August 23, 2018
Updated on: August 23, 2018
Reviewed by: Ellen Vora, MD
Illustration by Manjit Thapp
Like many psychiatrists, Dr. Ellen Vora sees a mix of patients: some on antidepressants, some who want to come off of them, and some who have never been on medication. Of course, no two individuals are the same—so there’s no single path to mental health and balance. What many of Vora’s patients do have in common, however, are questions.
“As a holistic psychiatrist, I routinely encounter people taking antidepressants who ask me: Do they really work? Is it actually doing anything for me? If I stopped taking my meds, would I get depressed? Can I even get off these pills?”
The controversy over antidepressants, and over SSRIs (selective serotonin reuptake inhibitors) specifically, is ongoing. The medical community is split on how effective SSRIs are and whether or not they can be addictive. “The issue of SSRI dependence and withdrawal has nowhere near the exposure it warrants,” Vora says. “But at least the awareness is growing. We should be having a public conversation about the real risks and benefits of these medications. And more practitioners should be learning how to support patients to safely taper off medication.”
Tapering off SSRIs, as Vora underscores, isn’t for everyone and isn’t to be done alone. This is a conversation to have with your doctor. It’s one that Vora navigates with many of her patients, and it looks something like this:
A Q&A with Ellen Vora, M.D.
There’s controversy around SSRI effectiveness. A large meta-analysis published in JAMA in 2010 shocked patients and doctors alike, revealing that SSRIs don’t separate from placebo in mild to moderate depression. In other words, the drugs worked just as well, or just as poorly, as a sugar pill. This was a bit discouraging, considering millions of people are prescribed these meds for mild and moderate depression, and they can cause significant side effects, such as decreased libido and weight gain.
A more recent meta-analysis, published in The Lancet in February 2018, claims to refute this finding, showing that when we choose “depressed mood” as our outcome measure rather than the standard depression rating scale, SSRIs separate from placebo and have a modest effect on depression. Of note, most of the studies included were acute studies, meaning they follow subjects only for the first eight weeks of treatment. This underwhelming shift in evidence was met with sensational media headlines hyping up the value of SSRIs. So what are we to believe?
I suspect the truth lies somewhere in between. Antidepressants can have a beneficial effect in certain circumstances, and they can be no better than a side-effect-inducing placebo in other cases. More worrisome is that they can induce a kind of emotional numbness and they can be incredibly difficult to discontinue.
There are so many factors that go into whether someone is going to benefit from a medication. Beyond genetics and individual biochemistry, your personal expectations and beliefs have an outsize impact on whether these meds work for you. If you like your doctor and you like going to their office, if you feel like they genuinely care about you, if you have a friend or sibling who swears by this med or you saw a beautiful woman on a commercial suddenly get happy and start going to the farmers’ market carrying a wicker basket after taking this pill—all of this can actually make the medication more effective for you. Note that I didn’t say it’s going to make you think it’s more effective; it actually can make it more effective. When it comes to medications that treat the mind, expectation is POWERFUL.
Say you start on an SSRI with a strong expectation that it will help you, and it does help you: What just happened there? Was it “just placebo”? Were you tricked into feeling better? Is that a bad thing? Or is this actually the desired effect? And how do we define “help”—are you thriving? Or just crying less?
What about the reverse: Say you don’t like your doctor, and you don’t feel genuinely cared for. Perhaps you have misgivings about the medication—maybe you’ve taken various psych meds in the past and you’ve had bad experiences. Now there’s a new treatment on the market, but you’re jaded and not particularly hopeful this one will be any different. Does this expectation of failure matter to the course of your treatment? You bet it does. Expectations, positive or negative, influence how a medication affects your mood.
Does this expectation-driven effect last? Not really. Just like the placebo effect, the benefit from positive expectation is short-lived. This may be why so many people have the following experience: I went on a medication, it helped me for a while, but now I feel like it has worn off. While it’s true the body adapts to the medication, it’s not that medications wear off; the placebo effect does.
These medications are not simply placebos. Take, for example, all the people who start a medication without expectations that it will help, or studies of subjects who are blinded and don’t even know they’re taking the active medication, and then they do feel better. Is this an example of the medication actually working? Maybe. These medications have an undeniable biochemical effect on the brain. Though, let’s define “working.”
It’s not as if these medications do nothing; they do quite a lot. SSRIs are powerful psychoactive substances that strongly impact brain chemistry. But the real effect is not what I would call “antidepression” or “anti-anxiety.” If anything, the physiologic impact of SSRIs is that they narrow the range of feeling. It’s a numbing effect, blunting both the highs and the lows.
This doesn’t sound awesome, but there are cases where numbing is arguably an improvement. For someone who is suffering from severe depression, crying all the time, hopeless, and preoccupied with morbid thoughts, you could argue this narrowing effect is a positive. One day that person is crying; the next day they’re not. So the medication “worked.”
While I’m happy to continue meds for someone already on them, I rarely start people on meds. As a holistically minded psychiatrist, I have more tricks up my sleeve, and usually feel I can get someone feeling better by addressing their depression at the root, rather than blunting their sadness with a drug. Even when someone is helped by an SSRI, they are rarely thriving.
Thriving is when someone sleeps well, has energy, poops every day, feels a sense of fulfillment, gratitude, or even awe for the state of being alive, and is capable of flowing gracefully among various moods and feelings, from tears and exquisite sadness to ecstatic joy.
I personally believe we can all achieve a state of authentic well-being, and I like to empower patients to access this state. I’ve learned it has to be done the old-fashioned way, through diet and lifestyle. If there were a pill that could do this, I’d be all for it. But it turns out pharmaceuticals can’t take the place of real food, sunshine, fresh air, exercise, relaxation, nature, and community. These are the necessary ingredients for thriving, and SSRIs are irrelevant and, at times, potentially get in the way.
In my experience, people who are helped by SSRIs are often in a state of modified well-being. They may be functioning, going to work, exercising, feeling more stable, and behaving more appropriately in their interpersonal relationships, but they are rarely thriving.
“Thriving is when someone sleeps well, has energy, poops every day, feels a sense of fulfillment, gratitude, or even awe for the state of being alive, and is capable of flowing gracefully among various moods and feelings.”
Some people slip into a state I call the SSRI slumber, where they’re just existing. They feel numb as they go about their days, commuting, going to work, coming home, watching Netflix until they fall asleep on the couch. They might not be moving forward in their lives, and they’re not feeling anything deeply. It’s sleepwalking through life. This is a very troubling potential effect of these medications, and not one that’s measured in any meta-analysis. And of course, this is not a potential side effect that most patients are briefed on before being prescribed that first pill.
The tricky thing with SSRIs is that even if you’re not feeling great and wondering if they’re working, they can still be incredibly difficult to get off of. They create physical dependence, and tapering off can cause physical withdrawal. The withdrawal can be crippling, and it can last for months. Many of us think addiction and withdrawal apply only to illegal drugs, like heroin, or notoriously addictive substances, like nicotine—but it’s time for us to open our eyes to the myriad prescription medications that also cause physical dependence and withdrawal, such as SSRIs.
If you’re considering tapering off of SSRIs: First, recognize that medication discontinuation should not be approached lightly. Enlist support. Ideally you would work closely with a supportive psychiatrist who has experience managing psychiatric medication tapers. You may also want to talk this through with the important people in your life because you’ll require their support more than you realize.
You may be thinking: But I’m only on a small dose. There is quite a bit of minimization that happens to try to make these meds approachable to the average person. Many patients and doctors say “tiny dose” even when it’s the full therapeutic dose. If you’re on a proper dose of the medication—even if it’s been described to you as small—and you decide you may want to taper off, take the process seriously and get support.
“Are there things you can do on your own to support your taper? Yes, yes, a thousand times yes.”
Once you’ve found your practitioner, the name of the game is self-care and patience. You will spend at least a month preparing your body before you make the first change, and once you start tapering, go gradually. I work with a compounding pharmacy so patients can decrease the dose by about 10 percent per month rather than relying on the commercially available doses, which require much bigger jumps. You’ll want to decrease slowly, and, if you’re on a cocktail of psych meds, you’ll want to take it one medication at a time, letting your body restabilize for a while in between tapers.
Are there things you can do on your own to support your taper? Yes, yes, a thousand times yes. In my experience, the work you do on your own to cultivate a healthy diet and lifestyle is what matters most to the success of the taper, in my experience. That being said, no taper is guaranteed to be smooth.
Dr. Kelly Brogan taught me so much about how to manage psychiatric medication tapers, and as she puts it: “The key to the kingdom” is food. I generally recommend my patients adhere to a Whole30 diet for a month leading up to the first medication change and then throughout the duration of their taper—and ideally, happily ever after as well. The basic tenets of Whole30 are described in a concise and engaging way on its website. A quick and dirty summary is that the Whole30 diet eliminates gluten, dairy, sugar and artificial sugar, grains, legumes, alcohol, processed foods, additives, vegetable oils, replacement foods, and “treats.”
This is the point where most people’s eyes roll to the back of their heads and they feel woozy. Deep breath. A lot of us in the holistic health space get so caught up in what not to eat that we often forget to mention what you CAN and SHOULD eat. So here are the delicious and satisfying foods you can and should enjoy:
Eat hearty stews and balanced plates of meat, veggies, and starch.
Eat a boatload of darkly pigmented vegetables of every color and variety.
Eat well-sourced pastured meat and poultry and wild cold-water, small, fatty fish. Eat the succulent, fatty skin.
Eat starchy vegetables, like sweet potatoes and plantains.
Douse your food in plentiful healthy fats like grass-fed ghee, olive oil, and coconut oil.
Make a habit of eating fermented foods like sauerkraut, kimchi, beet kvass, and apple cider vinegar.
Round out your meals with bone broth.
Snack on fruit, nuts and seeds, avocados, olives, grass-fed jerky, and hard-boiled eggs.
It’s time to reframe how we think about eating clean. We’ve been incorrectly picturing dry arugula and chia pudding. Eating real food is not deprivation, sacrifice, or being chronically hungry. It’s a hearty, delicious, and satisfying way to eat. It just happens to be a total paradigm shift from the ways we’re typically feeding ourselves, which look like cereal and milk, sandwiches, misguided gluten-free substitutions, or even—the horror—low-fat diet foods. Eating well just means eating real food. That’s your new compass.
“Eating real food is not deprivation, sacrifice, or being chronically hungry.”
After diet, your next priority should be sleep. I’ve learned over the years that there are two things that are most impactful for getting busy, stressed people to finally sleep: Get the phone out of the bedroom, and go to bed by 10 p.m.
The phone is toxic to sleep on multiple levels. It emits blue-spectrum light that suppresses the secretion of melatonin—the hormone that makes us sleepy. Also, when we keep the phone on our bedside table, it’s often the last thing we look at before bed and the first thing we look at when we wake. Those innocent glances can provoke feelings of stress, excitement, disappointment, and overwhelmedness. None of this juju promotes restful sleep. When we check our phone first thing in the morning, we miss the chance to set our own intention for the day. Instead, we’re passengers, driven by whatever notification has pushed its way to the top. This is not the way to set a life-affirming tone for your day.
I get that a 10 p.m. bedtime is a hard sell. I used to think all versions of eight hours of sleep were created equal, whether I slept from 10 p.m. to 6 a.m. or 2 a.m. to 10 a.m. What I’ve learned is that the body prefers to be in rhythm with the sun and the moon—if there’s a less hippie way to say this, I’m all ears. There’s a sweet spot around three hours after sunset when we’re perfectly tired. If we fall asleep then, we sleep our deepest, and we’re less likely to wake up throughout the night. When we miss that window, our body releases the stress hormone cortisol, and we become overtired. You know the feeling when you get a second wind and suddenly feel tired but wired? Overtired. I recognize my overtired state because, even though I was falling asleep on the couch a few hours earlier, now I’m feeling jazzy and raring’ to clean the kitchen. On these nights, it’s a struggle to fall and stay asleep because cortisol is coursing through my bloodstream. Get to bed earlier, around 10 p.m., and save yourself the trouble of fighting against your cortisol.
“What I’ve learned is that the body prefers to be in rhythm with the sun and the moon—if there’s a less hippie way to say this, I’m all ears.”
And look, if you’re missing the 10 p.m. lights out because you’re connecting with people you love, you’re making the right trade-off. Ultimately, our relationships fulfill us and promote health even more than sleep. But if you’re staying up scrolling Insta or watching Netflix in bed, bring consciousness to these choices: Recognize that sleep will serve you better, and start driving the ship for yourself. These choices elevate in importance when you’re embarking upon a medication taper.
After sleep, prioritize meditation. If you already have a regular practice, or if you enjoy using something like the Headspace app, that’s great—keep doing what you’re doing. If you’re starting from scratch, I would suggest a daily Kundalini practice. This ancient technology is one of the most efficient ways to trip your body into a relaxation response and reframe problematic thought patterns. Medication tapers jack up your nervous system, and you’ll need a way to self-soothe, ground, and put yourself back into a relaxation tone every day to stay afloat. There’s no better tool than meditation. Do this every day, even if it’s only for a few minutes.
In addition to diet, sleep, and meditation, you need to exercise. This will keep your mood stable while helping you sweat out and release what your body needs to shed as it chemically reconfigures. Patients often ask me what’s the best kind of exercise. In general, HIIT or hiking/surfing/exerting yourself in nature are best. But the real answer is that the best exercise is the one you’ll actually manage to do sustainably. I would love to be a surfer/yogi/rock climber, but with a busy practice in NYC and a kid, here’s what I do: After I put my daughter to sleep, I exercise for about five to ten minutes on my living room floor. I usually do some Pilates or yoga, then perhaps a silent disco with my husband. I don’t have washboard abs, but I’ve been doing this consistently for about three years and counting. That’s the real mark of a good exercise routine.
The last piece of a smooth taper is building detoxification practices into your daily life. Medication tapers tax your body’s natural detoxification pathways, and your body needs an efficient way to release medication metabolites, lest they build up and leave you feeling toxic. Some people like infrared saunas; others do coffee enemas—I know, I know…. The choice will come down to personal preference and your practitioner’s suggestions. At the very least, consider getting in the habit of a simple dry skin-brushing routine before the shower, regular Epsom salt baths, oil pulling, and starting the day with a large glass of spring or filtered water with lemon juice.
Extra credit: If you can find a community of kindred spirits who are also going through a medication taper, that is gold. No doctor can ever truly understand the patient experience. Find someone who has gone through what you’re going through to provide support and the occasional sanity check. I recommend Kelly Brogan’s Vital Mind Reset for this.
This is a complicated question that can really only be answered with a comprehensive psychiatric evaluation. But let’s paint some broad strokes. If you’re stable and able to commit 100 percent to the diet and lifestyle practices that will make a taper go relatively smoothly and safely, you’re a good candidate to consider this process under supervision. On the other hand, if you harbor fear or doubt about getting off psych meds, if your life is currently chaotic, if you’re currently in crisis or very symptomatic, if your support system doesn’t support this choice, or if you’re not in a place where you can commit to these intense diet and lifestyle changes for the duration of your taper, then this may not be the right time to begin.
I tend to believe that most psychiatric medications can be tapered, but I’m personally more comfortable tapering people off of antidepressants, anti-anxiety meds, stimulants, and mood stabilizers. Antipsychotics being used to treat psychotic disorders can pose additional challenges.
In my experience, if a patient is in the process of getting off meds, or has recently completed a taper, and goes through a funk, those mood changes are usually attributable to withdrawal. We would all do well to recognize that tapering off antidepressants causes a true-blue drug-withdrawal state, which can impact mood for several months. If someone has a new episode of depression years after a medication taper, this brings up larger questions about the very nature of depression—i.e., something has gotten out of balance and needs to be addressed at the root. For the purposes of this conversation: If there is such a thing as a depression relapse, we can’t begin to identify that while someone is still in the throes of withdrawal.
“We would all do well to recognize that tapering off antidepressants causes a true-blue drug-withdrawal state, which can impact mood for several months.”
In my practice, I consider the entire duration of a taper and about the first six to twelve months after med discontinuation as phases of withdrawal, ranging from acute to subacute withdrawal. Tapering too quickly or without lifestyle support can cause even more protracted withdrawal effects. All of this is to say: We can’t identify relapse while someone is still in an overwhelming experience of drug withdrawal. It would be like seeing a drug addict withdrawing from heroin and saying, “You seem like you’re having a depression relapse.” If someone is years out from a medication taper and their depression symptoms return, we can call that a relapse, but it’s really a call to action to address the potential underlying causes of depressed mood.
If you feel stuck on antidepressants, know that:
You very well might be, and it’s not your fault. Nobody told you when they started you on these meds that they create physical dependence.
The meds might be narrowing the range of how you’re feeling and making you feel numb but not actually “working” to help you feel good.
The meds might be helping you, and that’s okay, too. Don’t be ashamed to be on antidepressants or for wanting to stay on.
If you decide you want to taper, know that getting off of these meds can be incredibly difficult. Intensive diet and lifestyle modifications are important and you’ll need support from an experienced practitioner who “gets it.”
Listen to your body, surrender to your process, and trust that you’ll ultimately be okay.
The goal here is not to convince you to get off of meds, but to give you the informed consent you should have gotten with that first prescription. When you have all the information you need, it’s then up to you to decide how to navigate the path forward. If you’re out there and you feel you’re stuck on antidepressants, and they’re not helping, at the very least, know that you’re not alone, it’s not your fault, and there are ways to get free. You have a birthright to thrive, but it requires treating yourself to an entirely different paradigm of food, rest, activity, and relaxation, and stripping away any substances that are numbing you to your human experience. If you feel ready to make this massive shift, you probably are. You will likely experience a broader range of human feeling in the process, which can be intense but also exquisite. If you sense it’s not the right time for you to make this shift or perhaps you find the meds are helping, there’s no shame in remaining on meds. The goal is for you to have all the information and make a conscious, self-loving choice.
Dr. Ellen Vora received her M.D. from Columbia University Medical School and her B.A. in English from Yale University. She’s a board-certified psychiatrist, an acupuncturist, and a yoga teacher based in New York City.
The views expressed in this article intend to highlight alternative studies. They are the views of the expert and do not necessarily represent the views of goop. This article is for informational purposes only, even if and to the extent that it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice.
Even after decades of study, the science of SSRIs and other antidepressants isn’t always conclusive—and that’s a statement itself hotly debated. When we look at the science of SSRIs versus placebos, there are a few things to keep in mind:
A study’s control group often receives a placebo pill—that doesn’t chemically do anything in the body—but that isn’t always the whole story; research ethics and good study design may require a control group to receive all the other standard interventions, besides the medication, that the experimental group gets. In the case of an antidepressant study, that may include talk therapy and other care. So what these studies look like, in practice, is comparing one set of interventions against the same set of interventions plus medication to see if the medication makes treatment more effective.
What does seem apparent is that the worse your depression is, the more likely it is antidepressants will help manage your symptoms and improve day-to-day function. In studies of patients with mild to moderate depression, experimental groups (that is, often, medications plus other care) don’t usually do much better than control groups (other care only). In studies of patients with severe depression, however, medication seems to offer a larger benefit in addition to other interventions.
There are reasons to get on antidepressants, reasons to stay off them, and reasons to quit—and it all comes down to the individual. Below, we’ve bookmarked some landmark studies in antidepressant research, as well as some popular media coverage we’ve found helpful in evaluating where the science stands and how people are managing their mental health care.
Kirsch, I., Deacon, B. J., Huedo-Medina, T. B., Scoboria, A., Moore, T. J., & Johnson, B. T. (2008). Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS medicine, 5(2), e45.
Fournier, J. C., DeRubeis, R. J., Hollon, S. D., Dimidjian, S., Amsterdam, J. D., Shelton, R. C., & Fawcett, J. (2010). Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA, 303(1), 47-53.
Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y., … & Egger, M. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis. The Lancet, 391(10128), 1357-1366.
ANTIDEPRESSANTS IN THE NEWS:
About that New Antidepressant Study by Neuroskeptic (Discover magazine)
Do Antidepressants Work? Yes, No, and Yes Again by Joe Pierre, MD (Psychology Today)
Do Antidepressants Work? by Aaron E. Carroll (The New York Times)
Many People Taking Antidepressants Discover They Cannot Quit by Benedict Carey and Robert Gebeloff (The New York Times)
People are hacking antidepressant doses to avoid withdrawal by Clare Wilson (New Scientist)
CRISPR powers the hunt for new, better antidepressants by Jim Dryden (Futurity)
Why psychedelics could be the new class of antidepressant by Jack Dutton (The Independent)