A besceechment from your brain, 'Please, don’t just stop your meds!'

As a clinical psychologist my work frequently brings me into contact with people who take psychiatric medications, sometimes more than one, and often for a multitude of clinical diagnoses. By virtue of my designation, and my proximal involvement thus in such interventions, I have had to learn over time how to shoulder this responsibility to my patients as part and parcel of running a private practice, the gravity of which is never lost on me.

It is not uncommon that, for example, if deemed necessary after a period of clinical assessment, I might refer a patient to a psychiatrist colleague for medical intervention to supplement and support my patient’s recovery. Similarly, it often happens that a patient is referred to me by a psychiatrist, medications already initiated, for on-going psychotherapeutic work, or talk therapy.

However it might come to past, the prevalence of psychiatric medications in circulation today is ubiquitous, and everyone – patients, family members, psychologists, psychiatrists, and allied professionals – has their role to play in the management of this phenomenon and its far-reaching consequences. This is what I hope to explore in more detail in this article.

• Psychiatric meds in the 21 st century: A cloudy milieu.
• Medical vigilantism: Who is your Guru?
• So, why do people suddenly stop their meds?
• Handing back the reigns in ‘health’.
• Resources

Psychiatric meds in the 21 ^st century: A cloudy milieu.

The proliferation and use of psychiatric medications today has produced many curious, challenging – certainly – predictable and, at times, unforeseen, consequences that confront us all at some point or another. Increased contact and collaboration between different role-players, shifts in and struggles for the balance of power, advocacy rights groups, mistrust fostered through miseducation at times, and, indeed, professional negligence and/or misappropriation at still others, prevailing socio-political trends, dissenting views, beliefs, and ideas about the role and necessity of medication in our lives more generally, are but some of the many dissonances that pique this lively space.

If all that wasn’t enough, today’s milieu is rendered more complex via the waxing and waning of our mutual confidences in, and understanding of, the mechanism(s) of action that underwrite treatment efficacy with medication. This dearth of exactness remains a blight on the mental healthcare professional’s mandate, particularly in his ability to motivate for – confidently – the use of psychiatric medication as the clinical mainstay for treatment of psychiatric disorders above all other, or at least in conjunction with, other interventions.

Our own knowledge, therefore, of how – precisely – why - precisely – and when – precisely – medications do and do not ‘work’, is a recurrent topic of intensive study, controversy, and debate. And while the aforementioned quandaries play out largely between men and women in white coats with petri dishes, it would be an assumption easily dismissed to suggest that our wavering confidences in our own knowledge has had no deleterious effect on the subsequent dissemination, perception and use of psychiatric drugs in the general public, even though they remain the sole beneficiaries of our collective research endeavours.

Medical vigilantism: Who is your Guru?

This breakdown of trust is perhaps one reason why, for better or for worse (prescience pending…), there are so many divergent – at times, contradictory - branches of interest competing today in the ‘alternative medicine’ arena, all espousing their own treatment modalities and (claimed) outcome efficiencies - ketamine, esketamine, psilocybin, cannabis-assisted, ayahuasca retreats, to name a few. A necessary and requisite trust has failed, it seems, one that would otherwise have served to bind us together under the weight of what we do not yet know, whilst in pursuit we go of further clarification. Failing which, as I suspect has already happened, a kind of ‘medical vigilantism’ has ensued, one which seems to have taken up resonance with many dis-configured, vulnerable parties in whom science, given their inevitable blunders, no longer turns the key towards a kind of certainty they feel they need.

This state of affairs, rather unfortunately, makes for a highly fragmented framework from which to attempt to intervene meaningfully in people’s lives with psychiatric medications. Notwithstanding the innumerable challenges highlighted above, I, as a healthcare practitioner in the 21 ^st century, continue to hold to the notion that when these two entities – namely, psychology and psychiatry – work well together, they can facilitate the optimal treatment conditions for a patient’s eventual return to adequate functioning.

So, why do people suddenly stop their meds?

Less controversial, perhaps, but of no less interest to me, is why it is that so little thoughtfulness goes into coming off one’s medications (or ‘titrating’, in medical parlance) relative to the amount of investment that goes into the initiation phase of treatment. More often than I would like to encounter do I see the effects of a cursory attitude towards such an important decision wreak havoc on a patient’s emotional stability, even, in some instances, bringing one’s hitherto gains in the therapeutic process into disrepair.

The ensuing cognitive-emotional reactivity resulting from such a decision is a consequence of the sudden withdrawal, and subsequent disruption to, the delicate alchemistic balance that had come to be been entrained and maintained in the brain via the medication(s) (provided, of course, they were being taken with due compliance to begin with).

Psychiatric drugs are incredibly powerful, their effects immediate and pronounced, and they initiate a recurrent and complex set of neuromodulatory consequences in the brain’s neurochemistry. These effects are their intended purpose. Bringing a sudden halt to the availability of these targeted alchemistic affordances introduces a schism that the brain’s neurochemistry is then forced to respond to, the effects of which are experienced by the person as a labile mood, anxiety, confusion, and dysphoria, albeit temporarily or until such time as the brain has managed to recover from the withdrawal.

Noting the apparent, at times, lopsidedness between the investment at the initiation vs titration phases of treatment warrants some investigation, does it not? It is an interesting phenomenon to ponder, given that both its frequency and associated negative outcomes are so willingly endured by so many. When this happens, I will inevitably hear of the wave of anxiety that sweeps over the patient who attempted - on a whim - to stop their psychotropic medications, such were the effects of the withdrawal that followed. In predictable fashion they soon report that they, on second thought, don’t feel they were ready to come off their medications.

However, what they are failing to realize in the current circumstances is that what they are actually perceiving - in vivo - is, in fact, their active withdrawal from the medication(s) in question (and their associated side-effects) and not what they would have likely experienced had they entered into the titration process more thoughtfully, carefully. In other words, the kickback of their ensuing dysphoria should not be taken, a priori, as the predicted posterior outcome reflecting their ‘true’ state of readiness to otherwise titrate their medication. Stopping one’s medications whilst holding oneself in mind tends to facilitate far more forgiving, tolerable outcomes that to do otherwise, hence the rather unrestrained tone of this article’s title plea.

Why, then, might this occur? Is it the case, perhaps, that the patient themselves, no longer in states of such desperate disarray, can now transcend the dependency they once had on others (i.e., their treatment team; family) and, in such moments of invulnerability, ‘forget’ about themselves and their wellbeing. Or is it perhaps the (unconscious) effect of a gradual tapering off of the care, thoughtfulness and attention once received and enjoyed from various role-players (psychiatrist, psychologist, family members) during the initiation phase, which, after a period of time, as it naturally starts to taper off then increases the likelihood of this medical Hail Mary (things like: Psychiatrist: ‘Here, take this every morning at the same time after breakfast, and come back and seem me in a month from now to see how you’re doing’)? Plausible, certainly. Or is it simply that they now ‘feel better’ and are inclined, therefore, to overlook the value of consistent self-care, including how to come off their medications timeously and thoughtfully? Possibly. Is it instead a murmur of the insidious work of unconscious self-sabotage again rearing its head in the patient, which seeks to keep them on their rollercoaster of disrepair? Perhaps. Or is it less inconspicuously simply a matter of miseducation?

It is worthwhile considering it from the other cheek as well, namely from the side of the mental healthcare professionals themselves. Might they (unconsciously, too) like the feeling of helping more when someone is in need, rather than when the patient has been successfully treated, thus overlooking the value of their role in such a decision? We are, after all, people too, prone to the natural ebb and flow of our own ever-changing need/feeling configurations, which, sometimes require us (again, unconsciously) to need a patient more when they need us and less so when they do not.

Although less common (one would hope, at least!), I do believe the latter consideration is still worth noting. There have been times in my own practice when the arc of treatment is running its course that I have caught myself becoming more complacent – less attentive - to the implicit value of my passive-observer role in this phase of treatment. It is often during these lapses that I have been caught off-guard with the dreaded phrase: ‘oh, by the way, I’ve decided to stop me medications.’ ‘How did I miss that,’ I am left thinking? ‘Was I not paying attention to them?’ ‘Have I stopped caring about this patient in ways that I used to?’ It is tempting to fob these musings off with a self-reassuring ‘No’, but then I might be inclined, at that moment, to seek out instead another vocation to better pass my time.

Handing back the reigns in ‘health’.

Paralleling anything that might represent the ‘true’ cacophony of reasons for a patient suddenly stopping their meds, is this: if it is true that the process of a therapy is about a slow, methodical return to agency (among other things) within the patient, then part of that agency must concern, as one of its vital markers, a sense that the patient is able to make sound decisions for themselves. Making sound decisions for themselves (i.e., the provision of reasonably applied judgement over time) about themselves (and others) includes, centrally, such a decision process exemplified in the act of coming off one’s meds.

At a certain point, then, considering that mental healthcare professionals generally do want their patients to get better, the reigns need to be handed back to the emerging agentic patient. In other words - and said in as much a non-defensive tone as is possible - once the patient is no longer as helplessness as they once were after effective treatment, it would be unreasonable for psychiatry and psychology to shoulder too much responsibility for such a disruption in treatment.

Helping people towards reclaiming their agency should not mean that, forevermore thereafter, mental health care professionals need to be holding in mind, or even preempting, their patients’ every decision. If the patient hasn’t learnt to care for themselves in necessary, kind, and important ways, then their decision to abruptly stop their medications is to be treated as yet another symptom of the patient’s underlying psychological functioning, requiring, therefore, without disdain or judgement, another foray into their deeper selves to those parts that might need further attenuation, healing, and consolidation over time.

Bryn O’Reilly is a South African-born clinical psychologist living in the Central Algarve, Portugal. It is from there that he runs his private practice, offering both in-person and online services.

Resources

Mind - Guides individuals considering stopping mental health medication, emphasizing careful planning, understanding potential withdrawal effects, and consulting healthcare professionals.

WebMD - Explains the process and symptoms of antidepressant withdrawal, providing tips for managing effects and highlighting the importance of tapering under medical supervision.

Medical News Today - Explains the effects of stopping antidepressants, including potential withdrawal symptoms and how they vary by person. It emphasizes the importance of gradually tapering off under medical guidance to avoid serious side effects.