How to Taper Antidepressants: A Practical Perspective on Tapering Antidepressant Medications with Mindfulness and Microdosing
Navigating the decision and process of tapering an antidepressant medication in a personalized and supportive way.
By Katie Simons, PharmD, BCPS
Tapering antidepressant medications is a transformative process that takes time, energy, and flexibility. Due to the often chronic use of antidepressant medications to treat anxiety and depression and lack of data supporting tapering practices, providers are often ill-equipped to assist with taper plans. The end result for many people is a lack of practical, accessible guidance on tapering. Some people find the tapering process too quick for their bodies and minds to adapt, leaving them with undesirable withdrawal symptoms that often mimic the very anxiety or depression they are trying to alleviate. The process of tapering an antidepressant medication should be individualized and driven by your personal experience, not a standard protocol.
This guide is built to help you better understand the tapering process in a personalized and supportive way. It should not be used as a substitute for medical and professional advice.
Assessing Your Readiness to Taper Antidepressant Medications
Many factors determine your readiness to taper prescription antidepressants. As you make this decision for yourself, here are a few things to consider.
Questions to ask yourself in assessing your readiness:
Is my mental health currently stable, and can I maintain a sense of safety during the tapering process?
Has my mood been improved on my current dose and been stable for 6-9 months?
What is my current relationship with my antidepressant? Am I ready to go through life without it?
Am I ready to undergo a process that may be emotionally or physically difficult at times?
Do I feel I have the tools and personal and professional support I need to make the transition off of my antidepressant?
Am I willing to make other lifestyle changes to support myself during the prescription taper process, if necessary?
Can I tell when I am having a mental health crisis and do I have a plan if it occurs?
If the answer to any of the above questions is “no”, it may be beneficial to prepare further by discussing your plans with your provider, therapist, or health coach prior to starting the tapering process.
“The Ask” of the Body and Mind when Tapering an Antidepressant
The underlying cause of mood disorders, such as depression and generalized anxiety, continues to evade Western medicine. Many of us within medical and healing communities believe these are symptoms that have their roots in nervous system dysregulation, often stemming from prenatal or developmental (early childhood) trauma.
Our autonomic nervous system (the part of our nervous system that controls our body’s unconscious processes such as breathing, digestion, and our heart beat) is divided into two main systems: the sympathetic and parasympathetic nervous systems. When we perceive danger, our sympathetic nervous system activates our fight/flight (survival) response. If our fight/flight response is unsuccessful, our parasympathetic system takes over and activates our freeze (emergency) response. Our parasympathetic system is also responsible for our rest and digest (safety) response. A well-regulated nervous systems moves easily between states.
Our nervous system begins to develop around the third week of pregnancy and continues for several years after birth. During gestation, we begin to recognize and respond to “threats” within our environment. Before the age of about 7, we are sponges and readily absorb external stimuli that trigger our fight/flight/freeze response creating the blueprint for our nervous system that is then programmed into our subconscious mind. These “threats” and external stimuli range from stress hormones from our mothers while carrying us in their wombs, to being teased or bullied by peers or caregivers, to being emotionally or physically abused.
As adults, this subconscious program from childhood continues to operate behind the scenes, sometimes causing us to react to perceived “threats” even when they are no longer harmful. When the nervous system is calibrated to perceive and react to unharmful “threats,” we can quickly become overwhelmed by out of place feelings and the need to fight (anger) or flee (anxiety) (also known as hyperarousal), or freeze (depression) (known as hypoarousal). This can hijack our nervous system, create unsupportive behaviors and become detrimental to our bodies, and emotional, mental and physical wellbeing.
Often times, antidepressant medications are prescribed without a full understanding of our history, the dynamics of our triggering process or our feelings. Today’s cultural expectations generally assume that life is overwhelming and feelings of depression (freeze) or anxiety (flee) are considered somewhat normal. Since their discovery, the medical community has relied heavily on SSRIs/SNRIs to help people deal with feeling overwhelmed. When SSRIs were first presented to the medical community by pharmaceutical companies, there was a lot of hope they would cure depression and anxiety.
Unfortunately, that has not been the case. To make matters worse, we now know that pharmaceutical companies withheld the publication of studies showing SSRIs are no better than placebo in mild to moderate depression, choosing to publish only positive results instead. With all this data now made public, we know that the therapeutic benefit of SSRIs over placebo is much smaller than originally thought.
So, what is “The Ask” of the body and mind when beginning the process of tapering an antidepressant? It’s to begin to work with our nervous system by being mindful of the sensations in our body. As we remove the medication that seemingly makes the feelings more manageable, nervous system regulation requires us to practice feeling, identifying, and processing our emotions. The best part about this ask is that is is attainable for everyone.
Mindfulness Tools for Rebuilding the Mind-Body Connection
Mindfulness is a term that is thrown around a lot and often times seems mystical, but it is actually quite grounded and practical. Mindfulness is simply allowing ourselves to feel our emotions as they comes up and having the awareness to name and accept the sensations within our body. We can then process these emotions and sensations by recognizing and tapping into healthy expressive outlets.
Mindfulness is a state of being, and studies have shown that being mindful creates a sense of safety in our bodies by activating the rest and digest state of our parasympathetic nervous system. As we begin to practice mindfulness, it may feel unnatural and even uncomfortable at first. Many tools can assist us with this practice, such as breath work, intentional movement, meditation, sound, and microdosing psychedelics.
The journey from muting the sensations of our nervous system response to mindfully being present brings us back to a felt sense (or whole experience) of life that includes the knowledge of our own innate capacity and resilience. Simple mindfulness practices, such as naming an emotion and feeling it fully, have been shown to trigger our parasympathetic nervous system, which creates a sense of calm and safety in our body. In other words, our bodies are literally wired to support our ability to feel and process emotions instead of suppressing them, even when we experience difficult emotions.
Tools that help us practice mindfulness and increase our capacity and resilience in the face of difficult emotions include, but are not limited to, the following:
Breathwork
Meditation
Intentional movement including yoga, tai chi, ecstatic dance, etc
Sound
Microdosing psychedelics
The part of mindfulness practices that tends to baffle people a bit is the part of quieting the mind. We live in a society that over-emphasizes cognitive understanding and processing of information and under-appreciates the felt experience of being in our bodies and feeling the sensations of being a human.
The felt sense of being human is so under-appreciated culturally that many people do not know how to stop the chatter in their minds and just feel their bodies. This dissociation is part of what mindfulness practices help us repair; they help us embody mindfulness by rebuilding the mind-body connection through nervous system regulation.
As you begin to practice mindfulness and rebuild your mind-body connection, it may feel awkward at first. With time, you’ll begin to realize that you have access to a very calming space whenever you need it. Instead of being hijacked by big emotions, you’ll realize you have the capacity to pause long enough to recognize what’s going on in your body and to respond mindfully instead of reacting to an emotion. The more comfortable you become with feeling the sensations of emotions within your body and being able to recognize what is triggering them, the more you’ll have access to information regarding the underlying causes of your depression and anxiety.
These practices are all available to everyone, truly. If you are working with a coach or therapist, ask them to assist you in identifying practices that can be integrated into your daily routine. If you do not have a coach or therapist supporting you, you can find these practices on YouTube or with a Google search. There are endless resources available online, so be curious and see what intrigues you.
The most important piece of all of these practices is making them part of your daily routine. They are a practice, so they take practice. Creating the time and space, even if it’s just 10 minutes a day, for mindfulness practices is the best way you can support yourself through this process.
Withdrawal Symptoms vs Recurrence
It is important to remember that your response to tapering can run the entire gamut of experiences. Some people stop their antidepressant cold-turkey and have no change in mood or symptoms of withdrawal or recurrence, whereas, others experience both with only small decreases in dose. The medical community does not have a good enough grasp on this to predict your individual experience.
Stil, tapering is an INDIVIDUAL experience. The protocols and tapering outlines available in this guide, on the internet, and from your provider are guides only. They are general outlines to assist you with this process and meant to be informed by your felt experience. It is so very important to listen to your body and honor what it is telling you through this process. Be flexible and allow yourself the time and space for this process to unfold whether it takes 4 weeks or 6 months.
Generally speaking, tapering an antidepressant decreases the rate and severity of withdrawal symptoms compared to stopping cold-turkey. Withdrawal symptoms affect anywhere from 27-86% of people. On average, 56% of people experience these symptoms at some point while stopping an antidepressant.
Withdrawal symptoms include, but are not limited to: fatigue, insomnia, dizziness, nausea, sensory disturbances such as feeling abnormal sensations or ‘brain zaps’, anxiety, irritability, and other “rebound symptoms” similar to the original illness the medication was prescribed to treat. Typically, symptoms occur within one week of decreasing or stopping an antidepressant. This quick onset suggests symptoms are related to withdrawal as they tend to resolve with time.
It is important to note this timing as often times withdrawal or rebound symptoms are confused with disease recurrence and used as justification for why a medication is “needed” to manage symptoms. The goal of tapering is to minimize the severity and duration of withdrawal and rebound symptoms.
Many folks find that tapering an antidepressant goes fairly smoothly until they get down to really small doses. This may be because the changes to serotonin receptor occupancy (the percentage of serotonin receptors being occupied by the medication) do not drop significantly until the dose of antidepressant is back to starting doses or less. In other words, the effect of the medication in the brain does not decrease linearly. For this reason, taper plans with a larger decrease in dose at the beginning may be tolerable while still requiring small, incremental decreases in dose or longer periods of time on a given dose towards the end of the taper.
Alternatively, the recurrence of depression or anxiety typically occurs 3-4 weeks after stopping the antidepressant completely. As discussed previously, antidepressants do not address or cure the underlying nervous system dysregulation that contributes to depression and anxiety, so unless these challenges are addressed, the possibility of disease recurrence remains.
Ideally, by using mindfulness tools and support strategies to address the underlying causes for your depression or anxiety during the process of tapering, you’ll feel equipped to better regulate your nervous system and emotional responses by the time you are off the medication.
Microdosing as a Mindfulness Practice
Microdosing psychedelics has been reported by 1,000s of users to have a broad range of beneficial effects. Compiled data of user experiences report consistently improved focus, creativity, mood, sleep, physical energy, emotional awareness, presence, and emotional connection to others with a small percentage of people (less than 4%) reporting negative effects. As a mindfulness practice, microdosing can assist with becoming aware of emotional sensations within the body and rebuilding the mind-body connection.
Microdosing by itself is not a “magic bullet.” It is a tool to assist with the work of embodying mindfulness. Psychedelics disrupt coordinated brain activity in the regions of the brain collectively termed the Default Mode Network (DMN). These are the areas of the brain associated with “autopilot” cognition, introspection, rumination, sense of self, autobiographical memory, and future imagination. In other words, the DMN is where the subconscious operates from.
When the DMN is disrupted, there is a window of neuroplasticity, or increased ability to create new neural pathways, during which subconscious programs are easier to release and replace. For this reason, microdosing has the most benefit when it is used with proper preparation, intention, and integration. Microdosing creates neuroplasticity; creating new belief structures is your job. Working with a microdose coach or professional to assist with the process can be helpful in creating sustained change from the practice of microdosing.
A microdose should be sub-hallucinogenic and often the effects are so subtle that they are not physically perceptible. The effects are often noticed in mood, creativity, attention, etc. The effects of psychedelic substances used in microdosing, such as LSD or psilocybin, are blunted by most antidepressants. They are safe to use at the same time, but the dose may be on the higher end of microdose range for the substance being utilized.
There are several different microdosing protocols, varying from dosing 4 days a week to dosing every third day. None of them are a daily practice in order to prevent tolerance to the substance. All of them are taken over a span of weeks with a scheduled 2-4 weeks rest after completing the cycle.
For complete transparency, there is no data showing microdosing to be helpful for tapering antidepressants. That said, I have found in my practice that many people find it to be a helpful tool to assist with this process. The benefits I have seen with clients include improved mood, assistance with withdrawal symptoms, and enhanced ability to practice mindfulness and nervous system regulation.
For more information on microdosing, check out The Microdosing Institute here: https://microdosinginstitute.com/microdosing-101/.
Please note, psychedelic substances are still illegal in many states and federally within the US and other countries, even in small amounts. It is important to educate yourself on the legality of taking these substances before you start.
Example Taper with Microdosing Protocol
Since there are many, many antidepressants and antianxiolytics on the market, this example is simply a general starting point to give you a sense of what a taper protocol can look like when coupled with a microdosing protocol.
Things to consider when building a practical taper plan:
Starting dose, available formulations of medication (tablet, capsule, ER formations, suspensions, etc), and smallest commercially available dose should all be considered to build a practical taper plan.
Prescribing providers should always be included in the conversation when tapering an antidepressant. Ideally, they will be willing to work with you to create, monitor, and adjust your taper plan as needed. At the very least, it is important to stay in touch with your prescriber so you don’t run out of medication during the tapering process.
Generally, taper plans span over 10-12 weeks when starting on a full dose. That time frame is helpful as a starting point, but once the taper begins, the length of the taper should depend on your experience. Sometimes tapers take 6-12 months, and that is ok.
Many antidepressants are prescribed as extended release tablets or capsules and are not intended to be split or opened because when these formulations are split or opened their absorption is altered. In these cases, it is important to work with an immediate-release tablet or capsule or a liquid formulation that is safe to take in smaller increments.
If tapering with the smallest, commercially available prescription dose is not tolerable due to withdrawal and rebound symptoms, the best option is to work with your provider to obtain a prescription for the medication in liquid suspension formulation so you can taper 1-5mg at a time, depending on the medication.
Example: Tapering prescription Sertraline 100mg daily
Considerations before starting: Sertraline is available as an immediate-release tablet formulation. The smallest, commercially available tablet strength is 25mg and can be split in 1/2 or 1/4 because it is immediate release.
Week 1: Sertraline 100mg daily. Start microdosing protocol every third day.
Establish microdose by stepping up the dose of psychedelic substance in small increments every third day until the dose is just barely perceptible or there is a perceived shift in mood, attention, sleep, or other somatic symptoms.
Weeks 2-3: Sertraline 75mg daily. Continue microdosing every third day.
Assess if dose of psychedelic needs to be decreased based on perceptibility. Adjust as needed.
At the end of week 2, assess tolerance of lowered dose
If tolerating well with no changes in symptoms, proceed with taper.
If withdrawal symptoms have occurred at any time or if the person has a history of withdrawal symptoms when stopping an antidepressant, increase dose to 87.5mg daily, continue that dose until withdrawal symptoms have resolved, and continue taper with 12.5mg dose increments instead of 25mg.
Weeks 4-5: Sertraline 50mg daily. Continue microdosing every third day.
Assess if dose of psychedelic needs to be decreased based on perceptibility. Adjust as needed.
At the end of week 4, assess tolerance of lowered dose as above
If tolerating well with no changes in symptoms, proceed with taper.
If withdrawal symptoms have occurred at any time, increase dose to 62.5mg daily, continue that dose until withdrawal symptoms have resolved, and continue taper with 12.5mg dose increments instead of 25mg.
Weeks 6-7: Sertraline 25mg daily. Continue microdosing every third day.
Assess if dose of psychedelic needs to be decreased based on perceptibility. Adjust as needed.
At the end of week 6, assess tolerance of lowered dose as above
If tolerating well with no changes in symptoms, proceed with taper.
If withdrawal symptoms have occurred at any time, increase dose to 37.5mg daily, continue that dose until withdrawal symptoms have resolved.
Weeks 8-9: Sertraline 12.5mg daily (1/2 tablet). Continue microdosing every third day.
Assess if dose of psychedelic needs to be decreased based on perceptibility. Adjust as needed.
At the end of week 8, assess tolerance of lowered dose as above
If tolerating well with no changes in symptoms, proceed with taper.
If withdrawal symptoms have occurred at any time, increase dose to 18.75mg daily, continue that dose until withdrawal symptoms have resolved.
Weeks 10-11: Sertraline 6.25mg daily (1/4 tablet). Continue microdosing every third day.
Assess if dose of psychedelic needs to be decreased based on perceptibility. Adjust as needed.
At the end week 10, assess tolerance of lowered dose as above
If tolerating well with no changes in symptoms, proceed with taper.
If withdrawal symptoms have occurred at any time, increase dose back to 12.5mg daily, continue that dose until withdrawal symptoms have resolved, and consider switching formulation to liquid suspension in order to decrease dose by 1-2mg increments until off.
Week 12: Stop sertraline. Continue microdosing protocol.
Week 13: End microdosing protocol. Take 2-4 weeks off microdosing and assess whether another 12-week round would be supportive.
The Benefits of Working with a Coach
Throughout this document, I hope to have presented a perspective of empowered healing. We create our personal realities in our minds. The work of reconnecting to our bodies, regulating our nervous systems, and becoming aware and mindful of ourselves is how we create the change we want in our health and lives.
We are not meant to do this work in a vacuum. Creating lasting change requires a literal rewiring of brain pathways and shifting the paradigm of how we view our bodies and the world. The process can often feel uncomfortable.
Working with an individual who can hold space for your work, has done this work for themselves, has personal experience with microdosing, and can act as both a support and guide, logistically and emotionally, through this process is invaluable.
The role of a coach includes but is not limited to:
Holding space for you as you are right now
Encouraging self-compassion and continued curiosity
Mirroring back self-limiting belief structures
Providing a safe space to explore, connect with, and express emotions
Offering alternative perspectives as you discover new, aligned belief structures
Assisting in processing and integrating emotions and insights that arise with microdosing
Inviting personal accountability for mindfulness practices
Providing access to different mindfulness modalities, such as breath work or somatic release practices
If you are looking for assistance with coaching or building a personalized taper plan, please reach out to set up a strategy call with me at TheHolisticApothec.com.
Please remember, this guide is not intended as medical advice, a substitute for medical care, or promotion for illegal activity.
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