Going off your meds? Taper, don't go cold turkey.

I've discussed the potential problems that come with going off SSRIs in the past. In my experiences, these have included light-headedness, a feeling of going inside your head, a feeling of distance from the world around you -- and, in the case of Paxil, what some call the "zaps," the feeling that there are tiny electrical storms taking place in your brain. (Quite disconcerting, this sensation.) In the past, when I've gone off SSRIs -- and I've discontinued taking several of them over the years, either because I was feeling well and convinced I could do fine without them, or because I was sick and tired of the side effects -- I've had more success at avoiding unpleasantness when I weaned myself slowly rather than stopping suddenly, all at once.

But it turns out that the downsides of quitting psychiatric medications cold turkey go beyond discomfiting sensations while your brain is adjusting to life without meds. According to a recent study in the American Journal of Psychiatry, cited here, going off your meds quickly can result in your ailment storming back into your life. From the link:

In patients with major depressive disorder, panic disorder, or bipolar disorder, the risk for illness recurrence is far greater following abrupt or rapid, vs gradual, discontinuation of clinically effective antidepressant treatment....
"The general point for clinical practice," Dr. [Ross J.] Baldessarini said, "is that it appears that most psychotropic drugs, when discontinued abruptly or rapidly, can lead to early and severe exacerbations of the illnesses being treated.

"It is my impression that this concept has been widely accepted and that clinical practice has been modified appropriately in many cases to include gradual dose tapering and slow discontinuation when feasible clinically," he added.

Optimal dose-tapering times and protocols still need to be worked out, Dr. Baldessarini noted. However, in general, he said, it is wise to taper off most psychotropics during at least several weeks.

Dr. Baldessarini is an MD at Harvard Medical School and Massachusetts' McLean Hospital, so if you're not willing to listen to me when it comes to this stuff, perhaps his voice carries a little more authority to you.

Feeling crazy? There's an app for that.

I've looked at various ways researchers and therapists are using high technology to treat and study anxiety and panic in various posts in the past. Along those same lines, a recent NPR piece entitled Mental Health Apps: Like a 'Therapist in Your Pocket' addresses the increasing availability of mobile apps for use in managing a variety of mental health ailments. From the article:

Here's how one of the apps, called "Mobile Therapy," works: Throughout the day at random times, a "mood map" pops up on a user's cell phone screen. "People drag a little red dot around that screen with their finger to indicate their current mood," says Dr. Margaret Morris, a clinical psychologist working at Intel Corp. and the app's designer. Users also can chart their energy levels, sleep patterns, activities, foods eaten and more, she says....  

Morris designed the app, which can be downloaded onto most cell phones, to try to help people manage the stress of everyday life, to improve their mental health and reduce the risk of cardiovascular disease.

Based on the information entered by the user, the app offers "therapeutic exercises" ranging from "breathing visualizations to progressive muscle relaxation" to useful ways to disengage from a stressful situation, Morris says. And the information the app captures can later be charted, printed out and reviewed. The idea is that users can look at a whole week of mood data to see if there are any connections between their mood and other factors happening in their lives, and record it into the app.

Morris' Mobile Therapy app has been beta-tested in 60 people, and "everyone who used it described new insights about their emotional variability" and said it helped reduce their stress, she says.

Speaking as someone who's suddenly on time to appointments a whole lot more often now that I have a smartphone and essentially carry my calendar (and its built-in alarm) with me 24/7, I say Whatever works.

How about you? Have you tried any mental-health apps? How'd it go?

On nervous breakdowns.

Chances are, if you've been agoraphobic, depressed, or anxious for any significant portion of your life, you've experienced something approximating the classic nervous breakdown -- a feeling of being overwhelmed by life and a capitulation to and admission that you are helpless to overcome the pain it brings.

On the Verge of 'Vital Exhaustion?' is a New York Times piece from Sunday, May 31. It traces the history of the concept of the nervous breakdown:

This is the latest umbrella term for the kind of emotional collapses that have plagued humanity for ages, stemming at times from severe mental difficulties and more often from mild ones. There have been plenty of others. In the early decades of the 20th century, many people simply referred to a crackup, including “The Crack-Up,” F. Scott Fitzgerald’s 1936 collection of essays describing his own. And before that there was neurasthenia, a widely diagnosed and undefined nerve affliction causing just about any symptom people cared to add.

Yet medical historians say that, for versatility and descriptive power, it may be hard to improve upon the “nervous breakdown.” Coined around 1900, the phrase peaked in usage during the middle of the 20th century and echoes still.

It also looks at evolving attitudes towards sufferers of nervous breakdowns:

A nervous breakdown was no small thing in the 1950s or ’60s, at least by the time a person arrived at a doctor’s office. Psychiatrists today say that, most often, it was code for an episode of severe depression — or psychosis, the delusions that often signal schizophrenia.

“I don’t remember people who got that label ever using it as their own complaint — it was very much stigmatized,” said Dr. Nada L. Stotland, a former president of the American Psychiatric Association and a professor at Rush Medical College in Chicago, who began practicing in the 1960s. “Whether it was ‘nervous exhaustion’ or ‘nervous breakdown,’ anything that sounded psychiatric was stigmatized at that time. It was shameful, humiliating.”

Famous people who've had nervous breakdowns include Beach Boy Brian Wilson (upon hearing the Beatles' Sgt. Pepper's Lonely Hearts Club Band), comedian Richard Pryor (onstage in Las Vegas in 1969), Enron CEO Jeffrey Skilling (as evidence of his company's greed, arrogance, and disregard for the law came to public light), writer Joan Didion (who wrote about hers in The White Album) ... the list goes on.

Special bonus (!): an autobiographical depiction of a nervous breakdown (at least, I think that's what it was)....

Whoosh. The automatic door closed behind me, and I stood there in front of the Walgreens. In my chest I sensed the emotion beginning to gallop, a dark, unsettled feeling; if I didn’t seize the reins, I knew, that feeling would only grow. In my mind I saw the Asian man at the pharmacy counter, handing me my bank card and saying, “Sorry, insufficient funds.” 

Around me, the neighborhood went about its midday business. A pretty Latina mom walked by pushing a stroller and talking on a cellphone. A couple of teenaged boys in baggy jeans and oversized white t-shirts; a lady cop, strolling her beat. All of them walking right past me, inches away, without even noticing me. I might as well have been a ghost.

It had been 16 years since my first panic attack. I’d had thousands more since then. Without my pills, I knew, I faced the danger of yet another debilitating cycle of panic. Because of panic, I was 40 years old but unable to keep a steady job. Because of panic, I was almost $60,000 in debt. Each night when I brushed my teeth my gums bled, but I couldn’t afford to visit a dentist. I couldn’t afford health insurance, either, and even if I had been able to, my pre-existing condition made me an unacceptable risk to insurers. And because of panic, I’d lost every woman I’d ever loved, and more than a few important friendships.

I really, really didn’t want to start having panic attacks again. I’d long since stopped believing panic signaled imminent death, yet the attacks remained searing, unbearable; each and every time, they left me feeling like I’d been the victim of physical violence. I was tired of fighting them off, of trying to soften my shoulders and breathe slowly and evenly into the depths of my belly, of telling myself this will pass, this is only temporary. I was tired of the knowledge that even as I endured one panic attack, there was always another waiting to strike.

Twenty years earlier, if you’d told me this was where I’d end up, I’d have laughed right in your face. I was popular. I'd gone to an Ivy League school. I had a fancy job on Wall Street. I was good in front of an audience. Girls liked me. The future seemed bright.

Too often since then, though, I’d been seized by sudden, inexplicable terror. In banks, department stores, supermarkets, bodegas, fast food restaurants, airports, subway stations, elevators, taxicabs, movie theaters, night clubs, art museums, auto dealerships, jury-selection waiting rooms, Las Vegas casinos, and multi-level parking structures; on ski lifts, commuter railroads, crosstown buses, suspension bridges, fishing boats, downtown sidewalks, and alpine hiking trails. And that’s just the short list.

I’d been transformed in the process.

The January sun shone down on Mission Street, penetrating and merciless. Something had to change, I knew; if it didn't, I'd end up killing myself or caked in dirt and living under a highway overpass, all my worldly possessions stored in a shopping cart. I'd missed so much, lost so much, failed in so many ways.

The weight of memory pressed down on me, and right there on Mission Street, all 6'5" and 250 pounds of me, I began to weep.