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Antipsychotic Withdrawal Symptoms, Signs, and Detoxification

When you think about substance abuse, you probably think of substances such as heroin, cocaine, and alcohol—not psychiatric medications. Although they aren’t abused as commonly as illicit drugs, antipsychotics can be abused, and are in fact finding their way onto the streets.

The lure of antipsychotics may be different from other types of substances that come to mind. Growing research suggests that antipsychotic misuse is attributed to its calming effects on the brain and body as opposed to causing feelings of euphoria.1 People who struggle with anxiety and sleep disorders may be prone to misusing antipsychotics because of this.1 

Medical professionals are becoming increasingly concerned about the potential for misuse of antipsychotics including quetiapine (often referred to by the brand name Seroquel). Changes in prescribing practices over the past century may shed light on the increase in antipsychotic use.1 As awareness has spread about the potential dangers of benzodiazepines and barbiturates, practitioners have changed their prescribing practices, which has led to the prescribing of more antipsychotics.1

What Are Antipsychotics?

Antipsychotics are mainly prescribed to treat mental health disorders that have psychosis as a main symptom, such as bipolar disorder, severe depression, and schizophrenia.2 Antipsychotics do not cure mental health disorders, rather they help alleviate certain symptoms.

There are two categories of antipsychotics: first-generation and second-generation antipsychotics. First-generation antipsychotics are also called typical antipsychotics or neuroleptics and include medications such as fluphenazine, perphenazine, haloperidol, and chlorpromazine.2

Second-generation antipsychotics, also known as atypical antipsychotics, were developed after first-generation antipsychotics, and several can treat a broader range of disorders.2 Some common second-generation antipsychotics include risperidone, quetiapine, ziprasidone, and olanzapine. Quetiapine, also known by the brand name Seroquel, is a medication that can be used to treat schizophrenia, bipolar depression, mania, and unipolar depression; it can be used alone or combined with other medications. It also can be used to help prevent manic or depressive episodes in people with bipolar disorder.3 

Antipsychotics are sometimes used with a combination of other medications to treat various other mental health disorders. These can include depression, posttraumatic stress disorder (PTSD), eating disorders, attention-deficit hyperactivity disorder (ADHD), and anxiety disorders including generalized anxiety disorder and obsessive-compulsive disorder (OCD).2 In fact, growing research is suggesting that atypical antipsychotics combined with antidepressants (especially SSRIs) can help improve the symptoms of drug-resistant depression. Low doses of second-generation antipsychotics combined with SSRIs can improve the antidepressant effects of SSRIs.4 Risperidone, an atypical antipsychotic, has been shown to be an effective adjunct treatment for PTSD and OCD.5

Like most medications that treat mental health disorders, antipsychotics influence various chemical transmitter systems in the brain. First-generation antipsychotics block a certain type of dopamine receptor, specifically the D2 receptors. Second-generation antipsychotics also block the D2 receptors, but, in addition, they block certain serotonin receptors. Some newer second-generation antipsychotics actually partially activate the D2 receptor rather than blocking it.6

Individuals can respond differently to the same medication, so it may take trials with different antipsychotics to find the right fit for an individual.2

Are They Abused?

Studies suggest that the most commonly abused antipsychotic is the atypical antipsychotic quetiapine (also known by the brand name Seroquel).1 Misuse of a prescription drug includes when a person obtains a prescription medication off the streets or from a friend or family member (as opposed to obtaining their own prescription from a medical provider), faking symptoms to obtain a prescription, using a medication more than directed by the prescriber, or otherwise using it in a way that was not directed. Signs that quetiapine is the most commonly misused atypical antipsychotic include that it has street names and black market value, that individuals will fake symptoms to obtain it, and that individuals will snort quetiapine or inject it into their veins.1

Atypical antipsychotics are sometimes used to treat withdrawal symptoms from substances such as cocaine, alcohol, opioids, and benzodiazepines. However, research has not found consistent evidence that this is successful. Furthermore, some case studies suggests that quetiapine can cause drug-seeking behaviors. 1 

Individuals may be more likely to abuse antipsychotics in restrictive environments such as jails and prisons since obtaining drugs off the street and obtaining controlled substances like opioids and benzodiazepines from medical providers generally aren’t options.1

Do They Cause Withdrawal?

Although you may have heard the term “withdrawal,” the term “antipsychotic discontinuation syndrome” may be new to you. Antipsychotic discontinuation syndrome is a name for the collection of symptoms that may occur when someone suddenly stops an antipsychotic or drastically lowers their dose.

A person may stop taking their antipsychotic medication for various reasons, such as because the medication is (or is perceived to be) not effectively treating symptoms, because it is causing unbearable side effects, or because the person does not think they should be taking the medication or do not agree with how they were instructed to take it.7

Symptoms that may be experienced during antipsychotic discontinuation syndrome include:7

  • Vomiting, nausea, and/or diarrhea
  • Difficulty sleeping, restlessness, anxiety, and/or agitation
  • Dizziness
  • Runny nose
  • Problems with muscle movement including involuntary muscle contractions, inability to stay still, and/or uncontrollable movements

Antipsychotic discontinuation syndrome symptoms generally appear within the first few days after you stop use or significantly reduce use.7 The symptoms tend to be the most severe around the one-week mark and subside after that.7

The limited research that does exist suggests that up to 40% of the people who stop taking antipsychotics, including first- and second-generation, may experience antipsychotic discontinuation syndrome.7

Discontinuation of clozapine, an atypical antipsychotic, has been shown to have more severe symptoms, including rebound psychosis, than discontinuation of other types of antipsychotics. Clozapine discontinuation is also associated with more rapid onset of symptoms.7

As previously mentioned, antipsychotics are sometimes prescribed with other types of medication, such as antidepressants. Suddenly stopping or significantly decreasing an antidepressant can cause an antidepressant discontinuation syndrome. Therefore, if an individual suddenly stops both an antidepressant and an antipsychotic medication, they may experience additional withdrawal symptoms or more severe symptoms. Antidepressant discontinuation syndrome symptoms may include:10

  • Dysphoria.
  • Gastrointestinal issues.
  • Sensory disruptions.
  • Dizziness and/or trouble with balance.
  • Fatigue.
  • Anxiety and/or hyperarousal
  • Trouble sleeping.
  • Headache.
  • Flu-like symptoms

When people who are prescribed antipsychotics for psychotic disorders stop taking them, some relapse, meaning that their psychosis returns. However, some patients are able to sustain a psychosis-free existence after the cessation of antipsychotics. Several studies show that only 25%–55% of patients with schizophrenia who stopped taking antipsychotic medication experienced the relapse of symptoms in the first 6 to 10 months after they stopped taking them.9

How to Safely Stop Taking Antipsychotics

You may wonder if you should stop taking antipsychotics. Beginning and discontinuing the use of antipsychotics is a quandary faced by doctors treating patients with psychosis. Research has yet to determine the best practices for management of schizophrenia over the long term.

You should never stop or change how you take your medication on your own. Talk to your medical provider prior to any medication changes or cessation of use. If it’s an emergency, such as if you are having severe side effects, call 911. Medical professionals can monitor your symptoms as well as provide guidance on safely titrating your dose. Research indicates that gradually lowering the dose of antipsychotics can decrease antipsychotic discontinuation syndrome symptom severity.7

When stopping or switching antipsychotics, medical providers may prescribe additional medication to help prevent or lessen the symptoms of withdrawal.11 Keep in mind that there is no “one-size-fits-all” when it comes to safely and effectively stopping or switching antipsychotics. Symptoms that were being treated with the antipsychotic, such as psychosis, depression, and agitation, can re-emerge after you stop taking the antipsychotic medication. Discuss any symptoms that develop with your healthcare provider.11

Short-term risks of stopping your antipsychotic medication include antipsychotic discontinuation syndrome and the return of symptoms that were being treated. Long-term risks can also include the return of symptoms.

Treatment Options

If you are using an antipsychotic as prescribed by a medical professional but would like to stop it or switch to something else, talk with your healthcare provider. If you struggle with misusing antipsychotics, you may need substance use disorder treatment. Options for treatment providers include general mental health care providers and providers that specialize in substance use disorders specifically. Treatment may be offered in an inpatient and/or outpatient setting.

If you suffer from a mental illness and also struggle with misusing antipsychotic medication, you may want to consider a treatment setting that specializes in integrated care for co-occurring disorders. Co-occurring disorders are when a person has both a substance use disorder and a mental health disorder.  For individuals with co-occurring disorders, integrated treatment that addresses all psychiatric disorders provides better results.12

Severe depression, bipolar disorder, and schizophrenia can have severe symptoms. Those symptoms combined with withdrawal symptoms can be especially challenging. Staff in facilities offering integrated treatment should have specialized training in treating mental health and substance use disorders and the symptoms that accompany both. If you have been misusing antipsychotics and are addicted to other substances, substance use disorder treatment is especially important.

Sources:

[1]. U.S. National Library of Medicine. (2017). Quetiapine misuse and abuse: Is it an atypical paradigm of drug seeking behavior?

[2]. National Institute of Mental Health. (2016). Mental health medications.

[3]. U.S. National Library of Medicine. (2018). Quetiapine.

[4]. U.S. National Library of Medicine. (2013). Combined treatment with atypical antipsychotics and antidepressants in treatment-resistant depression: preclinical and clinical efficacy.

[5]. U.S. National Library of Medicine. Should psychiatrists use atypical antipsychotics to treat nonpsychotic anxiety?

[6]. U.S. National Library of Medicine. (2016). Dopamine targeting drugs for the treatment of schizophrenia: Past, present and future.

[7]. Salomon, C. & Hamilton, B. (2014). Antipsychotic discontinuation syndromes: A narrative review of the evidence and it’s integration into Australian mental health nursing books. International Journal of Mental Health Counseling. 23(1), 69-78.

[8]. Medicines and Health Products Regulatory Agency. (2018). Dependence and withdrawal.

[9]. National Institute of Mental Health. (2013). Post by former NIMH director Thomas Insel: Antipsychotics: Taking the long view.

[10]. Psychiatry and Neurology Resource Center. (2017). Debate and dilemma on starting and stopping antipsychotics.

[11]. U.S. National Library of Medicine. (2013). Withdrawal symptoms and rebound syndromes associated with switching and discontinuing atypical antipsychotics: Theoretical background and practical recommendations.

[13]. Kelly, T. M., & Daley, D. C. (2013). Integrated treatment of substance use and psychiatric disordersSocial work in public health28(3-4), 388-406.

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