Psychiatric medication has become increasingly ubiquitous in American society over the last two decades—with reports of around 20% of women ages 40 to 59 and nearly 25% of women ages 60 and over using antidepressants in the last 30 days according to the latest data from the National Center for Health Statistics. The figure is close to 10% among women ages 18 to 39, and for men, the figure hovers between 8 and 13%, depending on age.
Prescribing of antidepressants in children aged 5–12 years has increased by more than 40% between 2015 and 2021, according to recent analyses. Another national survey likewise found just under 9 percent of U.S. children under 18 have been on “medication for ADD/ADHD, autism/ASD, or difficulties with emotions, concentration, or behavior”—ranging from 1.2% of pre-schoolers and 13% of 12- to 17-year-olds.
Some have grown uncomfortable with this level of dependence of individuals or families on external psychotropic interventions—pursuing various ways to titrate their reliance and taper down or off medication, often simultaneous with an increase in other emotional resiliency efforts.
But for many others, the medications have become so central to well-being that they can hardly imagine life without them. In deliberation with medical support, many of these individuals and families have decided that longer-term interventions are both necessary and welcome. For these families, the idea of tapering off is something they would never consider—not unless they are forced to.
Growing medical shortages. I wrote for the Deseret News last week about the growing shortages of mental health and medical professionals, as part of the broader pattern in supply-chain issues across the nation—noting that “shortages in general, of course, are starting to become a feature of American life, and not just of toilet paper [and] baby food.”
Now we are seeing shortages in the supply of psychiatric medication, according to the latest data from the National Center for Health Statistics—something that began during the pandemic. The U.S. Food and Drug Administration (FDA) lists over 125 medical products with current shortages—including Adderall and antibiotics like Amoxicillin. There are some indications that these specific shortages will continue through early 2023.
More broadly, of course, the instability in our world today has raised new questions about many things many people didn’t expect to have to question—including whether and how we will access important resources around us. Supply-chain issues connected with COVID and other international trade disputes have made clear our systems are more fragile than many of us expected.
Referring to these psychiatric medication shortages, Dr. Craig Surman, Massachusetts General Hospital, was recently quoted as saying, “ideally, treatment is sustainable, and not going to start and stop, but, as people have learned, unfortunately, recently, people need to have Plan B’s.”
It’s important to be clear about how terrifying this can be for some who have become reliant on this kind of daily medical support. A recent PBS analysis quoted several individuals describing what the Adderall shortage has been like:
- “I take my medication to literally just function, to be what society would consider a normal person. So that means I need my medication to do my laundry. I need my medication to complete my tasks. I need my medication to work. I need my medication just to get out of bed and shower and feed my cat.
- “I rely on that for things like driving. If I’m out of medicine, I can’t. That would be way too dangerous for me to drive.”
- “When I don’t have it—I find life hard enough without it. And I don’t think that people really understand what it does.”
Although they vary from person to person, withdrawal effects for a drug like Adderall can include severe fatigue, mood swings, irritability, appetite suppression and, in severe cases, suicidal thoughts. People might also experience headaches, jitteriness, intense fatigue and gastrointestinal distress. Similar kinds of withdrawal effects can occur with other kinds of psychiatric medications as well.
Despite these real possibilities, over-preoccupation or paranoia about any of this is unproductive. And we can all hope—and even expect—that access to medication will be preserved for any who want it. But what happens if that access becomes limited or unavailable for some period of time?
Thinking through a Plan B. In light of the possibility of continuing and future shortages like this, Dr. Surman continued with recommendations that people “minimize the anxiety and have Plan B’s”:
Whether it’s other medications they might go to, that they have had some small stockpile that they can use, or that they’re going to taper off of medication and be off for a while, while they figure out what is the sustainable plan for them?
As with other kinds of emergency situations, the act of preplanning and being as prepared as possible for even extreme possibilities brings its own kind of reassurance and peace.
In fact, these kinds of access worries are not new. Such limitations and disruptions have happened before. Even in normal times, access to a particular drug can be cut off temporarily. For instance, a prescriber can’t see you anymore, your pharmacy can’t get the brand that you’re on, or a generic lab shuts down (or won’t be making the drug again for six months), making it unavailable to you right now. Colleagues of mine have also seen examples of a doctor deciding to stop a medication for someone abruptly for different reasons.
Whether in normal or abnormal times, then, I believe this is a possibility worth taking seriously and maybe even making preparations for in the event you ever needed to face such a moment.
There are some things we can’t control. But there are many others we can—and that’s where I want to focus here, in the spirit of emergency prep. I’m going to summarize here some best practice guidelines to guide individuals and families forced to think through situations like this. These recommendations have been created in consultation with experts with years of experience in tapering medications in different circumstances.
None of this should be taken as prescriptive or a substitute for individual guidance from a medical professional. All are offered as supplemental assistance on an important question deserving more attention than it currently receives. I hope it’s helpful!
Twelve Tips to Be Prepared and Stay Safe
1. Read up a little more. Learn more ahead of time about what you’re currently taking and what it’s doing in your brain and body. Look into the different places available to access it. You might also consider learning more about the most chemically similar other drugs that you could get access to in an emergency situation. Find out as much as you can.
2. Appreciate the wisdom of gradual tapers. The biggest mistake people make in the event they need to discontinue a medication is tapering too quickly. Some people try to go off “cold turkey,”—and others are encouraged to “cut the dosage in half.” Unless you’ve been taking a drug for only a short time, this is far too quick of a pace for most people’s bodies. One of the most important steps of preparation, then, is simply to get in the mindset of gradual tapering.
3. Learn about various tapering methods. Familiarize yourself with different approaches to tapering, and decide on what method feels best to you. As part of the Withdrawal Project’s Companion Guide to Psychiatric Drug Withdrawal, they review in detail the various methods others have tried. As you will see, it sometimes requires a little creativity to get it just right—opening capsules, counting beads, etc. But attention to detail can really pay off.
4. Familiarize yourself with mindfulness. One thing people learn in mindfulness practice is that you are not your thoughts, your feelings, or your physical sensations. However real, intense, and persuasive all this mental, emotional, and physical content may be, it doesn’t necessarily reflect “reality”—and certainly not a forever one. This insight can be life-changing—especially for those in the middle of difficult emotions, thoughts, and sensations. The more you learn that for yourself—by practicing mindfulness when things are calmer—the better able you’ll be to work through and navigate turbulence in the tapering process well.
5. Strategically pace the taper. Gradual tapering doesn’t mean linear tapering. Researcher Mark Horowitz notes that because of a tendency for people to be overmedicated, a strategy of “hyperbolic” tapering can sometimes be effective—where the beginning taper can be faster, depending on how much drug excess there is in your system. (In the case of a surplus, this extra drug isn’t likely to be fully occupying or affecting the body or brain). For that reason, similar to an airplane landing, some have found it easier to taper more quickly in that first reduction of 25% or so. Then, they typically slow down after that and space out the rest—anticipating the closer they get to zero, the more difficult it may become.
So, for instance, if you only have one bottle of medication left—you might opt to taper 25% the first week, then cut another 5% or 10% the second week to see how you feel. Then use extra medication to drag out the long tail—calculating your most gentle reduction rate possible with the remaining medication left.
6. Adjust the taper, moment by moment. Because these things are not easy to determine in advance, much of the wisdom guiding a healthy tapering process arises in the evolving process itself—paying attention as best you can to changing sensations, emotions and thoughts. How much of an initial tapering is too much versus just right? And how much of a drop are you ready for after that? Each and every one of these steps along the way can be guided by the feedback your own body and mind give you over time. Among other things, listening carefully to these internal signals can help minimize withdrawal effects as much as possible.
7. Focus on what you can control. There is plenty we don’t have a lot of control over—that is clear. But we don’t always remember all that we do have control over: What food do we put in our bodies? What people are around us? How do we move our bodies, and how much sun are we getting on a daily basis? Where do we focus our time day to day? And what are we taking into our minds?
All these questions (and more) are generally under our control. Especially in a circumstance where other things feel out of control, it can be helpful to really focus on what we do have power over. There’s good evidence that doing extra in these different areas of self-care and lifestyle can make an (indirect but measurable) difference in the other areas that feel out of our control.
8. Deepen your foundation. Even with the best lifestyle and most refined mindfulness practice, it’s likely that any taper involves some tumultuous emotions. Anything you have in place foundationally to ground and settle you will be invaluable—so your own thoughts and feelings are not the only or ultimate reality on which you depend. For instance, what kind of higher meaning and purpose do you have in your life? Are there cultural, philosophical, or spiritual traditions that can help ground you? Many people find spirituality and a relationship with the God of their understanding to be a source of reassurance and peace during otherwise difficult times. So if there are practices (from service and community to prayer and meditation) that can help establish some kind of foundation outside of only your thoughts and feelings, consider prioritizing those.
9. Get others involved. Any taper is stronger and easier with good support around us. In cases of expected turbulence—such as an impending cold-turkey state, it’s especially important to inform people around us about some of the uncertainties of what could happen. Especially if you anticipate your own capacities being influenced, it’s extra security to have others around being watchful and attentive for additional support we may need.
10. Hang on for the ride. Even in the best of circumstances (with all the medication you need), tapering off medication can be uniquely challenging. In circumstances where you are limited in the amount of medication to use in a taper, it’s likely the taper will be even more challenging. In that case, there may not even be a way to avoid experiencing some significant withdrawal effects.
It’s true that abrupt cessation of medication can be difficult, even dangerous. Yet people rapidly taper all the time and for different reasons; some experience only mild withdrawal. Another group can have very difficult withdrawals. Since it’s hard to know which category you would be in, it’s best to plan for a positive experience while being ready for real turbulence along the way.
This kind of an awareness of likely withdrawal effects alone can make a significant difference—especially if you can learn what they are for the specific kinds of medications you are taking. Rather than being surprised and shocked (and misinterpreting them), this empowers you to recognize them if and when they take place.
The end is virtually always the most challenging. And after someone is off, there can be additional difficulties that arise. This is all where your mindfulness skills become especially handy. Being able to sit with discomfort—and watch all those thoughts, feelings, and sensations, like a movie you are in. Not the final reality. And not who you are. Instead, content that will pass eventually.
11. Trusting the wisdom of your body. Some of the most challenging parts of tapering are the fears that can arise. Your mind might try and convince you, for instance, that your body is incapable and too messed up to do this. Don’t believe it! No matter what turbulence comes up, you can do this. Many have done it before you.
Your body is amazing—with a built-in capacity to heal. Remember that through this process.
12. Consider making adjustments now. In light of all of this, now might be a good time to rethink your relationship with medication, when you still have some relatively easy and comfortable access.
For someone who hasn’t yet started a taper, they might find the possibility of disruptions like this enough to consider an adjustment. And for others who haven’t liked the feeling of dependence or reliance in their own life, this may be a good opportunity to move in that direction as well. Someone might say, “I wasn’t really ready to start a taper and was planning to start it next year. But maybe I will make a tiny reduction now—so I’m a little less dependent on this external support.”
To reiterate, none of these tips constitute formal medical advice—and all of them are intended as supplemental and supportive guidance to complement the specific directions you are given by trusted practitioners. Everything above, of course, is premised on an extraordinary situation where the usual access to medications (or even to physicians) might not be available. In such a situation, it’s not likely people would be able to draw upon the same direction from the medical system around us now.
In an extreme circumstance like that, it could become necessary to consider other measures not usually advised (and, in fact, illegal in most places), such as sharing medication or building up a small stockpile of extra medication. Especially in such a case, it would be wise to not ever throw extra pills away—saving extra drugs and conserving supplies in anticipation of a needed taper.
In exceptional circumstances like this, you might also look online for other options—researching and potentially ordering from international pharmacies (with all the caution that should entail).
It’s likely there would be physicians and others available online to offer support in that case. There are various kinds of online lists of thoughtful practitioners available to provide targeted support.
In the meanwhile, just being aware of these possibilities—and a wise path to tapering, should you choose to need it or want it—can be helpful and reassuring. That can be true not only for those on medication currently but as well as for family members trying to support them. It’s when we’re not aware of these best practices that problems arise—e.g., assuming there is no need to taper gradually, or any risk of ever having to do so in the future.
As legendary basketball coach John Wooden once said, “Confidence comes from being prepared.” I hope that’s true for you too.