Stopping Antidepressants: What is Hyperbolic Tapering?

The Challenges of Stopping Antidepressants

Before diving into hyperbolic tapering, it’s important to understand the hurdles individuals face when discontinuing antidepressants.

While the risk of relapse is often discussed, a much more overlooked challenge is how to manage withdrawal symptoms. When coming off of an antidepressant too quickly, withdrawal symptoms such as dizziness, nausea, irritability, and insomnia can occur. These symptoms can persist for weeks to months or even years, and are often mistaken for relapse of an “underlying” mental health condition, further complicating the discontinuation process.

This is an under-appreciated contributor to the rise in long-term antidepressant use, where a person is kept on their medication not because they have a mental health condition but because the withdrawal symptoms make it too difficult to stop.

A well-managed, gradual tapering approach is important to help minimize withdrawal effects and provide a more comfortable discontinuation experience. Having a supportive and informed healthcare team, as well as access to resources about managing withdrawal, can make a significant difference in a patient's ability to cope with such symptoms. 

What is hyperbolic tapering?

Hyperbolic tapering, proposed by Dr. Mark Horowitz in 2019, is a tapering method that diverges from the traditional linear tapering approach for antidepressants. While linear tapering involves reducing the medication dosage by a fixed amount over time, hyperbolic tapering employs a more different approach: initially, larger dose reductions are made, followed by smaller reductions as treatment progresses. 

This distinction is important because of the relationship between antidepressant dose and its effect on the brain. When there is not a lot of antidepressant drug in the brain, every milligram has a large effect, because there are more available receptors in the brain for the drug molecules to bind to. At larger doses, however, every additional milligram of the antidepressant has less and less effect, because more of the receptors in the brain have already been occupied by drug molecules.

A helpful analogy

You can think of it like golfing - imagine that your brain receptors are golf holes on a putting green. Initially, when you putt golf balls (representing drug molecules) into each hole, you feel satisfaction as you sink each shot and your score improves. However, once all the holes are filled with golf balls, putting more balls will not improve your score; the holes are already occupied. Similarly, once your brain's receptors are saturated with a drug, taking more of the drug won't lead to increased effects; the receptors are already filled, and any additional doses won't enhance the experience, just like trying to putt more golf balls into already filled holes.

This relationship between antidepressant drug dose and brain effect is described as “hyperbolic” because it is steep at very low doses and flattens out as the dose gets higher. Effectively, very tiny amounts of antidepressant medication have an outsized effect on the brain. 

Where traditional methods fall short

What does this mean for tapering? Well, traditional linear tapering fails to take this hyperbolic relationship into account. It simply decreases the antidepressant dose by the same amount each time, without accommodating for the outsized impact of very small doses. In terms of the effect on your brain, this is akin to walking down a set of stairs that ultimately ends several yards off the ground - not very safe or comforting.

In contrast, hyperbolic tapering decreases the antidepressant dose in smaller and smaller increments so that the drug’s effect on the brain is the same size at each step. This provides a safer and more comfortable journey to get down to the ground. Additionally, dose reduction sizes as well as frequency can be determined based on monitoring the reaction to the previous step, so that you never feel like you have to make a giant leap down.

This method gives the body’s biological systems more time to adapt to the reductions in medication, with the aim of minimizing withdrawal symptoms and enhancing tolerability during the tapering process.

The Benefits of Hyperbolic Tapering

Hyperbolic tapering offers compelling benefits for individuals navigating antidepressant discontinuation. By taking a more flexible and customized approach, individuals may experience fewer withdrawal effects compared to traditional tapering methods. Hyperbolic tapering may also improve tolerability and adherence to the tapering schedule by allowing for adjustments based on an individual’s response to previous dose reductions. This grants a greater sense of control in the discontinuation journey, ultimately increasing the likelihood of successful discontinuation and leading to better patient outcomes.

Supporting Scientific Evidence

A groundbreaking 2019 paper published by Dr. Horowitz and colleagues examined the fundamental science of hyperbolic tapering in antidepressant discontinuation. The conclusion suggests that hyperbolic tapering minimizes SSRI withdrawal symptoms compared to a linear tapering approach.

Slower tapering regimens (on the order of months or years, as opposed to weeks) were also recommended to help reduce symptoms, as the shorter regimens recommended by pre-existing guidelines were shown to be ineffective at helping patients successfully taper and avoid withdrawal symptoms. 

Practical Considerations

Moving beyond the research, it’s important to consider how hyperbolic tapering can be implemented in clinical practice.

Close collaboration between patients and their healthcare providers is a vital part of successful decision-making in the tapering process. Careful monitoring for withdrawal symptoms is essential for guiding individualized tapering plans and adjusting the tapering schedule as needed. Certain patient factors such as medication history, starting dosage, and patient preferences should all be considered. The cooperation of specialty pharmacies may also be necessary, as the hyperbolic tapering method requires small antidepressant doses towards the end of the taper that may not be available in commercial form. As doses get smaller, individuals may also transition from taking them in tablet form to liquid form.

Changes Antidepressant Tapering Guidelines

The evolution of clinical guidelines for tapering of antidepressants reflects a growing recognition of the importance of individualized and gradual approaches to discontinuation. In 2009, the UK’s National Institute for Health and Care Excellence (NICE) guidelines for depression provided only general, high-level advice on discontinuation over a 4-week period:

“When stopping an antidepressant, gradually reduce the dose, normally over a 4 week period, although some people may require longer periods…”
NICE guidelines for depression, 2009

However, acknowledging emerging evidence and patient experiences, NICE updated their guidance in 2023 to recommend a slower hyperbolic tapering approach. This shift underscores the significance of adapting clinical practices to align with evolving research and patient needs.

By embracing a more flexible and patient-centered approach to antidepressant discontinuation, clinicians can better support individuals in safely and effectively transitioning off their medication, minimizing withdrawal symptoms, and enhancing overall treatment outcomes.

Enhancing the Patient Experience when Stopping Antidepressants

Hyperbolic tapering is a promising approach for individuals seeking to stop antidepressant medication. By prioritizing gradual dose reductions and flexibility in tapering schedules, hyperbolic tapering may mitigate withdrawal symptoms and improve adherence to the process. This novel method stands out as a gentler and more effective approach that holds the potential to greatly enhance patient outcomes. 

At Outro, we’re always building and exploring ways to improve the overall discontinuation experience. We offer safe, evidence-based hyperbolic  tapering for antidepressants, designed by expert clinicians and patients who’ve been there. If you’re considering stopping antidepressants, be sure to check out Outro and discuss hyperbolic tapering with your healthcare provider to determine the best approach for you.