FAQs

Frequently Asked Questions

About Outro

Who is Outro for?

Outro is for people 18 years and older who are currently taking an antidepressant medication and thinking about decreasing or stopping the medication altogether.
Outro’s services are currently not available for people in certain situations or with certain conditions. These include (but are not limited to) people who:

Have active and serious substance abuse issues
Have been diagnosed with dementia
Have been diagnosed with schizophrenia or schizoaffective disorder
Have been hospitalized for bipolar disorder in the past
Have attempted to end their life in the past 12 months
Are actively suicidal or in crisis

To see if you are a candidate for Outro’s services, click “Get Started” to answer a brief questionnaire. Your responses to our questionnaire are not actively monitored by Outro. If you are in a life-threatening situation, call 911 or the National Suicide Prevention Line at +1-833-456-4566, or go to the nearest emergency room.

Why should I work with Outro if I want to stop my antidepressants?

‍Antidepressant discontinuation is a serious process that demands specialized knowledge and attention. Our methods minimize the main risks of stopping: disruptive withdrawal symptoms or relapse, which cause many people to go back on their medications.

Grounded in first-hand experience and the latest scientific evidence, Outro's care team provides the personalized guidance and support that members need to graduate from their time on antidepressants, and onto a path of sustainable mental well-being.

How is Outro different from working with another provider?

‍Safe antidepressant deprescribing requires a comprehensive approach that is often difficult for an individual prescriber to provide, due to the time required. It also requires up-to-date knowledge on the latest techniques in tapering antidepressants that are not yet widely taught in North America. Think of Outro as a specialist in tapering.

At Outro, we walk with you every step of the way. Our specialized, high-touch care team takes time to get to know you and your goals, and provides an advanced, individualized approach to tapering off antidepressants informed by the latest guidance and clinical evidence. Through Outro’s app, your symptoms and progress are continuously monitored by your Provider, who can reach out to offer coping strategies or adapt your care plan accordingly. If you have questions or concerns that arise in between appointments, your Outro provider is available via 1-to-1 chat.

How does Outro help minimize withdrawal and relapse?

Outro helps to minimize the risk of withdrawal by relying on the latest science and guidance in this special area of psychiatry. Outro offers a flexible and medically supervised tapering plan, with gradual reductions tailored to you. Your tapering plan is adjusted according to your response to tapering, your personal preference and what is going on in your life.

We utilize hyperbolic tapering, meaning that the dose reductions get smaller and smaller over time. This is based on an understanding of how the drugs affect the brain, which suggests that this method of tapering will minimize disruption to the nervous system and the uncomfortable effects of reducing your dosage.

Outro’s multidisciplinary team uses a holistic approach to ongoing mental health, working with you to reduce the chance of relapse of your original condition. In addition to close clinician guidance throughout your taper, we have a self-guided educational library and the option to add-on psychotherapeutic support, including mindfulness-based cognitive therapy (MBCT).
Studies have shown that people who go off antidepressants gradually with psychological support did as well as people who stayed on antidepressants, in terms of relapse (return of the original condition)¹.

1. Breedvelt JJF, Warren FC, Segal Z, et al. Continuation of Antidepressants vs Sequential Psychological Interventions to Prevent Relapse in Depression: An Individual Participant Data Meta-analysis. JAMA Psychiatry. 2021;78(8):868-875.

How does Outro’s program work?

Outro offers an individually tailored approach to safely reducing or tapering off antidepressants, from the comfort of home. Here is how it works:

Intake: You connect with your provider via Outro’s web or mobile application and complete your intake forms to provide us with the information we need to thoroughly evaluate your situation.
Assessment: Once your Outro provider has reviewed your intake forms, you meet via video where we get to know more about you and your medical history and answer any questions you may have regarding our services. If you and your provider think it is a reasonable decision to start the process of tapering, you subscribe to Outro’s services and book your preparation appointment.
Preparation: In your second meeting with an Outro clinician, you will discuss specifics of the tapering process and receive your personalized tapering plan. Once you are ready to begin tapering, your clinician prescribes custom doses of your medication whenever required by your personalized plan.
Individualized tapering and support: After the first dose reduction is made, you will have a follow-up appointment with your Outro clinician to assess your response and make any adjustments necessary. Follow-up visits will be provided at regular intervals over the course of your taper.

Between appointments, members can report their symptoms and progress via Outro’s app for monitoring by their provider, and message with their provider at any time during their journey. Outro providers typically respond to messages within 48 hours on weekdays. In addition to 1-to-1 support, members are provided with resources, articles, and guided coursework, focusing on holistic approaches to mental health and wellbeing.

Therapy (Add-on): You have an option to add individual psychotherapy support throughout the program with one of Outro’s knowledgeable, compassionate, and dedicated therapists.

Who provides Outro’s care?

Currently, Outro’s multidisciplinary team includes psychiatrists, nurse practitioners, physicians, and therapists.

Outro’s core deprescribing support is provided by Nurse Practitioners (NPs), who work hand-in-hand with each member throughout the journey, assessing, prescribing, and monitoring the antidepressant tapering plan. Your Outro Nurse Practitioner works in collaboration with psychiatrists, who provide supervision and case discussions as well as professional consultation services and case review where required.

Does Outro offer therapy?

Starting in December 2022, Outro will offer therapy as an add-on service. Therapy can be a part of long-term mental health and wellness and very helpful during acute phases of stress such as during an antidepressant taper.

If you choose to add psychotherapy to your Outro subscription, our therapists – who can be psychotherapists, social workers, or clinical counsellors – provide virtual therapeutic support using various modalities to help members cope, process and gain skills needed to reach the member’s identified goals for overall health.

Do I need a referral to Outro from my primary care provider?

You do not need a referral from your primary doctor or healthcare provider to work with Outro. However, with your permission we may reach out to your primary care provider for more information on your medical history, or to keep your primary doctor informed of your medical progress if you decide to subscribe to Outro.

Do I need to transfer my prescription?

No, your existing prescription does not need to be transferred to Outro. Your Outro provider will write new prescriptions for the doses required by your Outro tapering plan.

Is my information secure?

Your security is paramount to Outro and our mission. Personal health information provided throughout your intake, assessment, and ongoing consultations is strictly and legally confidential between you and your Outro care provider. All of your account information (including your personal information, personal health information, and payment information) is also stored safely and securely.

Outro ensures compliance with the Personal Health Information Protection Act (PHIPA) of Ontario. It is our duty to protect your data with comprehensive security infrastructure and stringent data policies to ensure it stays private and secure.

Membership & pricing

How much does an Outro membership cost?

Outro’s memberships are regularly priced at $199/month. For a limited time, early access memberships are available for $99/month.

Membership charges commence on the date of your Preparation Appointment.

Why does Outro have commitment periods?

Based on guidance and research, if someone has been on medication for more than a year, 3-6 months is the absolute minimum amount of time we would expect anyone to safely come off of their antidepressant. Outro encourages commitment periods to minimize the risks of both withdrawal symptoms and relapse.

What happens if I want to pause or stop my taper?

If you need to pause or stop your taper with Outro for any reason, please speak to your Outro provider. We may pause or cancel your membership depending on individual circumstances.

What is included in my Outro membership?

Outro’s membership fees include your personalized tapering plan, proactive symptom monitoring, monthly appointments and unlimited messaging with your provider, and Outro’s educational resources.

Outro’s membership fees exclude the cost of medication. Payment for medication is arranged between you and the pharmacy selected to fulfill your medication. The cost of your medication may be covered by your private insurance plan.

Your brain & Antidepressants

How does the brain change while on antidepressants?

The brain adapts to psychiatric medications, like antidepressants, in order to maintain homeostasis (physiological balance). For example, when it is too hot the body cools us down, and when it is too cold the body tries to warm us up.

There is evidence of brain cell adaptation (particularly in serotonin receptors) in people starting after just a few weeks of antidepressant treatment.^1,2 Other studies in humans¹and animals³ show that these effects can persist for months and years after antidepressants are stopped. The risk of withdrawal symptoms appears to increase with long-term use.

1. Bhagwagar Z, Rabiner EA, Sargent PA, et al. Persistent reduction in brain serotonin1A receptor binding in recovered depressed men measured by positron emission tomography with [11C]WAY-100635. Mol Psychiatry. 2004;9(4):386-392.

2. Haahr ME, Fisher PM, Jensen CG, et al. Central 5-HT4 receptor binding as biomarker of serotonergic tonus in humans: A [11C]SB207145 PET study. Mol Psychiatry.

3. Renoir T. Selective serotonin reuptake inhibitor antidepressant treatment discontinuation syndrome: A review of the clinical evidence and the possible mechanisms involved. Front Pharmacol. 2013;4 APR(April):1-10.014;19(4):427-432.

What happens to the brain when an antidepressant is stopped?

When the dose of the drug is reduced or the drug is stopped, the difference between what the brain ‘expects’ and the actual input of the drug is what causes withdrawal effects. A similar process happens when people stop caffeine or smoking.

Withdrawal effects from antidepressants can last for months or years in some people, probably because the adaptation to the drug can last for this long. This may be the time required for the brain to re-adapt to there being less drug available.

What if I’ve been told I have a chemical imbalance or suffer from “low serotonin”?

You wouldn’t be alone in hearing that you have a chemical imbalance or serotonin deficiency (“low serotonin”) BUT did you know that there is no convincing evidence to support the idea that depression or anxiety is caused by such a thing? The chemical imbalance theory has been widely communicated by the drug industry, however there was never any proof of it.^1,2

Depression being caused by “low serotonin” or “serotonin deficiency”, also referred to as “the chemical imbalance” theory of depression, was an idea conceived in the 1960s. It was amplified by drug companies in the 1990s and 2000s because it helped promote their products (which act on serotonin). Psychiatrists widely dismiss the chemical imbalance theory today.^1,2

There is still much doctors do not understand about mental health conditions such as depression and anxiety. It is more widely believed that these conditions occur largely due to your family background, life events, and relationships, and other biopsychosocial factors.

1. Pies (2011). "Doctor, Is My Mood Disorder Due to a Chemical Imbalance?". Psychiatric Times. Accessed: 28 October 2022.

2. Moncrieff, J., Cooper, R.E., Stockmann, T. et al. The serotonin theory of depression: a systematic umbrella review of the evidence. Mol Psychiatry (2022).

Considering Coming off Antidepressants

For what reasons do people stop their antidepressants?

There are many reasons one might consider stopping antidepressant medications–some are related to medical concerns, while others are personal preference. Based on research surveys, common reasons people give for wanting to discontinue (stop) their medication include:

Feeling that the trouble that they first went on medication for has resolved or improved
Experiencing unwanted medication adverse effects, often called side effects (e.g., emotional numbing, sexual problems, issues with memory and concentration)
No longer feeling that their medication is helping them
Being pregnant or trying to get pregnant
Concerns around the risks associated with long-term medication use

Should I come off my medication if I’m still experiencing depression or anxiety?

In general it is better to come off antidepressants when you are feeling well but there are times when someone may wish to come off of antidepressants even while they are experiencing depression or anxiety. For example:

You feel that you get no benefit from the drug
You are experiencing adverse effects that you feel outweigh any helpful effects
Your antidepressant conflicts with another medicine or treatment
Being pregnant or trying to get pregnant

The Canadian guidelines most often used to guide treatment (the CANMAT Guidelines¹) recommends that an episode of depression should be treated with antidepressants for 6-9 months after they feel better. People with severe conditions are advised to stay on antidepressant treatment for 2 years after they feel better. For anxiety disorders treatment is generally recommended for 6-12 months.²

It’s important to talk to your healthcare provider about the risks and benefits of stopping antidepressant treatment while still experiencing depression or anxiety, so you can have a plan in place to manage those symptoms.

1. Kennedy et al. 2016. “Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder” Can J Psychiatry 62(5): 356.

2. Katzman et al. 2014. “Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders.” BMC Psychiatry 14, Article number: S1.

What are the benefits of coming off antidepressants?

The main benefit of coming off antidepressants is a reduction in the adverse (or side) effects they can cause and avoiding the potential long-term health consequences of staying on them.

As with any type of medication, there are risks with both short-term and extended use. Antidepressant medications have a variety of possible adverse effects, many of which show up early in treatment and continue throughout use of the medication. These adverse effects can have significant effects on other body systems and general well-being.

Sometimes when people take antidepressants for long periods, they do not connect adverse effects to the medication – either because they come on slowly, or because they do not recall what they were like before starting the medication (especially in long-term use).

Common adverse effects include:^1,2,3:

Feeling ‘foggy’ (or difficulty concentrating)
Weight gain
Disrupted sleep
Sexual problems -- difficulty with erection and ejaculation in men (including a lack of ejaculation or altered ejaculation, reduced or absent sensation and capacity for orgasm in women, etc.)
People taking antidepressants often find they become emotionally numb or apathetic; this is sometimes paired with sexual problems or loss of sex drive

1. Read, John, and James Williams. 2018. “Adverse Effects of Antidepressants Reported by a Large International Cohort: Emotional Blunting, Suicidality, and Withdrawal Effects.” Current Drug Safety 13 (3): 176–86.

2. Bet, Pierre M., Jacqueline G. Hugtenburg, Brenda W. J. H. Penninx, and Witte J. G. Hoogendijk. 2013. “Side Effects of Antidepressants during Long-Term Use in a Naturalistic Setting.” European Neuropsychopharmacology: The Journal of the European College of Neuropsychopharmacology 23 (11): 1443–51.

3. Sansone, Randy A., and Lori A. Sansone. 2010. “SSRI-Induced Indifference.” Psychiatry 7 (10): 14–18.

Are there risks from staying on antidepressants for many years?

Studies have identified potential health problems from staying on antidepressants long-term, such as:

Increased risk of developing osteoporosis⁴
Increased risk of bleeding⁴
Negative effects on the liver⁵
Increased risk of cataracts⁵
Increased risk of cardiovascular disease⁶
Increased risk of an early death⁴
Some antidepressants have been associated with an increased risk of dementia⁷
The longer you use an antidepressant also increases the likelihood of withdrawal symptoms when the dose is reduced or stopped⁸

Tolerance or “poop-out” also may occur from long-term antidepressant use. This brings on a gradual need to increase the dose of their medication over time, with less and less effect.⁹

Some studies suggest long-term use of antidepressants can cause low mood, possibly due to extended drug effects on the brain.¹⁰

4. Coupland, Carol, Paula Dhiman, Richard Morriss, Antony Arthur, Garry Barton, and Julia Hippisley-Cox. 2011. “Antidepressant Use and Risk of Adverse Outcomes in Older People: Population Based Cohort Study.” BMJ 343 (aug02 1).

5. Carvalho, André F., Manu S. Sharma, André R. Brunoni, Eduard Vieta, and Giovanni A. Fava. 2016. “The Safety, Tolerability and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature.” Psychotherapy and Psychosomatics 85 (5): 270–88.

6. Bansal, Narinder, Mohammed Hudda, Rupert A. Payne, Daniel J. Smith, David Kessler, and Nicola Wiles. 2022. “Antidepressant Use and Risk of Adverse Outcomes: Population-Based Cohort Study.” BJPsych Open 8 (5): e164.

7. Richardson, Kathryn, Chris Fox, Ian Maidment, Nicholas Steel, Yoon K. Loke, Antony Arthur, Phyo K. Myint, et al. 2018. “Anticholinergic Drugs and Risk of Dementia: Case-Control Study.” BMJ 361 (April): k1315.

8. Horowitz, M. A., Adele Framer, Michael P. Hengartner, Anders Sorensen, and David M. Taylor. 2022. “Estimating Risk of Withdrawal from a Review of Published Data (Accepted manuscript - CNS Drugs).”

9. Kinrys, Gustavo, Alexandra K. Gold, Vincent D. Pisano, Marlene P. Freeman, George I. Papakostas, David Mischoulon, Andrew A. Nierenberg, and Maurizio Fava. 2019. “Tachyphylaxis in Major Depressive Disorder: A Review of the Current State of Research.” Journal of Affective Disorders 245 (October 2018): 488–97.

10. El-Mallakh, Rif S., Yonglin Gao, Brian T. Briscoe, and R. Jeannie Roberts. 2011. “Antidepressant-Induced Tardive Dysphoria.” Psychotherapy and Psychosomatics 80 (1): 57–59.

Will stopping my antidepressants help reduce their adverse effects?

If an antidepressant is causing uncomfortable adverse effects, slowly and safely reducing the dose probably will help to reduce these effects. It is very important that you discuss a taper plan based on your individual risk factors with a knowledgeable clinician before reducing your dosage. NEVER STOP TAKING ANTIDEPRESSANTS SUDDENLY – this can lead to severe withdrawal symptoms.

Why can’t I just quit my antidepressant?

Going cold turkey (stopping in one day) is not a good idea! Why? Because the quicker you stop your antidepressant the more severe your withdrawal symptoms are likely to be, and the higher the likelihood that you’ll need to go back on your medication.

Sometimes these symptoms can be so unpleasant that they interfere with your ability to work or carry on normal social activities. Sometimes severe withdrawal symptoms can be very disruptive or even lead to hospitalization.

Tapering (stopping slowly in small steps) is therefore highly recommended to minimize the risks of these issues.

What if I’ve tried to get off antidepressants before?

Many people have difficulties when they try to go off antidepressants. Our team of expertly trained clinicians will develop a tailored tapering program designed to minimize withdrawal effects even for these people. Our approach is aimed to make the process less unpleasant than your experience in the past.

Will my depression, anxiety, or other condition return if I stop taking my antidepressant?

Many people try to go off their drugs and mistake antidepressant withdrawal symptoms with a relapse (return) of depression or anxiety. Some symptoms of withdrawal appear like depression or anxiety -– for example, low mood, anxiety, trouble sleeping, amongst others. Often people conclude that they cannot stop antidepressants because of this.

However, stopping antidepressants is often done too quickly. Many symptoms that resemble relapse can be avoided by stopping more gradually.

However, even the most careful taper of your antidepressant will not prevent you from experiencing emotional ups or downs, low moods, or anxiety in the future. But we know from studies that at least 40% of people can stop their antidepressants without experiencing a relapse (return) of depression.¹

Studies have shown that people who go off antidepressants gradually did as well in terms of relapse as people who stayed on antidepressants.²At Outro, we will provide you with support and coping techniques to lessen your chances of being overcome by mood problems again. Our focus is to help build sustainable long-term mental health and wellness while safely assisting members off antidepressants.

1. Lewis G, Marston L, Duffy L, et al. Maintenance or Discontinuation of Antidepressants in Primary Care. N Engl J Med. 2021;385(14):1257-1267.

2. Breedvelt JJF, Warren FC, Segal Z, et al. Continuation of Antidepressants vs Sequential Psychological Interventions to Prevent Relapse in Depression: An Individual Participant Data Meta-analysis. JAMA Psychiatry. 2021;78(8):868-875.

What techniques will help me avoid returning to my original mental condition?

There is evidence that suggests that Outro’s methods of tapering your antidepressant can reduce your risk of relapse. Studies show that if you come off antidepressants gradually (over months rather than weeks) that the return of your original condition is not any more likely than if you stayed on your medication.¹

Additionally, at Outro we encourage techniques that reduce the risk of relapse and aim to improve life-long wellness. These involve practicing the basics of a healthy lifestyle:

Regular exercise
Eating a well balanced healthy diet
Spending time in nature
Developing and maintaining meaningful connection with others
Managing stress levels
Continuing regular psychotherapy sessions.

These all can be beneficial in reducing the return of depression and anxiety.

One of the keys to minimizing the return of anxiety and depression is understanding what circumstances contribute to these feelings, and learning ways to manage these. Sometimes therapy can be helpful for this.

In addition to your basic subscription, Outro offers a psychotherapy add-on. Outro’s therapy is provided by qualified clinicians who understand the difficulties of going off antidepressants.

Tapering and Withdrawal Symptoms

How long will it take me to get off my antidepressant?

Stopping your antidepressant more slowly and in a method informed by the ways the drugs work, as Outro does, will reduce the severity of withdrawal symptoms, making the process smoother, so that you can continue your normal activities.

The time required to taper is individual, and likely depends on how much time your brain takes to readapt to a state without an antidepressant medication. We take a personalized approach, using careful observation to understand how dose reductions affect you and adjusting your taper plan accordingly.

Based on the latest guidance, if someone has been on medication for more than a year, 3-6 months is the minimum amount of time we would expect anyone to safely come off of their antidepressant. This helps in minimizing the risks of both withdrawal symptoms and relapse.

What are common withdrawal symptoms from antidepressants?

An important consideration for anyone thinking of lowering or stopping antidepressant medication is that withdrawal symptoms potentially can disrupt your life.

Our job at Outro is to minimize uncomfortable withdrawal effects. With our gradual, individualized tapering methods, most people can find a rate of withdrawal that keeps withdrawal effects to mild and bearable (or none at all).

The appearance of withdrawal symptoms and how bad they are will vary for everyone. Common antidepressant withdrawal effects include:

Dizziness
Headaches
“Brain zaps”
Insomnia
Emotional lability (emotions going up and down)
Depressed mood
Anxiety
Crying spells
Brain fog (difficult concentrating)
Irritability
Agitation
Fatigue/tiredness
Increased sensitivity to sounds and light
Muscle cramps
Sensation of spinning
Unsteady gait

1. Fava, Giovanni A., Alessia Gatti, Carlotta Belaise, Jenny Guidi, and Emanuela Offidani. 2015. “Withdrawal Symptoms after Selective Serotonin Reuptake Inhibitor Discontinuation: A Systematic Review.” Psychotherapy and Psychosomatics 84 (2): 72–81.

How can antidepressant withdrawal symptoms last so long when it only takes a few days for the drug to leave your body?

Most antidepressants do leave your body in a few days, but the changes to the brain that they cause can last for much longer. While these adaptations re-adjust towards your body’s factory settings (returning to its pre-drug state), you may have withdrawal symptoms. Withdrawal symptoms are a sign that your brain and body are hard at work to settle down.

What is the difference between a quick taper and a gradual taper of antidepressants?

A quick taper often means halving the dose, then quartering the dose, then stopping the antidepressant. It involves using commercially available tablets, perhaps split in half or taken every second day. For many patients, this technique is not much more comfortable than going ‘cold turkey’ (stopping in one day).

For most antidepressants, dosing every other day can cause the drug level to go up and down in your body, leading to withdrawal symptoms.

A gradual taper, which is the method we use at Outro, means slowly lowering your dose, allowing time for the brain and body to adjust to a new level of the drug. We follow a hyperbolic tapering method -- which means the size of the reductions become smaller as the dose lowers.

This involves using customized doses of the antidepressant that are not widely available, but need to be made up by a compounding pharmacist. The rate is determined by how you respond to the reductions, and often takes a number of months, according to your comfort level.

What is hyperbolic tapering?

Hyperbolic tapering (sometimes called the Horowitz-Taylor method)¹ is based on the fact that as antidepressant dose goes up, drug action on brain cells increases, but not in equal steps, higher dosages having less and less additional influence – a decreasing return on investment. The graph showing this is called a hyperbolic curve (goes up faster at low doses and flatter at higher doses).

Tapering based on this method gradually backs you out of the drug with reductions following this natural curve, with the size of dose reduction getting smaller as the dosage gets lower. As very low doses (e.g. 1 or 2mg) have much larger effects than people expect, many people need to taper down to very small doses before stopping so that the final ‘jump’ to zero is not too large a shock to the nervous system.

These very low doses are difficult to make up with commonly available tablets, so Outro recommends compounding pharmacies to make these options available.

1. Horowitz MA, Taylor D. Tapering of SSRI treatment to mitigate withdrawal symptoms. The Lancet Psychiatry. 2019;6(6):538-546.

What if I do not wish to continue tapering my drug?

The whole process at Outro is centered around what you feel comfortable doing, with your safety and comfort our primary concern. If at any point you wish to pause the taper, slow it down or stop tapering altogether and return to your original dose of medication we will help you to do so.