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The first time I stopped taking my Lexapro, I had a panic attack and was so overwhelmed by my own emotions that I hopped on a train from New York to Connecticut—a state I’d never been to. I’d gone off my meds for what I now know to be a horrible reason, which was that I sincerely believed I didn’t need them anymore—after months of therapy and medication, I felt great and was convinced that the mental illness had left my body. Obviously, I was wrong.
The second time I quit my meds abruptly was more complicated; I was in the process of switching psychiatrists, and I wasn’t able to find a new provider before I ran out of pills. This time, I braced myself for the worst. During the following days, I felt irritable and unable to sleep, and found myself getting into fights with friends.
But I also told people that I had just gone off my meds cold turkey, which is how I learned that the exact same thing had happened to a lot of them too. Whether it had been because of a lapse in insurance coverage or for personal reasons, people I knew had quit taking their antidepressants or anti-anxiety medication without a careful plan. In almost every instance, they’d had severe physical and emotional withdrawal symptoms.
“Running out of meds is really quite common, and people should try not to blame themselves,” Zachary Cordner, an assistant professor of psychiatry at the Johns Hopkins University School of Medicine, tells me. “There are really complicated situations that involve a lot of different factors.”
But when you’re prescribed a psychotropic medication to take daily, your doctor might not explain what will happen if you suddenly go off it (at least in my experience). After all, you’re not supposed to forgo refilling your prescription. I wanted to know what had been going on in my brain when I’d stopped taking Lexapro, and I could have handled things better—or even prevented the situation in the first place. If you find yourself in such a position, you should check with your doctor right away. But here are some starting points that I hope can help reduce the shame and confusion that can accompany facing an almost-empty pill bottle.
The most common antidepressants and anti-anxiety pills out there are classified as selective serotonin reuptake inhibitors. David Feifel, a professor of psychiatry at the University of California, San Diego, compares the process of SSRIs in your brain with ships entering a docking port: The serotonin is the ships, and the receptor cells are the docks. When you’re on your meds, there’s an abundance of ships, and in order to avoid getting overwhelmed by them, your brain closes a lot of its docks. When you quit your meds abruptly, the number of ships decreases dramatically. The docks go from getting too much cargo to not getting enough, so there’s a whiplash.
The immediate physical change can lead to an uncomfortable sensation in your brain, referred to as “brain zaps,” which feels like small electric shocks. Other accompanying symptoms can include irritability, insomnia, headaches, or even fevers that can last a week or more. The symptoms aren’t usually dangerous, just unpleasant, and the brain will go back to its pre-medicated levels. If you’re already at this point, or about to get there, take a sick day and treat yourself in the same way you would if you had a stomach bug or a cold.
Not all meds are created equal in this regard, though, and some can lead to more intense withdrawal symptoms than others. (And fast-acting medications like Xanax, which are typically not prescribed for daily use, present a whole different suite of issues if you abruptly stop taking them regularly.) According to Feifel, there is another important factor that affects how intensely you come down from a medication: its half-life, or how long it stays in your system before it’s cleared through your liver. SSRIs like Lexapro and Zoloft have a half-life of about 24 hours. This also means that the withdrawals from these medications will happen fairly quickly, within a couple of days, and explains why they might feel more intense to quit than other meds. In comparison, Prozac has a longer half-life, which means that it stays in your system for several days and it clears out of your system more slowly. If you stop taking Prozac suddenly, you are much less likely to have noticeable withdrawal symptoms. The same goes for Wellbutrin, which doesn’t involve serotonin at all. To learn more about what could happen with your specific medication, talk to the person who prescribed it—ideally before you wind up in an unexpected situation in which you’re facing the symptoms.
In addition to temporary withdrawal symptoms, going off your medication means your mood could return to a lower baseline. Valencia Jackson, a 26-year-old who works in the beauty industry in New York, tells me that in the several years she’s taken Zoloft, she’s run out of her meds three or four times and, for the most part, she doesn’t really have a mechanism for knowing exactly when she’ll need a refill. The most recent time she ran out was about a month ago, when she was in the throes of work projects and wasn’t paying attention to how much Zoloft she had left. She says that within a week of running out, she started feeling sad the way she had prior to having a Zoloft prescription, and her self-esteem plummeted. The overwhelm from her emotions made it difficult for her to get the energy to refill her prescription, creating a feedback loop in which she felt more helpless and more depressed.
In these situations, calling a friend or a crisis line and describing the issue might help you get through the rough patch, and to the pharmacy. If you are out of refills of your prescription and cannot reach your doctor, you can try going to the pharmacy and seeing if they’ll refill your medication anyway. The rules vary by state, but if the pharmacist determines that the medications are necessary for your well-being, they may be able to give you a small supply.
To make this scenario less likely in the first place, Feifel recommends always asking for a 90-day prescription as opposed to the 30-day prescription a doctor might give you by default. Using a delivery service like Capsule can save you from running the errand of picking up your meds (and needing to work that errand into your schedule). You should have several backup pharmacies in your area to go to in case your usual one runs out of stock, which has been a more common problem since the start of the pandemic. Lastly, pillboxes, as simple as they are, can be life-changing: They’ll give you a visual reminder of when you’re about to run out of pills a few days in advance.
If you are already in a situation where you know for a fact that you’ll run out of meds without having a chance to refill your prescription—for example, if you’re traveling abroad—the best thing you can do, Feifel says, may be to avoid going from 100 percent adherence to zero. In this situation, he might tell a patient to ration their medications by cutting them in half or taking one pill every other day. Rationing gives your body a chance to start adjusting to the lack of medication. (Of course, you should check with your own doctor about what will work best for your meds and situation.)
We also live in a country where losing your job can also mean losing your health insurance.
Feifel tells me that in these instances, you need to know your rights as a patient. By law, a doctor cannot abandon their patient, and they are obligated to make sure that you safely transition to another provider, even if your insurance is no longer valid. Cordner, the Johns Hopkins psychiatry professor, and Feifel both agree that patients should ask their providers if they offer sliding scales or payment plans, which are fairly common. If they don’t, you can also ask them to provide you with a final 90-day prescription, which will buy you time while you switch to a new provider. Some state regulations even allow you to get an emergency refill from a pharmacy before you get a new prescription, a provision that was put in place during the COVID-19 pandemic to avoid sudden interruptions. Whether this is a route you can take depends on where you live, as well as the judgment of the pharmacist on duty.
A virtual appointment may be less costly than an in-person appointment, and it can be easier to price-shop for a provider online; you can see available appointments on sites like Headway, among many others. To help with the cost of the prescription itself, Cordner tells me to look for discount coupons on Amazon RxPass and GoodRx, and to check if your medication is available on the Walmart $4 list.
It’s worth having a proactive conversation with your doctor about what going off your meds would be like, and working to create an emergency plan. Ask them about the half-life of your medication, and if there’s anything you need to keep in mind about your treatment plan. You can also talk to them about how medication will factor into your long-term treatment plan, and what it might look like to go off your meds intentionally someday. Rather than stopping abruptly, ramping down can be a decision you make together.
State of Mind is a partnership of Slate and Arizona State University that offers a practical look at our mental health system—and how to make it better.