Stopping or Coming Off Medication: Can I or Can’t I?

Psychiatric medications are prescribed to help people cope with emotions they cannot do so on their own.  These drugs may be a good or bad thing, depending on how one’s body reacts to them and what side effects these engender.  Although prescription medications have helped people who really need them, these sometimes exact their price from other areas of our health.  Some drugs could cause weight gain, a drop in libido, or loss of focus, among many other major and minor ramifications.  It is for these reasons that people decide to stop or gradually lessen their intake of medication.

Coming off or stopping medication altogether is not as easy or consequence-free as one may think.  It is not a simple “stop the drug; stop the side effects” scenario.  In fact, there are risks, some dangerous, to suddenly coming off the drug as well as being on it.  Much like being “between the devil and the deep blue sea,” the decision to discontinue taking medications that one has been taking for quite some time needs thorough thinking and awareness of the disadvantages.

stop-your-meds

Why People May Want to Stop Taking their Medications

People often mistake psychiatric drugs as cures when these simply hold the fort, so to speak.  Although they are a big help, psychiatric medications function as symptom reducers, not exactly recovery tools.  Over time, people can become dependent on these medications and have difficulty managing without them.  In other situations, the drugs don’t effectively block the symptoms but seem to enhance their degree.  For others, the side effects can be debilitating such as sleep deprivation, forgetfulness, excessive weight gain, feelings of detachment, and many more.

Some people would simply want to live a drug-free life.  While a no-drugs personal policy is ideal, it is not always workable or even safe.  In cases where the mental illness has become critical to the safety of the person and others around him, prescribed medication can be obligatory under the Mental Health Act.

Why Coming Off or Stopping Medications is a Risky Business

If you have been taking your prescription for three months and over, it is unwise to suddenly stop taking them.  Coming off psychiatric drugs may introduce withdrawal symptoms which may put you back to where you started in the first place.  While people who have been taking the drug for a very short time may sometimes safely stop cold turkey, this is not the case with people who have been following their prescriptions for months or years.

Because the brain has adapted to the presence of a drug, stopping its intake could cause severe withdrawal consequences.  One cannot simply say they will weather the withdrawal storm or hope to steel their minds to the physical and emotional aftermath.  In some cases, even gradual reduction of intake can lead to repercussions, ranging from moderate to severe, such as suicidal or violent behaviour.  This is why even gradual coming off a psychiatric drug must be a supervised situation.

The decision to come off or stop taking your medication altogether must be done after knowing your risks.  Your psychiatrist or general practitioner is the best person to consult on the matter as he is more knowledgeable of the drug.

Coming Off Gradually

The brain and body needs time to adjust to the reduction of intake.  Sudden dosage decreases may throw your body off-kilter and make you very sick from withdrawal symptoms.  Your mental illness, for which your drug was originally prescribed for, may also surface and pile on more symptoms.  Sometimes, it may be difficult to weed out whether the symptoms come from coming off or from the mental illness itself.

If you have been taking a drug for over six months, then expect a six-month or more timetable to get yourself completely weaned off the prescription.  If you have been taking the drug for ten years, then the reduction should be very slowly, spanning a period of years before being free of the medication.

Some people have prescriptions of two or more psychiatric drugs.  Coming off has to be done one drug at a time.  Since drugs affect how other drugs in your prescription work, your psychiatrist or GP must suggest which drug to reduce first and what other dosages need to be adjusted because of the change.

Alternative Support for Coming Off Drugs

Aside from your doctor, you may turn to these alternatives to help you deal with withdrawal symptoms for coming off your medications.

Talking Therapies

Medications can suppress emotions and creativity; so, coming off drugs can trigger these emotional issues.  Cognitive Behavioural Therapy (CBT), psychotherapy, and other forms of counselling may be very helpful in dealing with emotional upheavals.

Alternative Therapies

As further support to dealing with withdrawal symptoms, your doctor may recommend alternative therapies such as exercise, acupuncture, yoga, meditation, and aromatherapy.

Art Therapies

Art, music, dance, and writing can become invaluable and enjoyable ways of expressing one’s emotions.  The art therapist’s job is to encourage you to express yourself in whatever medium you feel comfortable doing.  You do not need to possess a painting talent, for instance, to engage in painting sessions because the main goal here is not to create good art work but use art therapy as a venue to deal with difficult feelings or memories.

You may use what you created to talk to your therapist about your work’s relation to your feelings.  For some people, art therapy in itself is a healing process that helped them deal with or even recover from their mental illness.

 

The decision to stop or gradually come off medications is something one must consider very carefully by weighing both one’s risks and benefits from the move.  Never stop taking or reducing your intake on your own.  With a decision like this, seeking your doctor’s medical advice becomes doubly imperative.

Community Treatment Order (CTO)

In November of 2008, the CTO or Community Treatment Order was inserted into the Mental Health Act 2007.  Applicable in both England and Wales, the CTO is a law that provides power to a responsible clinician to decide whether to psychiatrically treat an individual outside the hospital.

ctoIf a patient has been mandatorily sent to a hospital for psychiatric treatment, a Community Treatment Order may be issued by an approved clinician to get him out of hospital care, if patient is not harmful to himself and others, provided he agrees to certain conditions for community treatment.  If the agreed conditions are violated, the responsible clinician may make an order to return the patient to the hospital.  A patient under CTO is known as a community patient.

Criteria for Community Patient Eligibility

A patient may be granted a Community Treatment Order only if the following requirements are met:

  • The individual must have a diagnosed mental health disorder
  • The patient requires treatment in order to be safe from himself or to protect those he comes in contact with
  • The required treatment can be administered outside hospital bounds
  • The required treatment is available in the community or outside the confines of a hospital
  • The responsible clinician must be able to order the patient back under hospital care when necessary.

Duration of a CTO

From the date the order was issued, a CTO can last for about six months.  The order is renewable for another six months and thereafter on a twelve-month basis on the conditions that the patient:

  • has been available for examination under the conditions set by the CTO
  • has visited a second opinion appointed doctor (SOAD) when required to.  SOADs give their opinion on whether they agree with the current treatment the patient is receiving.

Conditions of a CTO

All CTOs have the above two conditions stipulated in every agreement.  Other conditions may apply but these will be influenced by your circumstances.  Examples of other conditions may include:community treatment order

  • place to stay during therapy
  • testing for alcohol or illegal drugs
  • attending scheduled therapies
  • cooperating with treatments such as taking the prescribed medications

These other conditions must involve a patient’s participation in planning his treatment after discharge.  If this is not applicable, then his nearest of kin or guardian must be fully aware and agreeable to the conditions under the CTO.  All these conditions should be based on the necessity behind the patient’s recovery and protection of other people around him.

Any condition in the CTO may be contested for unlawfulness if it unnecessarily restricts the patient’s freedom or if such condition is impractical in light of a patient’s circumstances.

Can Changes to Conditions of a CTO be Made?

The responsible clinician may change or stop the application of the conditions.  One may request for changes in the conditions through written or verbal communication with his clinician.  If the clinician refuses the request, the patient may have recourse by:

  • lodging his complaints using the hospital’s complaint procedure.
  • bringing his case to the Care Quality Commission
  • applying for a judicial review.  In this case, one would need special legal advice.

When a CTO Ends

A Community Treatment Order is limited by a timeframe.  When a CTO ends, a patient is no longer required to follow the conditions or compelled to be recalled for hospitalization by the responsible clinician.  A CTO ends when:

  • It expires and is not renewed.
  • It is revoked.  If a patient has been hospitalized, a CTO revocation can mean he is no longer eligible for treatment outside the hospital and must be detained in the hospital.  This is usually done when the responsible clinician deems he is of danger to himself and others.
  • The responsible clinician believes there is no more legal necessity to keep the patient under CTO and therefore discharges the patient.
  • The patient’s application to the Mental Health Tribunal is approved with a discharge.
  • A discharge comes from a hearing by the hospital managers.
  • A request for a discharge by the nearest relative or kin is approved.

What the Law Says on Disability Discrimination

Discrimination is a reality for many people and is based on a number of reasons:  gender, race, creed, religion…the list is sizable.  Physical and mental infirmities are part of the list rendering disabled persons unfortunate targets of society’s prejudices.  Disabled people may encounter discrimination at the workplace, school, or even in business dealings such as buying or renting property.  Disability does not only refer to physical impairment but includes mental infirmities as well.  People with mental health problems are considered disabled and are therefore entitled to the same disability rights and protections under U.K. law.

disability discrimination

Disability Discrimination Act 1995 (DDA)

The DDA or the Disability Discrimination Act of 1995 was a civil rights law which made discrimination of disabled persons unlawful when it came to provision of goods and services, education, and employment.  It demanded that disabled persons be accorded some reasonable adjustments with regard to their infirmities.  Modifications to the DDA have since been enforced when this law was repealed and replaced by the Equality Act 2010.

The Equality Act 2010

Injustice, unfairness, prejudice, harassment, and mistreatment of mentally ill people is categorised as discrimination.  Discrimination against the mentally ill and people with other types of disability is illegal and therefore can be challenged in court as per the Equality Act 2010.

Under the Equality Act 2010, any individual who is physically or mentally compromised to a point where there is a long-term negative effect on these person’s normal daily functions (such as driving, answering phone calls, talking with colleagues) is considered disabled.  This law provides protection from discrimination in many areas such as:

  • Employment — during an application for a job; leaving a job; or being currently employed
  • Education — when applying for and studying at a school or university
  • Business dealings — buying and renting property
  • Clubs — joining private clubs or organizations
  • Dealings with public functions such as crime investigations, tax collections, etc.
  • Services – hospitals, gyms, restaurants, etc.

When fighting on legal grounds, it is important to establish in court that a particular mental problem you are inflicted with is truly a disability.  The Equality Act can cover the conditions of autism, depression, dyslexia, schizophrenia, bipolar disorder, and many others.

Categories of Discrimination

Direct Discrimination

When a disabled person is prejudiced from receiving the same treatment as the average individual because of his infirmity, he is being directly discriminated.  To illustrate:   Joe who has been diagnosed with clinical depression has been bypassed for promotion in favour of a colleague who has fewer qualifications for the position.  Because of his mental illness, Joe has been discriminated from advancing in his career despite the fact that his condition can be lived with and controlled.  Joe has the right to turn to legal advice under the Equality Act 2010.

Discrimination by Association

When a person is discriminated against because he is associated or related in any way to a disabled person, then discrimination by association occurs.  For example, Catherine, who despite her mental illnes discriminationobvious qualifications, was rejected after a job interview for the sole reason that she has a schizophrenic mother at home.  The rejection was on the grounds that possible emergency situations in the future could hamper her work.

Discrimination by Perception

A 40-year old pilot has been bypassed for captainship just because he looks 15 years younger.  People’s perception of his young age was used as basis for impeding the pilot’s career advancement.

Indirect Discrimination

A rule or criteria applied to everyone but is unreasonably prejudiced to a certain individuals because of their disability.  A rule that all employees in a certain department must begin work at 7 a.m. may be discriminatory for an employee under long-term medication.  The 7 a.m. rule may not be feasible because the drug makes him less alert early in the morning.  If the company can afford to simply shift this particular employee’s schedule to 9 am and allow him to end his shift at a later time than his colleagues, but just unreasonably refuses to, then the company commits indirect discrimination.  The company has refused to make reasonable adjustments.

Victimisation

A person who made a complaint or supported a complaint made against circumstances violating the Equality Act 2010 may be treated badly.  Such discrimination is typed as victimisation.

Harassment

Harassment by one’s employers or colleagues occurs when unwanted behaviour from these individuals are directed toward person or persons with “the purpose or effect of violating an individual’s dignity or creating an intimidating, hostile, degrading, humiliating or offensive environment for that individual.”

A company may also be liable for harassment even if the perpetrators are not employed by the company.  For instance, if a client constantly pokes fun at a mentally ill employee of the company and management has not done anything to address this customer’s behaviour, then the company is liable for discrimination under the Equality Act.

What Do Reasonable Adjustments Mean?

The law requires companies to make reasonable adjustments where disabled workers are concerned. Reasonable adjustments refer to small changes in the workplace that allow disabled employees to do their jobs well.  The term reasonable is important because the company is not obliged to make unaffordable changes that would qualify as an “unjustifiable hardships” for the company.  If the required changes arising from the employee’s disability will cost the company some significant expenses or be detrimental to other employees, then the company has the right not to make any adjustments as these are no longer reasonable.  For instance, should adjusting the end working hours for a disabled person require the company to hire additional security for his safety,  the court may rule this requirement as an unreasonable change and may uphold the company’s right to keep its working hour rules despite being detrimental to the disabled person’s personal schedule.

About Community Care and Aftercare

 

U.K.’s Community Care Program

Community Care or Domiciled Care is the British government’s health policy for home treatment of the mentally and physically disabled.  The system does away with the practice of institutionalization in which patients were placed under the care of an institution.  Before the 80s, mentally ill people were given over to the care of mental institutions.

Presently, community care refers to various health care services available to the public.  These services are available through clinics, home therapy, day care centres, social work support, and counselling, among others.  The system by which specific types of care or treatment is delivered to a patient is called care planning which is usually arranged by the Community Mental Health Teams (CMHTs).

community care

Establishment of U.K.’s Community Care Policy

Institutionalisation of the mentally and physically disabled was a British medical practice for decades.  In the 1960s and 1970s however, the practice gained widespread criticism after the media focused on allegations of malpractice and mismanagement of care under these huge institutions.  Criticism reached its peak when a nurse exposed the brutality and inhumane treatment of mental patients in Ely Hospital in Cardiff.  Other scandalous stories surfaced, prompting official investigations into institutions.

Under then Prime Minister Margaret Thatcher, Community Care policy was established in the 1980’s.  The aim was to maintain and provide care for people in their own homes rather than being put away in large institutions.  The move was also a more budget-friendly alternative for the government.

Community Care for Mentally Ill Patients

Community care for mentally ill individuals has two types of caring systems:  health care and social care.

Health care is concerned with support for managing both physical and mental ailments.  This includes medications; talking therapies (Cognitive Behaviour Therapy, psychotherapy, and other types of counselling); support from a psychiatrist, a community mental health team (CMHT) or a community psychiatric nurse; crisis services; and preventative care to help people be aware of mental health problems.

Social care involves patient assistance in managing their everyday tasks which may be compromised by mental illness.  Examples for social care services may be help in obtaining transportation for attending therapies and group supports; financial management of personal finances; cleaning, cooking, and general housework; and managing relations with family and friends, among many other services.

Depending on individual needs, a patient may opt to receive only mental health care or just social care or both.  Ideally, community-based care should be able to give the opportunity for mentally ill individuals to integrate as much normalcy in their lives as they can.

How to Access Community Care

The most common point for accessing community-based care is through a general practitioner (GP) who will assess the patient’s needs and may refer him to other services.  For instance, if the GP feels a mental health problem is complex, he may refer the individual to a community mental health team (CMHT) which may provide the network of support he needs.  A CMHT is a group of various mental health providers such as psychiatrists, nurses, social workers, etc. who all work in tandem to deliver the necessary care.

If a person’s mental health situation warrants more support, the CMHT may put the patient under the Care Programme Approach (CPA).  The CPA is a system by which a patient is entrusted to a care coordinator responsible for managing both mental health care and social care assessments and services.  The patient is given a Care Plan which details the specific support and provider the patient needs.  The Care Plan should also include a crisis plan as a guide to patients hitting a low point during their care (ex. contemplation of self-harm or suicide).  This crisis plan details what to do, whom to contact, where to go, etc.

care chart

 

Aftercare

Mental health aftercare is a free service the government mandates under Section 117 of the Mental Health Act of 1983.  Free aftercare service is further government support given to mental patients under these circumstances:

  • Obligated by law to be detained in a hospital as per Section 3 of the Mental Health Act.
  • Sentenced to detention in a mental/psychiatric hospital by a criminal court
  • Transferred to a psychiatric hospital

Aftercare involves outpatient treatment, access to a psychiatric nurse, counselling or therapy, employment support, assistance with personal financial management, use of day care centres, and the like.

If one has been deemed eligible for aftercare, an evaluation of his needs should be outlined and provided before the patient is released from the hospital.  The patient will receive a plan detailing specific services he will need and expect from the aftercare program.

Dialectical Behaviour Therapy (DBT)

dbt

Dialectical Behaviour Therapy is a specialized type of talking therapy under the general category of Cognitive Behavioural Therapy (CBT).  This kind of CBT was developed by psychologist, Marsha M. Linehan, in the 1980’s  to especially focus on treating Borderline Personality Disorder (BPD) and has since proven to be a valuable treatment for this particular mental illness.

What does “Dialectic” in DBT mean?

The word dialectic in the term Dialectical Behaviour Therapy refers to the unification or synthesis of two opposing positions, concepts, or realities.  DBT seeks to meld two key concepts that naturally oppose each other:  acceptance and change.

Acceptance refers to coming to terms with who you are—your emotions, experiences, and natural responses.  Change means altering your responses and thoughts toward more positive behaviour and coping strategies in order to reach personal and social goals in becoming a more integrated individual.

People with Borderline Personality Disorder have very heightened negative emotions.  As a result, they are often acutely emotionally unstable and have a tendency toward inflicting self harm and attempting suicide.  DBT seeks to help BPD patients accept their personal liabilities and to help them acquire new behavioural skills to replace their ineffective and damaging responses for achieving emotional stability and personal goals.

Four Stages of Treatment with Dialectic Behaviour Therapy

The end goal of all four stages is to mould the patient toward making their own paradigm shift from feelings of worthlessness to:  I am worth as much as everyone else; life is worth living.

Stage 1:  Achieving Behavioural Control

At the start of therapy, the patient’s condition may be dangerously low—in psychological misery, out of control, and therefore may be self-destructive with drug and alcohol use, sexual promiscuity, or binge eating.  They may also be suicidal with a history of attempts or still at the contemplation stage.  The objective of Stage 1 therapy is to assist the patient into gaining command of his spiralling out-of-control thoughts and behaviour.

Stage 1 is all about setting and achieving three main goals:

  1. Stop suicidal or self-harming behaviour
  1. Rid the patient of obstacles or behaviour that prevent or interfere with therapy — the patient may justify to himself why he does not need to go on with therapy or his family may be embarrassed about his condition and prevent him from getting needed treatment.
  1. Addressing issues that lower patient’s quality of life — Problems like depression, unstable relationships, or being expelled from school may be issues distressing the patient to a volatile degree.

At this stage, the therapist tries to equip the patient with emotion-managing skills so that the patient can disengage from dangerous behaviour and gain some mastery over his negative thought patterns.

Stage 2:  Emotional Experiencing

Although Stage 1 behaviour control has been achieved, the patient continues to suffer quietly.  Their emotional turmoil is usually due to past trauma and invalidated feelings.  For those with Post Traumatic Stress Disorder (PTSD), past trauma is explored and analysed and its accompanying negative beliefs and behaviours, verified.  PTSD is treated at this stage.

The goal of stage 2 is to move the patient past suffering with inhibited emotions and on to a level where they experience their emotions in full.  At this second stage, the therapy involves the following:

  1. The patient is encouraged to remember and accept the traumatic event.
  2. Reduction of stigmatization
  3. Reduction of self-blame
  4. Lowering incidences of negative intrusive and denial syndromes

Stage 2 goals can only be achieved once negative behaviour is under control.

Stage 3:  Learning to Live

Stage 3 focuses on building self-esteem, owning one’s behaviour, creating trust and value for one’s self, and goal setting.  The patient is gradually led toward coming to terms with happy and unhappy events in life, thus enabling him to live life normally.

Stage 4:  Building Capacity for Joy

Some people stop at stage 3 but for others, stage 4 is an important part of recovery.  Stage 4 is all about spiritual fulfilment which helps the patient feel connected to humanity as a whole.  The goal at this stage is to help the patient go beyond just living day to day and be able to incorporate the ability to experience joy and freedom.

DBT-Skills

Scientific evidence has proven Dialectical Behaviour Therapy to be effective in lowering rates of suicides, self-harm, dropouts in treatment, depression, hospitalization, and substance abuse.  DBT has indeed helped many patients to improve functioning and relationships in their personal and social lives.