Harm Reduction Guide to
Coming Off Psychiatric Drugs
The Icarus Project and Freedom Center

This guide brings together the best information we've discovered and lessons we've learned at The Icarus Project and Freedom Center. It is not intended to persuade anyone to stop taking psychiatric medications, but instead aims to educate people about their options if they decide to explore going off.
In a culture polarized between the pro-medication propaganda of pharmaceutical companies on the one hand, and the anti-medication agenda of some activists on the other, we offer a harm reduction approach to help people make their own decisions. We also present ideas and information for people who decide to stay on or reduce their medications.
Many people do find psychiatric drugs helpful and choose to continue taking them: even with the risks, this may be a better option given someone's situation and circumstances. At the same time, psychiatric drugs carry great dangers and can sometimes do terrible harm, even becoming bigger problems than the conditions they were prescribed to treat. Too often, people who need help getting off psychiatric drugs are left without guidance, and medication decisions can feel like finding your way through a labyrinth. We need honest information that widens the discussion, and we hope this guide helps people trust themselves more and take better care of one another.

The Icarus Project C/o Fountain House 45 West 47th Street Northampton, MA 01062 New York, NY 10036 The Icarus Project is a website community, support
Freedom Center is an award-winning support, advocacy and
network of local groups, and media project created by activism community based in Western Massachusetts. Run by and for people struggling with bipolar disorder and other and for people labeled with mental disorders such as bipolar, dangerous gifts commonly labeled as "mental illnesses." The schizophrenia, and borderline, or who experience extreme Icarus Project is creating a new culture and language that states of consciousness, Freedom Center works for access to resonates with our actual experiences of madness rather holistic alternatives, compassionate care, and an end to forced than trying to fit our lives into a conventional framework.
This is a first edition and we welcome your input and ideas for future versions.
Written by Will Hall. Published by the Icarus Project and the Freedom Center. Thanks to Amy Bookbinder, Dave Burns, Oryx Cohen, Mary Kate Connor, Marc Dinacola, Dianne Dragon, Sascha DuBrul, Empties, Vikki Gilbert, Chaya Grossberg, Richard Gilluly, Molly Hardison, Gail Hornstein, Mollie Hurter, Jonah, Krista MacKinnon, Ashley McNa-mara, Alex Samets, Seven, Bonfire Madigan Shive, Jessica Max Stein, Terramuggus, and many other collaborators and allies.
Cover art: Ashley McNamara. Art design: Carrie Bergman.
Contributing artists: Fly, Gheena, Miss Led, Ashley McNamara, Erik Ruin, Janice Sorensen, and Bec Young.
This guide is available free as a file download at the Freedom Center and Icarus Project web sites. Contact us to order published book versions and multiple copies to distribute.
First edition, September 007.
Creative commons copyright: you are free to copy and distribute with source attribution, without content altera-tion, and without financial gain. Please contact us for other uses.
Printed with soy-based ink on 100% post-consumer recycled paper.
This guide is written in the spirit of mutual aid and peer support. It is not intended as medical or professional advice. While everyone is different, psychiatric drugs are powerful and coming off suddenly or on your own can sometimes be dangerous.

ContentsAuthor's Note . 5 Harm Reduction For Mental Health . 6 Key Resources For Further Learning . 8 Looking Critically At "Mental Disorders" and Psychiatry . 8 How Difficult Is Coming Off Psychiatric Drugs? .0 Universal Declaration of Mental Rights and Freedoms . Principles Of This Guide . How Do Psychiatric Drugs Work? .13 Do Psychiatric Drugs Correct Your Chemistry?.13 Who's To Blame? Yourself? Your Biology? Or Neither?.5 What Do These Drugs Do To Your Brain? .16 Why Do People Find Psychiatric Drugs Helpful? .16 Facts You May Not Know About Psychiatric Drugs .8 Health Risks of Psychiatric Drugs .9 How Withdrawal Affects Your Brain and Body . Why Do People Want To Stop Using Psychiatric Drugs? .23 Harm Reduction and Staying On Medications .4 I Want to Come Off But My Doctor Won't Let Me: What Should I Do? .5 Before You Start Coming Off .26 Working With Fear .8 Intermittent Use: Taking Psychiatric Drugs From Time To Time .9 What are the Alternatives to Using Psychiatric Drugs? .9 Coming Off: Step by Step .31 Special Considerations .34 Health Practitioner Editorial Advisors .40

Author's Note:This is a guide I wish I had when I was taking psychiatric drugs. Prozac helped me for a while, then made me manic and suicidal. I was sick for days after coming off Zoloft, with counselors telling me I was faking it. Nurses who drew blood samples for my lithium levels never explained it was to check for drug toxicity, and I thought the Navane and co-found Freedom Center, a support community in other anti-psychotics I took to calm my wild mental Western Massachusetts that brings together people states were necessary because of my faulty brain.
asking similar questions. I used many different psychiatric drugs over several Through the Freedom Center I discovered that I years, but the medical professionals who prescribed was denied a basic medical right: informed consent, them never made me feel empowered or informed. having accurate information about my diagnosis and They didn't explain how the drugs work, honestly medication. I learned that mistreatment like I went discuss the risks involved, offer alternatives, or help through is business as usual in the mental health me withdraw when I wanted to stop taking them. profession. I came across research ignored by the Information I needed was missing, incomplete, or mainstream media, including studies by the UK inaccurate. When I finally began to learn ways to charity MIND and the British Psychological Society, get better without medication, it wasn't because of which confirmed my experience: most professionals the mental heath system, it was in spite of it.
are not only ignorant about coming off drugs, but frequently stand in patients' way, sometimes ending Part of me didn't really want to be on psychiatric up harming them. drugs, but another part of me desperately needed help. My suffering was very serious – multiple The Freedom Center led me to work with the suicide attempts, hearing persecutory voices, Icarus Project, and together these communi- extreme mistrust, bizarre experiences, hiding alone ties of mutual support have helped many people in my apartment, unable to take care of myself. make wiser decisions about medications, including Therapy hadn't worked, and no one offered me exploring the possibility of coming off them. Many other options. I was under pressure to see my of us are living without psychiatric drugs that problems as "biologically based" and "needing" doctors told us we would need our whole lives, medication, instead of looking at medication as one and despite a diagnosis of schizoaffective disorder option among many. For a time medication seemed schizophrenia I have been medication-free for more like my only way out. It took years to learn that the answers, and my hope for getting better, were really within myself.
This guide brings together the best infor-
mation we've come across and the most
When I finally left the hospitals, residential facilities, important lessons we've learned at the
and homeless shelters I lived in for nearly a year, I Freedom Center and the Icarus Project.
began to do my own investigating. I started judging It's not perfect, and I invite you to contribute your my options more carefully, based not on misin- experiences and research for future editions, but it's formed authorities telling me what to do, but on my a guide that I hope can be helpful. own research and learning. That process led me to FOR MENTAL HEALTH Absolutist approaches to drug and sex education teach only abstinence and "just say We live in a world that, no." They work for some people, but not most, and people who do not follow the abstinence when it comes to drugs, model end up being judged, not helped.
is quite crazy.
"Harm reduction" is different: pragmatic, not dogmatic. Harm reduction is an international On the one hand there is the War on Drugs, which movement in community health education keeps some drugs illegal, overflows our prisons, and that recognizes there is no single solution to hasn't ended illegal drug use. Then there are the every problem. Abstinence is not necessar- acceptable drugs like alcohol and tobacco, advertised ily the only way. Instead of pressuring to quit, everywhere with promises of happiness and power harm reduction accepts where people are at while causing widespread disease, addiction and and educates them to make informed choices death. Legal prescription drugs, like anti-depressants, and calculated trade-offs that reduce risk sleep medications, and anti-anxiety pills, are just as and increase health. People need information, addictive and risky as street highs, with a doctor's options, resources and support so they can seal of approval. And there are neuroleptics, lithium, move towards healthier living – at their own and anti-convulsant drugs, which have dangerous pace and on their own terms. effects on the brain but help manage consciousness when people feel out of control, so we call them Applying harm reduction philosophy to anti-psychotics and mood-stabilizers.
mental health is a new but growing concept. It means recognizing that people are already With drugs in the picture, lives are often at stake, taking psychiatric drugs, and already trying to whether from addiction, adverse drug effects, or come off them. It encourages examining all the risks that go along with emotional crisis and the different kinds of risks involved: the harm madness. Combined with the confusing messages from emotional crisis that goes along with from society about drugs, the result is a lot of fear. experiences labeled mental disorders, as well Drugs become demons or angels. We need to stay as the harm from treatments to deal with on them at all costs, or get off them at all costs. We these experiences, such as psychiatric drugs, look only at the risks, or we're too frightened to diagnostic labels, and hospitalization. Making look at the risks at all. There is no compromise: it's harm reduction decisions means looking black and white, all or nothing.
carefully at the risks of all sides of the equation: honesty about what help drugs might offer for It's easy to fall into absolutist thinking when it comes a life that feels out of control, honesty about to psychiatric drugs. Pro-drug advocates focus on the how harmful those same drugs might be, and risks of extreme emotional states, while anti-drug honesty about options and alternatives. Any advocates focus on the risks of taking drugs. But it decisions may involve a process of experimen- is the belief of this guide, and the philosophy of our tation and learning, including learning from your pro-choice work at the Freedom Center and the own mistakes. Harm reduction accepts all this, Icarus Project, that either-or thinking around drugs is believing that the essence of any healthy life is a big part of the problem.
the capacity to be empowered.
like the only way to recognize the pain and serious- ness of our problems. And when everyone around us has come to view medication as essential to our survival, exploring a new path can feel too risky to even try.
Many of us get help from psychiatric drugs, but There is no formula for coming off psychiatric might not understand how they really work or drugs successfully. What there is, and what this what the other options are. Some of us never guide presents, is some common experience, basic found medications useful, or they even made our research, and important information that can problems worse, and we are ready to try living potentially make the process less difficult. Many without them. Sometimes people are torn between people successfully come off psychiatric drugs, with the risks of staying on them and the risks of going or without guidance, while others find it very hard. off, or we take multiple drugs and suspect we don't And many people end up staying on psychiatric need all of them. Others may want to go off but drugs even though they don't want to, because they it's not the right time, or we may have tried in the don't know any other way.
past, experienced a return of painful or "psychotic" symptoms, and decided to go back on them for When we've relied only on doctors, television, and mainstream sources, it might seem impossible to deal with our emotional extremes without medica- Our paths to healing are unique. Some of us may tion. Maybe we've never heard of anyone going not need to make any life changes, letting time and through what we go through any other way. Maybe patience make change for us. Others may need to a prescription was the beginning of people taking make significant changes such as in nutrition, work, our need for help seriously, and medications feel or relationships; we may need to focus more on self-care, expression, art and creativity; adopt other treatments like therapy, herbalism, acupuncture or ho-meopathy; or find new life interests like going to school or connecting with nature. We may discover that the first step is getting restful sleep, we may need structure to help get us motivated, or we may need to stop taking any recreational drugs or alcohol. Our priorities might be to find a home or a new job; we may need to establish stronger support networks of trusted friends; or we may need to speak up with greater honesty and vulnerability about what we are going through.
The process might feel mysterious and arbitrary, and
we may need an attitude of acceptance and patience.
Learning means trial and error. Because each of us is
different, it is as if we are navigating through
a labyrinth, getting lost and finding our way
again, making our own map as we go.
Key Resources For Further Learning This guide draws especially from research by MIND, the leading mental health non-profit in the UK; the British Psychological Society, a mainstream professional association; and Peter Lehmann Publish-ing, a psychiatric survivor press.

MIND Making Sense of Coming Off Psychiatric Drugs
MIND Coping With Coming Off Study
Recent Advances in Understanding Mental Illness and Psychotic Experiences:
A report by The British Psychological Society Division of Clinical Psychology.
Available free online at Coming Off Psychiatric Drugs: Successful Withdrawal from Neuroleptics, Antidepres-
sants, Lithium, Carbamazepine and Tranquilizers
edited by Peter Lehmann, Looking Critically at
simplistic sound-bites to persuade people to put their faith in science and doctors. These words "Mental Disorders" and
are in fact much more complicated and unclear. Biological factors (such as nutrition, rest, and food allergies) affect everything we experience: biological cause or "basis" plants the belief that there is one Doctors put people on psychiatric medications for root or key cause of our problem. To say something experiences labeled "mental disorders": extreme has a biological cause, basis, or underpinning is to emotional distress, overwhelming suffering, wild say that the solution must be a medical one and mood swings, unusual beliefs, disruptive behaviors, "treatment" has to include psychiatric drugs. Once and mysterious states of madness. Currently people have a diagnosis and start taking medication, millions of people world-wide, including infants it is easy to think of the medications as physically and elders, take psychiatric drugs when they are necessary for survival.
diagnosed with such labels as bipolar disorder, schizophrenia, depression, anxiety, attention deficit, Not only is there is no solid science behind viewing or post-traumatic stress. The numbers are climbing mental disorders as caused by biology, but many people with even the most severe diagnosis of schizophrenia or bipolar go on to For many people, these drugs are recover completely without medica- very useful. Putting the brakes on tion. The experiences that get labeled a life out of control, being able mental disorders are not "incurable" to function at work, school, and or always "lifelong." For some people in relationships, getting to sleep, psychiatric drugs are helpful tools, and keeping a lid on emotional but they are not medically necessary extremes can all feel lifesaving. treatments for illness. And once you The sense of relief is sometimes acknowledge these facts, the risks of dramatic, and the medications psychiatric drugs themselves deserve can stir very powerful emotions greater scrutiny, because they are and even feelings of salvation. At very serious, including chronic illness, the same time, the help psychiatric drugs offer mental impairment, dependency, worse psychiatric many people can sometimes leave little room to symptoms, and even death.
recognize that many others experience psychiatric drugs as negative, harmful, and even life-threaten- Because psychiatric medications are a multi-billion ing. As a result, it is rare in society to find a clear dollar industry like big oil and military spending, understanding of how and why these drugs work, companies have incentive and means to cover or an honest discussion of risks, alternatives, and up facts about their products. If you look more how to come off them if people want to.
carefully into the research and examine closely the claims of the mental health system, you will Doctors and TV ads tell people that psychiatric discover a very different picture than what pill medication is necessary for a biological illness, just companies and most doctors want us to believe. like insulin for diabetes. They promote the idea Companies actively suppress accurate assessments that the drugs correct chemical imbalances and fix of drug risks, mislead patients about how objective brain abnormalities. The truth is different, however. a mental disorder diagnosis is, promote a false "Biology" and "chemical imbalances" have become understanding of how psychiatric drugs really work, keep research into alternative approaches unfunded activists, and healers who are connected with and unpublicized, and obscure the role of trauma the Freedom Center and the Icarus Project. We
and oppression in mental suffering. For the mental encourage you to use this guide not as the
health system, it's one size fits all, regardless of the definitive resource but as a reference point
human cost: scandals are growing, and the fraud and for your own research and learning. And
corruption surrounding some psychiatric drugs are we hope that you will share what you have learned reaching tobacco-industry proportions.
with others and contribute to future editions. In this complicated cultural environment, people need accurate information about possible risks and How difficult is coming off benefits so they can make their own decisions. Too psychiatric drugs? often, people who need help getting off these drugs In working with hundreds of people over are left without support or guidance, and even many years, we have found there is no way treated like the desire to go off the drugs is itself a to predict how the coming off process sign of mental illness – and a need for more drugs.
will go. There is really no way to know in advance who can and who cannot live In discussing "risks" and "dangers," it is important without psychiatric drugs, who can live with to understand that all life involves risk: each of us fewer drugs or lower doses, or how hard it makes decisions every day to take acceptable risks, will be. We've seen people withdraw success- such as driving a car or working in a stressful job. fully after more than 0 years, and people It may not be possible to predict exactly how the need to continue to take them after being risks will affect us, or avoid the risks entirely, but on for just a year. Because it is potentially it is important that we know the risks exist and possible for anyone, the only way to really learn as much about them as we can. Looking at know is to slowly and carefully try, and see the risks of drug treatment also means looking at how it goes. Everyone should have the right the risks of emotional distress / "psychosis" itself, to explore this. and making the best decision for you, whether it is that psychiatric drugs are the best option given The study of coming off drugs by MIND, your circumstances and situation, or whether you the leading mental health charity in the UK want to try to come off. This guide is not intended confirms our experience. MIND found that to persuade you one way or the other, but to help "Length of time on the drug emerged
educate you about your options if you decide to as the factor that most clearly influ-
explore going off psychiatric drugs.
enced success in coming off. Four out
of five people (81 per cent) who were
Because of the pro-drug bias in medicine and on their drug for less than six months
science, there has been very little research on succeeded in coming off. In contrast,
psychiatric drug withdrawal. We based this less than half (44 per cent) of people
guide on the best available information, including who were on their drug for more than
excellent sources from the UK, and worked with a five years succeeded. (Just over half
group of health professional advisors (see page 40) of people who were on their drug for
including psychiatric doctors, nurses, and alternative between six months and five years
practitioners, all of whom have extensive clinical experience helping people come off drugs. We also (see Resources, page 38) draw on the collective wisdom of an international network of peer counselors, allies, colleagues, In some ways the issue of coming off psychiatric drugs is deeply political. People of all economic and educational backgrounds successfully reduce Universal Declaration or go off their psychiatric medication. However, of Mental Rights and sometimes economic privilege can determine who has access to information and education, who can afford alternative treatments, and who has the flexibility to make life changes. People That all human beings are created different. without resources are often the most vulnerable That every human being has the right to be to psychiatric abuse and injury from drugging. mentally free and independent.
Health is a human right for all people: we need a complete overhaul of our failed "mental health That every human being has the right to system" in favor of truly effective and compas- feel, see, hear, sense, imagine, believe or sionate alternatives available to all regardless of experience anything at all, in any way, at any income. Pushing risky, expensive drugs as the first and only line of treatment should end; priority should be on providing safe places of refuge and That every human being has the right to treatments that do no harm. Numerous studies, behave in any way that does not harm such as Soteria House in California and programs others or break fair and just laws.
in Europe, show that non-drug treatments can be very effective and cost less than the current That no human being shall be subjected system. And a medical and product regulatory without consent to incarceration, restraint, establishment honest about drug risks, effective- punishment, or psychological or medical ness, and alternatives would have never put most intervention in an attempt to control, psychiatric drugs on the market to begin with.
repress or alter the individual's thoughts, feelings or experiences.
Instead of viewing the experiences of madness from: as a "dis-ability," which can be a stigmatizing put-down, it is helpful to view those of us who go through emotional extremes as having "diverse-ability." Society must accommodate the needs of sensitive, creative, emotionally wounded, and unusual people who make contributions to the community beyond the standards of competi-tion, materialism, and individualism. To truly help people who are labelled mentally ill, we need to rethink what is "normal," in the same way we are rethinking what it means to be unable to hear, without sight, or with limited physical mobility. We need to challenge able-ism in all forms, and question the wisdom of adapting to an oppres-sive and unhealthy society, a society that is itself quite crazy. Our needs are intertwined with the broader needs of social justice and ecological sustainability. Principles of This Guide:
• Choice: Psychiatric medications affect the most intimate aspects of mind and
consciousness. We have the right to self-determination: to define our experiences as we want, seek out practitioners we trust, and discontinue treatments that aren't working for us. We don't judge others for taking or not taking psychiatric drugs: we respect individual autonomy. When people have difficulty expressing themselves or being understood by others, they deserve accommodation, supported decision-making, and patience from caring advocates, according to the principle of "first do no harm" and the least intrusion possible. No one should be forced to take psychi-atric drugs against their will. • Information: Pharmaceutical companies, medical practitioners, and the media
need to provide accurate information about drug risks, the nature of psychiatric diagnosis, alternative treatments, and how to go off psychiatric drugs. Medical ethics require practitioners to understand the treatments they prescribe, protect patients from harm, and promote safer alternatives. • Access: When we choose alternatives to psychiatric drugs and mainstream
treatments, there should be programs, affordable options and insurance coverage available. Choice without access to options is not real choice. Community con-trolled services should be available to everyone who needs help going off psychi-atric drugs or struggling with extreme states of consciousness without drugs. We urge all health care practitioners to offer free and low-cost services to a share of their clients, and for everyone with economic and social privilege to work to extend access to alternative treatments to all.
How Do Psychiatric Drugs Do Psychiatric Drugs Correct Most people begin taking psychiatric medications People are told that mental disorders exist because because they are "distressed and distressing." They brain chemistry levels are "abnormal" or "imbal- are either experiencing overwhelming states of anced," that this results from genetic "predisposi- emotional distress, or someone else is distressed tions" inherited from families, and that psychiatric with their behavior and sends them to a doctor drugs work by correcting these pre-existing brain – or some combination of both. There are many chemical imbalances. However, these claims have labels for these states, like anxiety, depression, never been proven by scientific study to be true.
mania, psychosis, voices, and paranoia, and labels change over time. Doctors Despite decades of effort and frequently tell people that billions of dollars in research, their emotional distress is no reliable and consistent due to a mental disorder evidence of preexisting which has a biochemical chemical imbalances, genetic basis, that their distress is predispositions, or brain dangerous (such as the risk abnormalities has ever been of suicide) and must be found to go along with any stopped, and that medica- psychiatric disorder diagnosis. tion with psychiatric drugs Even the fine print of drug is the most appropriate company ads now typically state that conditions are "believed to be caused by" Psychiatric drugs act on the or "thought to be caused by" brain to change mood and chemical imbalances, rather consciousness like any other mind altering drug. than making definitive claims. Genetic theories Because many medications can blunt or control today talk about complex interactions with the the symptoms of emotional distress – by either environment that differ from individual to individual speeding a person up, slowing a person down, based on experience, rather than genetic "blue- reducing sensitivity, or getting them to sleep – they prints" or causality. can take the edge off extreme states. They help some people feel more capable of living their lives. No elevated or lowered level of any neu-
It is important to realize, however, that psychiatric rotransmitter has ever consistently been
drugs do not change the underlying causes of proven to cause a psychiatric disorder. A
emotional distress. They are best understood as baseline has never even been established for what tools or coping mechanisms that can sometimes constitutes "normal" brain chemistry for all people, alleviate symptoms, with significant risks for anyone and no physical test, like urinalysis or blood draw, who takes them.
exists to detect mental disorders. Brain scans have never been able to distinguish consistently between "normal" people and people with psy-chiatric diagnoses (though medications can cause brain changes that show up on scans). Three people with an identical diagnosis might have completely different brain chemistry, and someone with very science can make no credible claim to have solved similar brain chemistry might have no diagnosis at the mystery of the mind-body relationship.
all. Western medicine has not isolated any biological causes in the same way it can describe the physical Ultimately, psychiatric diagnosis requires a doctor's mechanisms that cause illnesses such as tuberculo- subjective psychological evaluation of a patient, sis, Down Syndrome, or diabetes.
and the doctor relies on their own interpretations, fears, and preconceptions. Doctors often disagree Madness and mental disorder diagnoses do with each other, people sometimes have many sometimes seem to "run in families," but so do different diagnoses over time, and discrimination child abuse and artistic ability. Because of shared based on class, race, and gender is common.
learning and experience, family history can mean many things other than genetic determination. The decision to take or not take psychiatric
Despite ambitious claims by researchers that are drugs should be based on the usefulness
sensationalized in the media, no genetic cause, of the drug to the person who needs help
marker or set of markers has ever been discovered relative to the risks involved, not any false
and isolated for mental disorders. In fact, the more belief that they "must" be on the drug
that is understood about genetics, behavior and the because of biology or genes.
brain, the more complicated the picture becomes, and the less likely of ever finding a genetic "key." Using genetics to explain the diverse range of human behavior in a simplistic way is a throwback to the discredited concepts of social Darwinism and eugenics.
Identical twins have the same genes, but don't always have the same psychiatric diagnosis, which proves that genes alone cannot be causal. Studies show that twins do tend have a slightly higher chance of the same diagnosis, possibly indicating some genetic role, but these studies are often flawed, and claims exaggerated. Parents certainly know that children have different temperaments and qualities even at birth, but individual traits like sensitivity and creativity only become the experi-ences of madness and emotional distress after the very complicated social factors of experience, including trauma and oppression, have played a role. Every mood, thought, or experience exists somehow in the brain and body as expressions of biology, but society, mind, and learning intervene to make any causal relationship impossible to establish. Philosophers and scientists have been puzzling over the relationship between consciousness and the brain for hundreds of years. Psychiatry and neuro- Who's to Blame? Yourself? Your Biology? Or Neither?If biology and brain chemistry aren't to "blame" for your anxiety, voices, suicidality, or other distress, does this mean that you yourself are to blame? Is it either your brain's fault or your fault? A mental disorder diagnosis and a prescription can be a huge relief if the only other option is blaming yourself as lazy, weak, or faking it. When people haven't been taking your pain seriously, a doctor's decision that you have a mental disorder can feel liberating. Choosing to come off medication can then seem like the wrong message, that you don't really need help and your suffering is not really that bad.
This is an unfair either-or trap that ensnares people in the mental health system. Pharmaceutical company advertising preys on this dilemma. Coming off medications and challenging the medical model of disorders and illness means educating yourself and the people in your life to think beyond this narrow conception. Because medical science doesn't have definitive answers about what madness and extreme states are, it is up to each person to understand their experience in the way that makes sense to them. Grounding in solid research, like the sources used in this guide, can be a powerful antidote to main-stream messages. For example, the British Psychological Society report, referenced in the Resources section, acknowledges the limits of disease-model theories and suggests that stress vulnerability may be a more neutral, non-pathologizing way to understand what gets called "mental illness." Other explana-tions, such as spirituality, abuse, trauma, environmental illness, or holistic health, are also possible. Con-necting with other people who share your experiences can be crucial, and today with the internet it is easy to gather supporters even from distant countries. Taking medication doesn't mean your suffering is more serious than someone who doesn't take medication. Looking to non-biological factors like trauma, sensitivity, or spirituality doesn't mean your problems are more your own fault than someone who points to biology, genes, or brain chemistry. You don't need help any less just because you don't see yourself as having a "disorder" or being "sick." What Do These Drugs Do to Your Brain?Like street drugs and any mood or mind altering substance, psychiatric drugs alter mental states and behavior by affecting brain chemistry. Current medical theory is that most psychiatric drugs work by changing the levels of chemicals called neurotransmitters (anti-convulsants, anti-epileptics, and "mood stabilizers" like lithium appear to work by changing blood flow and electrical activity in the brain in general). Neurotransmitters are linked with mood and mental functioning, and all the cells of the nervous system, including brain cells, use neurotransmitters to communicate with each other. When neurotransmitter levels change, "receptor" cells, which receive and regulate the neurotransmitters, can grow or shrink to adjust, and become more sensitive. SSRI anti-depressants ("selective serotonin re-uptake inhibitors") for example are said to raise the level of the neurotransmitter serotonin present in the brain and reduce the number of brain serotonin receptors. Anti-psychotic medications like Haldol lower the level of dopamine and increase the number of dopamine receptors in the brain. This action on neurotransmitters and receptors is the same as for many street drugs. Cocaine changes the levels of both serotonin and dopamine, as well as noradrenaline, and alters receptors.
While these chemical changes are taking place, your consciousness works to interpret and respond in your own way, while your body responds in its way as well. Because everyone is different, your experience of medication may not be the same as other people, and will ultimately be uniquely your own. Trust yourself.
Why do People Find Psychiatric Drugs Helpful?Unlike their risks, the benefits of psychiatric drugs are widely and loudly promoted in the media. The helpful aspects of the drugs, however, tend to be mixed in with inaccurate claims about biological causes and distorted by sensationalistic advertising hype. The information below is an attempt to cut through the confusion and describe the basic ways that many people find psychiatric drugs helpful. • Sleep deprivation is one of the single biggest causes of, and contributors to, emotional crisis. Short term medication use can get you to sleep.
• Short term medication can interrupt and "put sugar pill the patient thinks is real, or undergo- the brakes on" a difficult extreme state of ing a "placebo surgery" believed to be real. In consciousness or an acute moment of crisis. clinical trials many psychiatric drugs have little Ongoing use can sometimes prevent episodes proven effectiveness beyond that of placebo, of mania or depression, or make them less because of the powerful mental effect at work. severe. Some people report that extremes and The mind plays a central role in any healing, and symptoms feel less severe and more manageable there is no way to determine whether effective- on medications.
ness for an individual comes from placebo or drug effects.
• Interrupting crisis and getting some sleep can reduce stress in your body and settle you down, • Compliance also contributes to the placebo which can allow you to reduce chaos in your effect: sometimes people will feel better when life and take care of yourself better with food, they find a clear official explanation of their relationships, and other basic issues. This can suffering to believe in, and when they follow and lay a groundwork for greater mental stability get support from a doctor, family member, or and making changes that might not have been other authority figure.
possible otherwise.
• Advertising, especially direct-to-consumer televi- • Medications can sometimes help you show up sion advertising (allowed in the US and New for and function at work, school, and in your Zealand), is extremely powerful and influences life, which is especially useful if you cannot people's experience to fit their hopes and change these circumstances. Work may require you to get up in the morning and avoid mood swings, and relationships may need you to avoid emotional reaction or sensitivity.
• All drugs have a powerful placebo effect: just believing they work, even unconsciously, can make them work. Recovery from very serious illnesses is possible just from receiving a placebo Facts You May Not Know About Psychiatric Drugs • Higher doses and longer term use of psychiatric be because dosages are often smaller, it can take drugs often mean brain changes can be deeper longer for negative effects to show, and individu- and longer lasting. The drugs are then often als have different expectations of different drugs.
harder to come off and can have more serious adverse effects. The human brain is much more • Sometimes people are told that adverse drug resilient than was once believed, however, and effects are due to an "allergic reaction." This can heal and repair itself in remarkable ways.
is misleading: psychiatric drug effects do not function biologically in the body the way food or • Neuroleptic or major tranquilizer drugs are pollen allergies do. Calling drug effects "allergic claimed to be "anti-psychotic," but in fact do reactions" treats the problem like it is in the not target psychosis or any specific symptom person taking the drug, not the drug's effect or mental disorder. They are tranquilizers that diminish brain functioning in general for anyone who takes them. They are even used in veteri- • Benzodiazepene – Valium, Xanax, Ativan and nary science to calm down animals. Many people Klonopin – addiction is a huge public health on these drugs report that their psychotic problem, and withdrawal can be very difficult. symptoms continue, but the emotional reaction Use for more than 4-5 days dramatically to them is lessened.
increases risks.
• The psychiatric use of chemicals such as • Psychiatric drugs are widely used in prisons to Thorazine and lithium was discovered before control inmates and in nursing homes to control theories of "chemical imbalance" were invented, the elderly.
and do not reflect any understanding of the • Sleep medication like Ambien and Halcyon can be addictive, worsen sleep over time, and cause • Newer anti-psychotic drugs called "atypicals" dangerous altered states of consciousness.
target a broader range of neurotransmitters, but • Because they work like recreational drugs, some they work in basically the same ways as older psychiatric medications are even sold on the drugs. Manufacturers marketed these drugs street to get high. Stimulants like Ritalin and (which are more expensive than older ones) sedatives like Valium are widely abused. Because as better and more effective with fewer side of their easy availability, illegal use of psychiatric effects, and they were hailed as miracles. But drugs, including by children, is widespread.
as reported in the Archives of General Psychiatry, • The "War on Drugs" obscures the similari- New York Times, Washington Post, and elsewhere, ties between legal psychiatric drugs and illegal this has been exposed as untrue, with some recreational drugs. Anti-depressant "selective companies even covering up the extent of serotonin re-uptake inhibitors (SSRIs)" work adverse effects like diabetes and metabolic chemically similar to slow-administered oral syndrome. However, because newer drugs are cocaine. Cocaine was in fact the first prescrip- somewhat different, people on older drugs might tion drug marketed for "feel good" anti-depres- feel better by switching to newer ones. This may sion effects, before being made illegal. Coca, the basis of cocaine, was even once an ingredient in Coca-Cola. Health Risks of Psychiatric Drugs Making a decision about coming off psychiatric drugs means evaluating as best you can the risks and benefits involved, including important information missing or suppressed from most mainstream accounts. Some risks may be worth taking, some risks may not be worth taking, but all risks should be taken into consideration. Because each person is different and drug effects can vary widely, the uncertainty involved should be met with your own best judgment and observations of how your body and mind are responding. This list cannot be comprehensive, and new risks are being uncovered regularly. Check a watchdog group (like for the latest information. Physical Health Risks • Psychiatric drugs are toxic and can damage the curately known. Taking psychiatric drugs is in body. Neuroleptic "anti-psychotics" can cause many ways society-wide experimentation, with the life-threatening toxic reaction called neuro- patients as guinea pigs.
leptic malignant syndrome, as well as Parkinson's • Combining with alcohol or other drugs can disease-like symptoms. Regular blood level tests dramatically increase dangers.
are required of some drugs such as lithium and Clozaril to protect against dangerous • Drug effects can lower the quality of life, organ damage. Many drugs can lead to obesity, including impaired sexuality, depression, diabetes, sudden heart attack, kidney failure, agitation, and overall health deterioration.
serious blood disorder, and general physical • Drug-induced body changes such as restlessness breakdown. Other toxic effects are numerous, or stiffness can alienate you from others and and include interfering with the menstrual increase isolation.
cycle, threats to pregnancy, and life-threatening "serotonin syndrome" when anti-depressants • Lithium interacts with salt and water in the are mixed with other drugs.
body, and when these levels change, such as from exercise, heat, or diet, potency can • Psychiatric drugs can injure the brain. The rate fluctuate. Even with regular blood tests and of tardive dyskinesia, a serious neurological dosage adjustments, this means people taking disease that can disfigure a person with facial lithium are sometimes at risk of exposure to tics and twitching, is very high for long-term damaging levels.
patients on neuroleptic anti-psychotic drugs, and even short-term use carries some risk. • ADHD drugs such as Adderall and Ritalin can Anti-depressants can also cause brain injury. stunt growth in children, and present other Other effects can include memory damage and unknown dangers to brain and physical develop- ment. Like any amphetamines, they can cause psychosis and heart problems, including sudden • Pharmaceutical company effectiveness and safety studies, as well as FDA regulation, are extensively corrupted and fraud is widespread. • ADHD stimulants, sleeping aids, and benzodiaz- There are few long-term studies, or studies of epene tranquilizers are physically addictive like how drugs combine together. The real extent street drugs, and benzodiazepenes are more of psychiatric drug dangers may never be ac- addictive than heroin.
Mental Health RisksMental health risks are some of the least understood aspects of psychiatric medications, and can make drug decisions and the withdrawal process very complicated. Here are some things that your doctor may not have • Psychiatric drugs can make psychotic symptoms • Once you are on the drug, your personality and worse and increase the likelihood of having critical thinking abilities may be very changed. It psychotic symptoms. Drugs can change might be difficult to properly evaluate the drug's receptors for such neurotransmitters as usefulness. You may need to get off the drug, dopamine, making a person "supersensitive" but not realize it because of how the drug is to becoming psychotic, as well as increasing affecting your thinking.
sensitivity to emotions and experiences in • Psychiatric drugs can interrupt and impair general. Some people report some of their first the mind's natural ability to regulate and heal psychotic symptoms occurred after starting to emotional problems. Many people report take psychiatric drugs.
having to "re-learn" how to cope with difficult • Many drugs now carry warnings about the emotions when they come off psychiatric drugs.
increased risk of suicide and violent behavior.
• Some people, even experiencing the worst • Many people experience negative personality depths of madness, say that by going through changes, including not feeling themselves, feeling their experiences rather than suppressing them, drugged, emotional blunting, diminished creativ- they emerge stronger and healthier in the end. ity, and reduced psychic/spiritual openness.
Sometimes "going crazy" can be the doorway • People who take psychiatric drugs, especially to personal transformation, and some people anti-psychotics, are often more likely to become are thankful for even the most painful suffering long-term and chronic mental patients. People in they have been through. Drugs can obscure this poor countries that use less medication recover possible positive side. Artists, philosophers, much faster than in rich countries that use a lot poets, writers and healers often attribute of medication. Many people recover faster and tremendous value to the insights gained from do much better without drugs.
"negative" emotions and extreme states.
Other Drug Risks and ConsiderationsUnderstanding the coming off drugs process means taking into account many different factors you may not have considered before: • While not publicized widely by a culture • Taking psychiatric drugs can mean being seen dominated by pharmaceutical companies, as mentally ill in society and starting to see alternative treatments, talk therapy, and even the yourself in that role. The stigma, discrimina- placebo effect can often be more effective than tion, and prejudice can be devastating, and even psychiatric drugs, without the risks.
create a self-fulfilling prophecy. Diagnostic labels • Keeping up with taking pills every day is difficult cannot be stricken from the record the way for anyone. Missing doses of psychiatric drugs criminal histories can. Studies show that trying can be dangerous because of the withdrawal to convince people that "mental illness is an effects, making you vulnerable if the drug is illness like any other" is a counterproductive strategy that actually contributes to negative attitudes.
• Doctors typically see patients infrequently for short visits, making it less likely to spot poten- • Psychiatric drugs can convey the false view that tially serious adverse drug reactions. "normal" experience is productive, happy, and well adjusted all the time, without mood shifts, • People with a mental disorder diagnosis fre- bad days or suffering. This encourages a false quently have difficulty getting insurance.
standard of what it is to be human.
• Taking psychiatric drugs often means giving up • Taking psychiatric drugs can put a passive hope control to the judgments of a doctor, who may in a "magic bullet" cure rather than taking not make the best decisions for you. personal and community responsibility for action to change.
How Withdrawal Affects Your Brain and Body All psychiatric drugs work by causing organic brain changes. This is why going off leads to withdrawal effects: your brain gets used to having the drug, and has a hard time adjusting when the drug is removed. When you go off the drug, it takes your brain time to bring the activity of receptors and chemicals back to the original state before the drug was introduced. While medical authorities sometimes use confusing terms like "dependence," "rebound," and "discontinuation syndrome," the psychiatric drug action that causes withdrawal symptoms is basically the same as addiction. Tapering off slowly is usually best: it allows your brain time to become accustomed to being without the drugs. Going off fast does not usually allow your brain enough time to adjust, and you may experience much worse withdrawal symptoms. Important: the symptoms of psychiatric drug
withdrawal can sometimes look exactly like the
"mental illness" that the medications were
prescribed for in the first place.
People can become "psychotic," anxious, or any Psychiatric drugs are not like insulin for a diabetic: other psychiatric symptom from drug withdrawal they are a tool or coping mechanism.
itself, not because of their psychiatric "disorder" or condition. Scientists used to believe that the brain could not grow new cells or heal itself, but this is now When someone goes off a psychiatric drug they known to be untrue. Everyone can heal. A strong can have anxiety, mania, panic, depression and and healthy body with good lifestyle and positive other painful symptoms. These may be the same, outlook will help support and nurture your or even worse, than what got called psychosis brain and body to heal. When you have been on or mental disorder before the drug was taken. psych drugs for years, it can however sometimes Typically people are then told that this proves take years to successfully reduce or go off them. their illness has come back and they therefore Many people on these drugs, especially long-term need the drug. However, it may be the withdrawal neuroleptic anti-psychotics, develop brain injury effect from the drug that is causing these symptoms. and damage. This may not be permanent, but sometimes people live the rest of their lives with Withdrawal symptoms do not necessarily prove these brain changes. You may find that the goal of you need a psychiatric drug any more than going off completely might not be right for you. headaches after you stop drinking coffee prove You may feel better staying on them, and decide you need caffeine, or delirium after stopping instead to reduce your medication or stay at the alcohol shows you need to drink alcohol. It just same dosage, and focus on other ways to improve means your brain has become dependent on the drug, and needs time to adjust to being off it. Why Do People Want to Stop Using Psychiatric Drugs?People are often told that whatever the negative side effects, taking psychiatric drugs is always better than suffering from "untreated" mental disorders. Some doctors claim that mental disorders have a "kindling" effect, and that the earliest possible medication is always best. Today these views are being discredited. Many people with even the most severe mental illness diagnosis have gone on to find ways to recover without psychiatric drugs, and they report their lives are much better without them. Many people who go into "psychotic" or extreme emotional states deal with them successfully without medication. Diverse, non-western cultures often respond to and understand these experiences differently, even sometimes seeing them as positive and spiritual. It's not an either-or choice between taking psychiatric drugs or doing nothing about your problems. There are many alternatives you can try. In fact, some of the problems that are called "mental disorders" might for some people actually turn out to be caused by the drugs they are taking.
Harm Reduction and Staying on Psychiatric DrugsYou may decide that, given the degree of crisis you are facing and the obstacles to workable alterna-tives, you want to continue psychiatric medication. It may still be a good idea to take a harm reduction approach. You can make whatever changes to improve the quality of your life, and work to minimize the risk or harm associated with the medications you are taking: • Learn what you can from a variety of sources about the adverse effects of your medications. Use nutrition, herbs and supplements to reduce these effects. • Consider experimenting with lowering the dosage of your drug, even if you don't intend to go off it completely. Remember that even gradual dosage reduction can cause withdrawal effects. • If you are starting a medication for the first time, many people report that an extremely small dose, much lower than recommended, can sometimes be effective, with fewer risks. • Try to reduce the number of different medications you take to those you feel are really essential, understanding which ones carry the greatest risks and sticking to temporary use when you can. • Take an active interest in your overall health, alternative treatments, and holistic wellness approaches, including those discussed in this guide. Finding new sources of self-care might reduce your need for medication and allow you to lower your dosage. • Make sure you have the prescriptions and refills you need, because missing doses can add stress to your body and brain. • Carefully follow your schedule of any blood draws, liver, kidney and other tests that monitor dosage and toxicity. • Get regular physical exams and consultations with health care providers, especially holistic practitioners, to watch your overall health. • If you are taking other medications, look out for any possible interaction with your psychiatric drugs. • Beware mixing psychiatric drugs with recreational drugs or alcohol, which can worsen adverse effects and be dangerous. • Don't just rely on your doctor for guidance. Connect with other people taking the same medications you do; the internet, local support and discussion groups can help. I Want to Come Off My Psychiatric Drugs, But My Doctor Won't Let Me. What Should I Do?Many doctors have a controlling attitude towards patients and will not be supportive of a decision to reduce or go off psychiatric drugs. They may hold the fear of hospitalization and suicide over patients as a danger. Some see themselves as custodians and feel like whatever happens to you is their responsibility. If your doctor doesn't support your goals, ask them to explain their reasons in detail. Consider what they have to say carefully – you may want to reevaluate your plan or put it off if the doctor is making sense. You may also want to get a friend, advocate, or ally to help you make your case to the doctor, especially someone in a position of authority like a family member, therapist, or health practitioner. Explain that you understand the risks, and describe how you are preparing to make your medication changes carefully with a good plan. Educate them about the research presented in this guide, and the studies documenting the many people who succeed in reducing and going off their drugs. Describe your reasons clearly. Remind the doctor their job is to help you help yourself, not run your life for you, and that the risks are yours to take.
You may need to inform your doctor you are going ahead with your plan anyway: sometimes they will cooperate even if they don't approve. If your doctor is still unsupportive, consider getting a new doctor. You can also rely on a health care practitioner such as a naturopath or acupuncturist. Sometimes people even go ahead with a medication reduction and elimination without telling their doctor or counselor. This may be understandable in many circumstances, such as if you have benefits such as health care, housing or transportation that might be in jeopardy if you are considered "noncompliant." Weigh the risks of such an approach carefully, though.
The UK charity MIND, in their study on coming off psychiatric
drugs, found that "People who came off their drugs against
their doctor's advice were as likely to succeed as those
whose doctors agreed they should come off." As a result
of this finding, MIND changed its official policy, and no longer recommends that people attempt to go off psychiatric drugs only with their doctor's approval. Before You Start Coming Off Everyone is different, and there is no cookie-cutter or standard way to withdraw from any psychiatric drug.
The following is a general step-by-step approach that many people have found helpful. It is intended to be shaped and changed to suit your needs. Be observant: follow what your body and heart are saying, and look to the advice of people who care about you. Finally, keep a record of how you reduced your medications and what happened, so that you can study the changes you are going through and others can learn from your experi-ence.
Get Information About Your Drugs and Withdrawal Prepare yourself by learning all that you can about withdrawing from your psychiatric drug. Meet and discuss going off with people who have succeeded. Read about your drugs from mainstream, holistic, • Do you have stability in your housing, and a and alternative sources. Additional resources are regular schedule? Would it be better to focus on listed at the end of this guide.
• Are there big problems or issues that need attention you have been putting off? Are there When is a good time to start coming off? When is things that are worrying you that you should prioritize? Settling other matters might help you feel more in control. If you want to reduce or go off medication, timing is very important. It is usually better to wait until • Did you just come out of a hospital, or were you you have what you need in place instead of trying recently in a crisis? Is this a bad time to begin to come off unprepared, though sometimes the withdrawal, or is the drug part of the problem? drugs themselves make this difficult. Remember, coming off may be a long-term process, so you • Are you noticing worsening of drug effects, or may want to prepare just like you were making have you been on the drugs for a long time any major life change. Coming off drugs will likely and feel "stuck"? These might be good times to not be a solution in itself, but the beginning of new prepare to come off. learning and challenges. contact and how to help, as well as treatment and medication preferences. Hospitals and pro-fessionals may look to your advance directive for • Get help if you can. Working with a doctor or guidance, and eventually they may be legally en- health care practitioner who is on your side forceable, like a living will. Your advance directive can make a huge difference. Have supportive will help people provide you with what you friends and family, and get help making your plan. need when you are having a hard time. Check Make sure they know that withdrawal may be the National Resource Center on Psychiatric rough, and that withdrawal symptoms do not Advance Directives at necessarily mean you should go back on the drug. Helpers can provide an outside perspec- • Get a thorough health evaluation, by a practitio- tive, offer feedback on your plan, help you when ner who can thoroughly assess your well-being things get difficult, and strengthen your resolve. and offer restorative and preventive ways to It might be a good time to make sure you have improve your health. Many people with psy- access to a cell phone, or stay with someone chiatric diagnoses have unaddressed physical close to you who can help cook good meals health needs. Chronic medical/dental problems, and help look after you during the rough times. toxic exposure, pain, and malnutrition can all Lacking support is not necessarily an obstacle undermine your health and make it harder to to coming off drugs – some people have done reduce or go off your medications. Take the it on their own – but in general a supportive time to work on your physical health, including community is a crucial part of everyone's searching for affordable options. Consider seeing a holistic practitioner: many have sliding scale or barter arrangements. • Create a "Mad Map" or "advance directive," which is a crisis plan telling people what to do • Pay extra attention to your health while with- if you go into serious crisis and have trouble drawing. This is a stressful detoxification process. communicating or taking care of yourself. A Strengthen your immune system with plenty of mad map, wellness plan, or advance directive rest, fresh water, healthy food, exercise, outdoor lists your warning signs and how people should air, sunlight, visits to nature and connections with respond, and includes instructions on who to your community.
AttitudeBelieve that you can improve your life. With the it is okay to have negative feelings sometimes: such right attitude you will be able to make some feelings may be part of the richness and depth of positive changes, whether it is coming off, reducing who you are. Talk with others about what you are your medications, or increasing your well-being. going through, try to stay connected with sensa- Many people, even if they've been on high doses tions in your body, and gradually build up your of psychiatric drugs for decades, have gotten off, skills. Alert people close to you how they can help. and others have reduced drugs or improved the quality of their lives in other ways. Believe in your Plan Alternative Coping ability to take greater control of your health and wellbeing. Make sure people around you believe in your ability to make change.
It's not always possible, but if you can, create alter-natives before you start reducing. You have been Remember that just lowering your dosage can be a relying on the drug to cope, and you may need new big step, and might be enough: what is important is coping mechanisms. There are many alternatives, that you believe in your ability to improve your life such as nutrition, holistic health, exercise, support by taking charge of your medication choices. groups, therapy, spirituality and being in nature. Everyone is different, so it will take some time to Prepare to Feel Strong Emotions discover the "personal medicine" that works for you. You may want to gain some confidence in your When you go off psychiatric drugs you may have to new tools before undertaking drug withdrawal. learn new ways to cope with feelings and experi- Make sure your helpers know about your alterna- ences. Be patient with yourself and do the best you tives, and can remind you about them and support can, with support. Remember that life is a con- you using them. If you can, give yourself enough stantly changing range of feelings and experiences: time to put alternatives in place first.
Working With Fear Many people who have come off psychiatric drugs report that fear is the greatest obstacle to beginning the process. You may worry about going into the hospital again, losing a job, conflicting with friends and family, stirring powerful altered states of consciousness, facing difficult withdrawal symptoms, triggering suicidal feelings, or stepping away from a tool that helps you cope with under-lying emotions and problems. And since there may be real risks, some fear makes sense.
Beginning a big life change is like embarking on a trip or journey: the unknown can be an exciting possibility or an intimidating threat. It is important to acknowledge that you may be a very different person than when you began taking psychiatric medications. You may have grown, developed new skills, and gained new understanding. It may be helpful to list your fears and get a friend to help you examine what is realistic and what might be exaggerated, as well as any concerns you may not have thought about. Can you be realistic about your fears and all the different possibilities? What kind of preparation can you do? Can you find room for hope – or transformation? The future doesn't necessarily have to be the same as the past: don't let a label of "disorder" or a dire prediction from a doctor convince you recovery is impossible. What are the Alternatives to Using Psychiatric Drugs? Intermittent Use: Taking Drugs From Time • Friendships with people who believe in your capacity to take charge of your wellness can be Some drugs take time to build up to crucial. Ideally these should be people who have effectiveness in the body, but others seen you on your "bad days," are there for you – especially to help with sleep and when you're in trouble, and are prepared for dif- episodes of anxiety – work right away. It ficulties that can come from withdrawal. At the might be wise to occasionally use them same time, they should be friends who know the to get rest, prevent crisis, or protect you limits of what they can offer and know how to from overwhelming emotional extremes. say "no" to protect themselves from burnout.
While many people who go off drugs do go back on them after some time, • Consider going off recreational drugs and there is, however, very little research on alcohol. Many people who go through extreme the possible risks of going off and then emotional distress and end up with psychiatric back on neuroleptics, lithium, or anti- labels are much more sensitive than others, so what affects your friends one way may affect you more strongly. Abstaining from drugs and alcohol can dramatically improve your mental wellbeing. consider taking proven supplements that nourish Even milder drugs like marijuana and caffeine the brain and help the body's ability to detoxify, can undermine health, stability, and sleep for such as vitamin C, fish oil / essential fatty acids, some people. Sugar (including sweet juices) and and b-vitamins. Eat plenty of fresh fruits and chocolate can also affect mood and wellbeing. vegetables, and beware of junk food. Some Some people even have reactions to blood sugar people are sensitive to artificial sweeteners like levels or caffeine that get mistaken for psychosis aspartame or saccharin, and to preservatives or mental disorders.
and other chemicals in processed foods. If you take herbs or medical drugs for physical illness, • Rest. Do what you can to ensure a healthy sleep consult with an herbalist about interactions, routine, and discover tools to help you sleep. especially if you are pregnant or nursing Medical sleep prescriptions, such as short-term psychiatric drugs like benzodiazepenes, might • Drink plenty of fresh water (nothing added) be good as a backup, but start first with herbs throughout the day: water is crucial to your like valerian and skullcap or homeopathics. If body's ability to detoxify. It is recommended you you have trouble sleeping, consider eliminating drink 1/2 your body weight in ounces per day caffeine such as coffee and sodas. Caffeine can minimum (i.e. someone weighing 140 lbs needs disrupt your sleep and make the sleep you do to drink 70 oz. of water every day). Each glass get not as restful. Remember that even if you get of wine, alcoholic drink, coffee, black tea or soft plenty of hours of sleep, staying up late means drink you drink dehydrates you, and needs to be the sleep might not be as good; if you don't feel replaced with an equal amount of water. If your rested, try to get to sleep before pm.
tap water is not good quality, consider a filter. If you are overheated or sweating, or become • Nutrition can play a huge role in mental stability dehydrated, make sure to replenish sodium, sugar, and overall health. Explore what foods you and potassium electrolytes.
might be allergic to such as gluten and milk, and • Chemical exposure and toxins in the environ- • A counselor, therapist, or support group can be ment can stress the body and cause physical and very helpful. Allow yourself time to settle in as mental problems, sometimes very severe. If you a new client or participant before beginning a can, reduce your exposure to such pollutants medication reduction plan.
such as furniture and carpet fumes, household • Many people find a spiritual practice helps them cleansers, harsh noise, and fluorescent lights. For endure hardship and suffering. Find a practice some people, going off psychiatric drugs might that is non-judgmental and accepts you for who make them even more sensitive to toxins for a • Being in nature and around plants and animals • Take a careful look at other medications you are can be very helpful to calm you and give you a taking for physical diagnoses. Some, such as the bigger perspective on your situation.
steroid Prednisone, can themselves cause anxiety, sleep disturbance, and psychosis.
• Art, music, crafts, and creativity can be a powerful way to express what is beyond words, and create • Many holistic practitioners such as homeopaths, meaning out of your ordeal. Even a crayon sketch naturopaths, herbalists, and acupuncturists are in a journal or a simple collage with the theme skilled in assisting people reduce psychiatric "what do I feel right now" can be very powerful. drugs, and can provide powerful, non-toxic alter-natives to help with anxiety and other symptoms. • Exercise such as walking, swimming, bicycling, Find a recommendation from someone you trust. yoga, or sports can dramatically reduce anxiety Be prepared to make recommended lifestyle and stress. Exercise also helps the body to detox.
changes such as diet and exercise and quitting • Consider on-line support networks such as drugs and alcohol. Be persistent if money is an and obstacle: some providers have sliding scale or as an addition to, but if possible not replacement offer barter or other options. If you do take for, direct support.
herbs, make sure to check for drug interactions if you are taking medical drugs.
Reducing Drugs and Doses Safely
The following are general considerations, and no one pattern fits everyone: • Usually it is best to go slow and taper off gradually. Though some people are able to Identifying and Managing Withdrawal
successfully go off all at once, withdrawing from psychiatric drugs abruptly can trigger dangerous withdrawal effects, including seizures Not all painful symptoms you experience when and psychosis. As a general principle, the longer coming off are part of the drug withdrawal effect. you were on the drug, the longer you should You may be experiencing emotions and distress take going off of it. You may need to take as that existed prior to the drug and which the drug long reducing the dose as you were on the has been helping to suppress. There is no definitive drug before you started reducing. This works way to distinguish the two, though many people up to about 8-4 months. So if you've been on report that the quality of the anxiety or depression 6 months, reduce over 6 months. If you were is different, and they can tell which is the drug and on for 8 months reduce over 8 months. For which is "themselves." Withdrawal symptoms, as longer periods on drugs (e.g. 5 years or more), opposed to prior emotions, tend to be those that aim to reduce over 8-4 months. begin right after a dosage reduction, and change more quickly over time as the brain adjusts to not • Start with one drug. Choose the one that is having the drug. Withdrawal symptoms are also giving you the worst negative effects, the drug much less like true emotions or states of con- you feel is the least necessary, or the one that is sciousness, and sometimes less manageable with likely to be easiest to get off. emotional and psychological approaches. You need to wait it out, and give your brain time to adjust. • Switch to an equivalent dose of a drug with a If the symptoms are unbearable or too disruptive, longer half-life – more gradual time leaving your you may be going too fast. Consider increasing the system. See the section on half-lives and the dose dosage again and trying more slowly.
comparison chart. Give yourself time, at least  weeks, to adjust to your new drug, or longer if It is possible you will experience long term with- there is difficulty switching. You can also switch drawal symptoms and dependency. The risk of this to liquid equivalents of any drug or use custom increases the longer you were on the drugs, and on pharmacies, if you need very small doses or you some particularly difficult drugs such as Paxil, the need to control the dosage very precisely. benzodiazepenes, and the neuroleptic anti-psychot-ics. Remember that your goal is to improve your • Make a plan. A good guideline is 10% reduction life: going slowly or staying on a lower dose can be of your original dose every two weeks. It is not very positive.
a good idea to skip doses, but to taper down gradually. Make a chart showing exactly how much of each drug you will be taking each day. Get a pill cutter or measuring cup. For example, if you started with 400 mg. of your drug daily, you could first reduce the dose by 10 percent (40 mg.), to 360 mg. After 2 weeks, if the feelings are tolerable, the next 40 mg. reduction would take yourself that if symptoms got worse directly after you down to 320 mg., then 280 mg., 240 mg., and you reduced the drug, they may be withdrawal so on. If you got to 00 mg. And then found that effects and may pass. a further drop of 40 mg. drop was too difficult, you could reduce by 0 percent of 00 mg. (0 • If withdrawal is unbearable, too difficult or mg.), and go down to 180 mg. continues for too long, increase the dose again. This is not a failure; this is a wise, long term • If you are taking an anti-Parkinson's drug for strategy. Give yourself two more weeks and try the toxic effects of neuroleptic anti-psychotics, again. If you still have difficulty, raise the dose remain on it until you substantially reduce the again and then reduce more slowly. You may find anti-psychotic, then start to gradually reduce the it difficult to go off, so accept this as a possibility, side-effect medication. and include other ways to improve your life and well-being.
• If you are taking other medical drugs along with your psychiatric drugs, dosages and effects might What Will It Feel Like?
be interacting. Be especially careful and slow, and try to get good medical advice. Everyone is different and it is important to keep an open mind towards what you will experience. You • If you are taking a drug as needed ("prn"), not may not experience any withdrawal at all – or with- on a set regular dosage, try to rely on it less, drawal may hit you like a ton of bricks. You might go but keep it as an option to help you with the through several rough weeks then even out, or you withdrawal process from other drugs. Then you might notice withdrawal effects long-term.
can gradually stop using this drug as well. Forty percent of people in the MIND coming off • After your first reduction, monitor any effects drugs study reported no significant problems with- carefully. Consider keeping a journal of your drawing. Sometimes, however, withdrawal can be so symptoms, maybe with someone's help. Remind severe you need to go back on the drug or raise agitation, and other psychiatric symptoms. Symptoms associated with anti-depressants can include severe agitation, "electrical jolts," suicidality, self-harm such as cutting, and aggression. Often people report the worst withdrawal effects at the end of the coming off process, when they have reduced their dosage to zero or nearly zero. Withdrawal from lithium and anti-seizure "mood stabilizer" drugs does not appear to act on neurotransmitters, but on electrical and blood flow to the brain, which can lead to withdrawal effects similar to other drugs. Sudden withdrawal from anti-convulsant or anti-seizure medications can trigger seizures. All of these effects may subside in a few days or
weeks, so it is important to be as patient as you
can. Emotional adjustment and tension can last
months or even a year or more, as you learn to
deal with feelings and experiences that have been
suppressed by the drugs. For many people the
most difficult part is after you are off the drugs
your dosage. It appears that the longer you have and struggling with your emotions and experi-
been on them, the more likely you will have signifi- ences, including long-term detoxification and
cant withdrawal. The healthier and stronger your body is, and the more coping tools you have, the more likely you are to tolerate withdrawal effects Neuroleptic malignant syndrome is a very serious well, but the chemical changes in your brain can be condition, which some people have developed on dramatic, and everyone is potentially vulnerable. drug withdrawal, but can also occur as a side effect Support your body's natural healing ability, and keep of the drugs. It can be life-threatening and involves in mind that time is on your side in any detoxifica- changes in consciousness, abnormal movements tion process. Preparation for possible problems, and fever. If you have been on neuroleptic anti-psy- including how to deal with crisis, is key.
chotics and have any of these symptoms when you reduce your dosage, it is important to seek medical The most common withdrawal effects are anxiety treatment immediately. If there is extreme agitation, and trouble sleeping. Other effects cover a vomiting, muscle twitching, and psychotic symptoms wide range, and can include but are not limited that persist when you withdraw from neuroleptic to: feeling generally ill, panic attacks, racing anti-psychotics, you may be experiencing tardive thoughts/obsessions, headaches, flu-like symptoms, psychosis from the drugs. These symptoms usually depression, dizziness, tremors, difficulty breathing, diminish when the dose is increased again. Once memory problems, extreme emotions, involuntary you feel better, start again with a more gradual movements, muscle spasms and twitching, and nausea. Withdrawal can also trigger crisis, personality changes, mania, psychosis, delusions, Children and Psychiatric Drugs
More and more young adults and children, and even infants, are being given psychiatric diagnoses and put on psychiatric drugs. Most prescriptions are stimulants for ADHD, but also anti-psychotic Drugs in Liquid Form, Half-Life, and
neuroleptics and other drugs. This is a new trend that reflects aggressive marketing by pharmaceutical Switching to the liquid form of a drug gives you greater control over reducing the dosage slowly; No long term studies exist on the impact of ask your pharmacist. You can also go to a "custom psychiatric drugs for children. Some prescribed pharmacy" (found on the internet) that will mix drugs are not even approved for child use by your drug into doses of your specifications. A pill the FDA. Only recently has psychiatry accepted cutter can also be useful.
diagnosing children with mental illnesses: in the past they were considered still developing with changing "Half-life" means how abruptly the drug washes out personalities, and not subject to the same criteria of your system when you stop taking it. Shorter half-lives means the drug wears off faster because it takes less time to leave your body. Withdrawal The exact extent of drug risks to children is effects will likely be more difficult on drugs with unknown, and companies have not been honest. shorter half-lives, so you may want to switch drugs For example, it took years of pressure before of equivalent dosage with longer half-lives before anti-depressant packaging started carrying the reducing, so that you are on the same dosage "black box" warning that they could cause suicide, but on a drug that will leave your system more or warnings on ADHD drugs that they can cause gradually. Consult the following list (from MIND), addiction and psychosis.
but make sure to get the advice of a doctor and pharmacist.
Child behavioral problems are very real, and families do need help in dealing with them. Fluoxetine (Prozac) has a longer half-life and tends However, trying to solve these problems with drugs to be easier to withdraw from. Change to 20 mg. raises serious issues. Unlike adults, children do not liquid fluoxetine from: paroxetine (Paxil/Seroxat) have the legal right to refuse drugs if their parents 0 mg., venlafaxine (Efexor) 75 mg., citalopram tell them to take them. The brains and bodies of (Celexa/Cipramil) 20 mg., sertraline (Zoloft/Lustral) children are still forming and are exceptionally vulnerable. Child personalities are very influenced by their surroundings and the support they receive, Diazepam (Valium) has a longer half life and tends making it even more difficult to assess the nature of to be easier to withdraw from. Change to 5 mg. of behavioral problems and the effectiveness of drug Diazepam/ Valium from chlordiazepoxide 15 mg., treatments. Children can also be more sensitive loprazolam 0.5-.0 mg., lorazepam 500 mcg. (0.5 to factors such as diet, exercise, and chemical mg.), lormetazepam 0.5-.0 mg., nitrazepam 5 mg., exposure. Some families are under growing oxazepam 5 mg., temazepam 0 mg.
pressure to compete and perform at school, including getting the additional help and support that medication and a "special needs" status can provide.
Confusing matters more is that sometimes "Insight" and Forced Drugging
children with behavioral problems get attention – punishment and scolding – when they do the The mental health system sometimes forces people very behaviors their parents want to change. This to take psychiatric drugs against their will, with the can end up inadvertently reinforcing the behavior, justification that they lack insight and risk harming and the child becomes the "identified patient" of themselves, harming others, can't take care of the family system.
themselves, or are incompetent. In practice, the definition of words like "insight" and "risk to harm Because of their youth, the relative short time to self or others" is very blurry and subjective. they are usually on drugs, their physical resilience It can depend on the doctor you get, the facility and the way their lives are supervised, children you are in, or even what your parents think is are often very suited for reducing and going off best, rather than any objective standard. Being in psychiatric drugs. Creating alternatives to help conflict, or acting in ways others don't know how these children often means addressing the needs to control, can lead to forced drugging, and force is of parents and changing the circumstances the often a convenience for overworked staff untrained children are living in. While many pressures on how to help in other ways. Sometimes people are families are economic and circumstantial, parenting forced onto drugs just for yelling, or for cutting skills classes and family therapy have proven (which is usually not a suicide attempt). Biological effective and helpful, as are many other alternatives theories that say people "need their medication" including diet, exercise, sleep, and being in nature.
are used to support forced drugging, and in many court settings, "lacking insight" amounts to dis-agreeing with a psychiatrist who thinks you are sick and should be medicated. The legacy of psychiatric treatment is violent and abusive. Today, thanks to patients' rights activism and the psychiatric survivor movement, laws often do recognize the harm that can be done by forced drugging, and there are protections that mandate the least intrusive, and least harmful, treatments be used. These protections, however, are rarely fully followed.
Forcing people to take drugs and go into treatment often traumatizes them and makes the situation worse, and it violates the most basic human rights: the right to the integrity of your own mind, consciousness, and sense of self. Drugging and This does not mean people don't need help, but locking someone up because of "risk" in some ways help should be based on what the person defines amounts to punishing them because authorities help to be, not what others define for them. From believe a crime will be committed in the future. the outside, cutting, suicidal thoughts, or recreation- While some people can feel helped by a forced al drug use might seem like the most important hospitalization or drugging, the dangers of abuse issue, but the person themselves may decide they and the infringements of rights are too great, espe- need help with housing, an abusive boyfriend, or cially when alternative, voluntary approaches can be access to health care. This means a mental health tried but aren't. system based on voluntary services, compassion, and patience, not force, control, and paternalism. It Sometimes other people seem to "lack insight" or also means communities taking more responsibility be unable to acknowledge their problems, but this to care for each other.
is one person's opinion about someone else, and not grounds to label others with a medical disorder If people have a hard time communicating, they and deny them basic rights. Spiritual states of need supportive helper advocates who can try to consciousness, nonconformist beliefs, conflicts with bridge the gap between madness and "ordinary" abusive family members, or trauma reactions might reality. Because forced drugging often takes place be considered "lacking insight," but they deserve to with the claim that it is in the patient's best interest, be listened to, not made into illnesses. Even people many advocates are suggesting people use "advance who are truly in trouble and making bad choices directives" to state before a crisis what they want share everyone's right to learn from their own and don't want. Advance directives are kind of like mistakes, and what others might consider "self-de- a living will for crisis, where you give instructions structive behavior" may be the best way someone on what to do, who to contact, and treatment knows how to cope, given other things they are preferences, including leaving you alone, in case you struggling with. Forced treatment may be more are in crisis and having a hard time communicating. damaging than their "self-destructive" behavior.
Advance directives are not legally binding (which may change through movement advocacy), but do sometimes carry weight in how people are treated.
If you have taken a psychiatric drug and experienced any negative effects, including difficulty withdrawing, you may be eligible to file suit against the drug manufacturer if they acted improperly. This is especially true about newer drugs. Over the years thousands of people on psychiatric drugs have received settlements totaling more than a billion dollars. Contact a reputable lawyer, and be sure to get a second opinion.
Future Drugs
Pharmaceutical companies plan to introduce a wide range of new drugs in the future. Many of these drugs will be marketed as improvements over past drugs.
The industry's record should make us skeptical about these innovations. Repeatedly drugs are brought to market as "new and improved." Then serious problems and toxic effects are revealed, corruption is exposed, and lawsuits are filed. Then the next cycle begins, with "new and improved" drugs introduced once again.
Medications lose their profitability when their patents expire after a few years. It is in companies' interest to pit new, expensive drugs against older, cheaper ones, even when they have to deceive the public to do so.
Of great concern is future drugs that target deeper parts of the brain and more complex aspects of the mind. Some new drugs aim to erase traumatic memories, or try to disable pleasure centers of the brain that play a role in addiction, while others work on the stress and fight/flight hormonal system. Marketing new drugs amounts to social experimentation. There is huge potential for dangerous negative effects and abuse. Like past drugs, miraculous claims are likely to give way to scandal.
"The Case Against Antipsychotic Drugs: a 50 Year Record of Doing More Harm Than Good" by Robert Whitaker Med Hypotheses. 2004; 62: 5-13 If you are looking for detailed information about psychiatric drugs and mental disorders from Coming Off Psychiatric Drugs: Successful Withdrawal from Neuro- beyond the mainstream and pro-pharmaceuti- leptics, Antidepressants, Lithium, Carbamazepine and Tranquilizers edited by Peter Lehmann cal company perspective, you can explore more deeply the following sources and references we relied on in writing this guide. In addition to the Key Resources on page 8, we recommend the web site of the Alliance for Human Research Protection Depression Expression: Raising Questions About Antidepressants watchdog group at, which monitors leading newspaper and journal articles closely. "The Emperor's New Drugs: An Analysis of Antidepres- sant Medication Data Submitted to the U.S. Food and Drug Advice On Medications by Rufus May and Philip Thomas by Irving Kirsch, Thomas J. Moore, Alan Scoboria, and Sarah Prevention & Treatment. July 00; 5() Alliance for Human Research Protection "Factors Involved in Outcome and Recovery in Schizophre- nia Patients Not on Antipsychotic Medications: A 5-Year Alternatives Beyond Psychiatry Multifollow-Up Study" edited by Peter Stastny and Peter Lehmann by Martin Harrow and Thomas H. Jobe Journal of Nervous & Mental Disease. May 2007; 195(5):406- Antidepressant Solution: A Step-By Step guide to Safely Overcom- ing Antidepressant Withdrawal, Dependence, and "Addiction" by Joseph Glenmullen Factsheets and Booklets "Are Schizophrenia Drugs Always Needed?" By Benedict Carey Full Disclosure: Towards a Participatory and Risk-Limiting The New York Times, March 21, 2006 Approach to Neuroleptic Drugs by Volkmar Aderhold and Peter Stastny "Atypical Antipsychotics in the Treatment of Schizophrenia: Systematic Overview and Meta-regression Analysis" Halting SSRI's by John Geddes, et al. British Medical Journal. 2000; 321:1371-1376 (2 December). Cited in "Leading Drugs for Psychosis Come Under New Scrutiny" by Erica Goode, The New York Times, May 20, 2003.
Harm Reduction Coalition Benzodiazepenes: How They Work and How To Withdraw (aka The Ashton Manual) by C. Heather Ashton Hearing Voices Network The Icarus Project drug withdrawal forum Protocol for the Withdrawal of SSRI Antidepressants "Is it Prozac, Or Placebo?" by Gary Greenberg "Psychiatric Drug Promotion and the Politics of Neoliberal- Mother Jones. November/December 2003; by Joanna Moncrieff The British Journal of Psychiatry. 2006; 188: 301-302. doi: "The Latest Mania: Selling Bipolar Disorder" Recent advances in Understanding Mental Illness and Psychotic PLoS Medicine. Vol. 3, No. 4, e185 Experiences: A Report by The British Psychological Society Division of Clinical Psychology Law Project for Psychiatric Rights Rethinking Psychiatric Drugs: A Guide for Informed Consent Long-Term Follow-Up Studies of Schizophrenia by Grace Jackson by Brian Koehler AuthorHouse Publishing Self-Injurer's Bill Of Rights Mad In America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill by Robert Whitaker "Serotonin and Depression: A Disconnect between the Perseus Publishing Advertisements and the Scientific Literature" by J.R. Lacasse and J. Leo MIND National Association for Mental Health (UK) www.
PLoS Med. 2005; 2(12): e392 doi:10.1371/journal.
MIND Making Sense of Coming Off Psychiatric Drugs "Soteria and Other Alternatives to Acute Psychiatric Hospi- talization: A Personal and Professional Review" The Journal of Nervous and Mental Disease. 999; 87:4-49 MIND Coping With Coming Off Study Soteria Associates or Universal Declaration of Mental Rights and Freedoms My Self Management Guide to Psychiatric Medications by the Association des Groupes d'Intervention en Defense Wellness Recovery Action Plan des Droits en Sante Mentale du Quebec by Mary Ellen Copeland National Resource Center on Psychiatric Advance and Your Drug May Be Your Problem: How and Why to Stop Taking Peter Lehmann Publishing Psychiatric Medications by Peter Breggin and David Cohen HarperCollins Publishers Health Professional Advisors While not co-authors, the following health care professionals are experienced with helping people come off psychiatric drugs. They reviewed this guide for its usefulness, and we thank them for their involvement: Alexander Bingham, PsyD
Joanna Moncrieff, MD
University College London author, The Myth of the Chemical Cure: A Patrick Bracken, MD
Critique of Psychiatric Drug Treatment University of Central Lancashire co-author, Post-Psychiatry, Mental Health in a Matthew Morrissey, MA
Postmodern World David Cohen, PhD
Catherine Penney, RN
co-author, Your Drug May Be Your Problem Dante's Cure: A Journey Out of Madness Daniel Fisher, MD
Maxine Radcliffe, RN
National Empowerment Center Peter Lehmann
Judith Schreiber, LCSW
Editor, Coming off Psychiatric Drugs: Soteria Associates Successful Withdrawal from Neuroleptics, Antidepressants, Lithium, Carbamazepine and Claudia Sperber
Licensed Acupuncturist Bruce Levine, PhD
Peter Stastny, MD
author, Surviving America's Depression International Network Towards Epidemic: How to Find Morale, Energy, and Alternatives for Recovery Community in a World Gone Crazy Philip Thomas, MD
Bradley Lewis, MD
University of Bradford New York University co-author, Post-Psychiatry, Mental Health in a Postmodern World Rufus May, PhD
Clinical Psychologist, Bradford, UK Barbara Weinberg
Licensed Acupuncturist Renee Mendez, RN
Windhorse Associates


European resuscitation council guidelines for resuscitation 2015: section 4. cardiac arrest in special circumstances

Contents lists available at European Resuscitation Council Guidelines for Resuscitation 2015 Section 4. Cardiac arrest in special circumstances Anatolij Truhláˇr , Charles D. Deakin , Jasmeet Soar , Gamal Eldin Abbas Khalifa , Annette Alfonzo , Joost J.L.M. Bierens , Guttorm Brattebø , Hermann Brugger , Joel Dunning , Silvija Hunyadi-Antiˇcevi ´c , Rudolph W. Koster , David J. Lockey ,

SMOKING CESSATION BEYOND THE ABC: Tailoring strategies to high-risk groups 36 BPJ Issue 64 Smoking rates are declining in New Zealand as more and more people are successfully quitting. However, rates remain unacceptably high among deprived communities, Māori and Pacific peoples and in people with mental health disorders. It is often helpful to think of smoking as a chronic relapsing disease, thereby acknowledging the difficulties of smoking cessation and the likelihood of relapse. Ideally, health professionals should be providing smoking cessation support in the ABC format to every patient who