- Many patients end up "parked" on antidepressant meds.
- It can be tough to quit on your own. Withdrawal symptoms can range from mild to severe.
- A first-of-its-kind microdosing service is opening in the US to help fill a gap in the guidance.
When Mark Horowitz first decided to quit his antidepressants in 2015, he'd heard that it usually takes a few weeks, maybe a few months, at most, for a person to safely wean off their meds.
It's taken him about 10 years to completely offramp himself, including one initial and "catastrophic" experience that made him so anxious he tried to literally outrun the experience, jogging so hard that his feet bled. He said that he also, for the first time, thought of killing himself.
"I feel like I've learned a very costly lesson about the harms and benefits of the drugs in the long term," Horowitz, a psychiatry researcher who's become one of the world's leading advocates for deprescribing antidepressants, told Business Insider.
Today, he's going commercial, harnessing his years of formal and informal study to cofound a first-of-its-kind American antidepressant deprescribing clinic, a cash-pay version of what he offers for free at a London clinic that's part of the UK's National Health Service.
The new American company is called Outro, and it's launching telehealth clinics in seven US states: California, Colorado, Florida, Illinois, New York, Texas, and Washington.
The clinics, operating entirely online, are geared toward helping people slowly discontinue five of the most common anxiety and depression medications, including Prozac, Zoloft, and Lexapro — ideally without the severe, but relatively common, withdrawal symptoms that Horowitz experienced.
This kind of venture has broad support among the psychiatric community. Roughly 1 in 10 American adults are taking drugs for depression at any time, per CDC data, and the number of young adults under 25 taking antidepressants has been on a particularly steep rise since the COVID-19 pandemic.
Most psychiatrists agree that patients should get help weaning off the drugs. Some have voiced concern about a growing movement encouraging people to quit psychiatric medication without medical support — with unqualified coaches offering counseling for a fee.
"Many patients are parked on antidepressants unnecessarily," Dr. Mimi Winsberg, a clinical psychiatrist in California who is not involved with Outro, told Business Insider.
"I've always been an advocate of tapering antidepressants when it's appropriate," Winsberg, the cofounder and chief medical officer at Brightside, an online mental health company, which uses therapy and drugs to treat mood, anxiety, alcohol and substance use disorders, said.
Still, whether people need an out-of-pocket pill compounding service to help them do so is up for debate.
An internet craze moves into clinical practice
For decades, Horowitz said, doctors had been taught that the drugs are effective, side effects are minimal, and quitting takes weeks.
Slowly, that framework has been shifting, with the recognition that these medications are not a one-size-fits-all, and more careful withdrawal schedules are needed. There's been a growing recognition that something called "antidepressant continuation syndrome" is real, and may impact between 15%-20% of patients who are trying to stop treatment.
Experts may still quibble about the finer details of the issue, but they generally agree that most patients trying to quit antidepressants will experience some kind of withdrawal, whether mild or severe.
In the UK, where he is based, Horowitz was part of a national reckoning about how the drugs are used. In addition to igniting an online firestorm about whether there's really a "chemical imbalance" of low serotonin being corrected by antidepressants, he published a widely-cited 2019 paper, "tapering of SSRI treatment to mitigate withdrawal symptoms." The study was one of the first to suggest that tapering should be done down to doses much lower than you can get by just cutting up pills at home.
He has also opened a deprescribing clinic in London, and coauthored a bestselling handbook for clinicians; it's the Maudsley Prescribing Guidelines' first de-prescribing reference. The UK's national healthcare service is now encouraging doctors to do more "social prescribing" for their patients, through initiatives like insomnia support groups, art and music classes, or more time outdoors for mental health.
In the US, Horowitz says, the overprescription problem has persisted, with many patients not getting the advice they need to properly taper. Since he went public with his own struggles a couple of years ago Horowitz says he's received over 20,000 emails, "mostly from Americans asking me to help them come off their drugs."
Winsberg says this may be down to the fact that the US has a more decentralized healthcare system than the UK. As a result, help with deprescribing is highly variable.
Some — including, at one point, Horowitz himself — find themselves digging through online communities on sites like Facebook or Reddit, looking for advice or to share their best practices for how to come off these medications without the mild to severe insomnia, anxiety, panic, fatigue, stomach problems, tingly fingers, and suicidal thoughts that can result from quitting too quickly.
Outro's equipment includes oral syringes and compounded microdoses. Some say that's overkill.
Outro moved into US beta mode last summer. Around 100 American patients have tried out the service. It's staffed by nurse practitioners and psychiatrists trained in Horowitz's methods.
For patients who don't have a doctor who knows as much about tapering, it's possible Outro could help fill a gap. Outro uses a risk calculator Horowitz developed to help determine the best deprescribing schedule for a particular patient. It considers factors including how long a person has been on their medication(s), and why. The program is designed to last from one to two years, but the schedule can vary.
During Outro's deprescribing, patients have regular check-ins with clinicians. Some gradually lower their dosage once a month, using compounded pills, others use a syringe to feed themselves incrementally smaller and smaller doses of their drug, day by day.
The method taps into patient demand for personalized, precision medicine, though it's unclear how many patients require — or stand to benefit — from new doses that aren't already available in pharmacies.
The company does not accept insurance (prices range from $125 to $295 per month, not including the compounded medicine).
"Having to pay cash just to get off antidepressants when that should be in the wheelhouse of the provider that is prescribing those antidepressants is problematic," Winsberg said. "To me, the problem is less about coming up with the perfect formula for tapering, it's more about introducing the idea of tapering when it's appropriate."
A holistic approach
The psychiatry field still hasn't quite cracked the code on how, exactly, antidepressant withdrawal syndrome manifests.
We know it's more common in female patients, and more than 70% of Outro's patients are women. Should women time their tapering based on their menstrual cycle? Maybe. It's something both Outro and Winsberg consider.
"We have more to learn about antidepressant discontinuation syndrome," Winsberg said. "Does it mean the patient is relapsing? Does it mean that we need to more carefully perfect when they're coming off?"
Horowitz says he is recruiting clinicians who are interested in exploring "lots of other things people can do to keep themselves from being depressed and anxious," besides drugs. "They're often into holistic health," he added.
That isn't just a woo-woo line of thinking: there is hard evidence suggesting that things like meditation and exercise can be just as effective as antidepressant medication in the long run.
"Our hypothesis is that more and more people will want to explore getting off their antidepressant," Horowitz's Outro cofounder, Brandon Goode, said. "More and more people will reconsider if long-term or lifelong antidepressant use is actually right for them, because they will have a fuller picture."
