Repetitive Thoughts in SSRI Withdrawal

It spins me round

SSRI withdrawal symptoms can range quite a bit.  There are physical symptoms, emotional symptoms, mood symptoms, and bizarre symptoms.  One of the more difficult symptoms to deal with are repetitive and recursive thoughts.  These are thoughts that keep repeating over and over again in the mind.  They can be about anything.  Sometimes, they feel like a dark mantra that won’t stop.

I talked to a person in withdrawal who repeated the same sentence for four hours.  “If only I could…”  It varied a little bit over time, but it didn’t really change for that whole conversation.  Repetitive thoughts grip your mind and won’t let go.  It’s very hard to break out of the mental cul de sac that they create.  Everything you try to replace it with inevitably leads back to the central thought.  Usually, the thought is a regret, or a memory.  It’s very common to critically review the past in withdrawal.  Somehow, the past becomes incredibly important and inescapable.  In our society, we grow up believing that the emotional and intellectual parts of the mind are separate.  “Mind over matter”, “Walk it off”, “Pick yourself up and go on”.  In reality, the intellectual and emotional parts of our minds are two sides of the same coin.  You can’t ignore one without damaging the other.

The first thing to do in combating a repetitive thought is to recognize it as one.  That seems like an obvious thing, but it’s not as clear in withdrawal.  Even irrational thoughts take on a certainty and weight that they wouldn’t normally have.  For a “normal” person, the memory of pulling a girl’s hair in kindergarten would be a passing regret.  In withdrawal, that regret becomes the centerpiece of an elaborate story about self inadequacy.  I was a terrible person for pulling her hair.  That has only grown as I have grown, and now I am the result of a lifetime’s worth of regret.  That’s the thought process in withdrawal.  It sounds remarkably like a diagnostic marker of depression, and it is.  That’s why withdrawal is often misdiagnosed as a new or existing condition.  The difference is that withdrawal is iatrogenic, caused by the drug, not a condition.

The thing that makes it hard to recognize a repetitive thought in withdrawal is that each step from the original thought feels natural.  The progression from the memory of pulling a kindergartener’s hair to a dark assessment of your adult life seems rational and correct.  We naturally filter out the more wild connections our minds are capable of making and don’t realize that something’s wrong when that check is missing.  In withdrawal, you need to make a conscious effort to moderate thought.  That’s not very easy when the thoughts are so persistent.

Breaking the cycle of repetitive thoughts is something that takes practice.  Being mindful of your thoughts is a frustrating thing at first.  It can feel like you’re just watching as things fall apart in front of you.  It’s important to keep trying to control those thoughts, though.  It starts with recognizing that a particular chain of thoughts is originating from withdrawal.  If you notice that the whole chain of thoughts keeps referring back to a single event to propel it, that is most likely withdrawal related.  It’s almost impossible to “discard” a whole chain of thought, but recognizing it can help in dealing with it.  Try to focus on something else, something with its own chain, like a story or a game.  It may not be in keeping with the societal norm of heroically overcoming a struggle to reach the happy ending, but the goal is to overcome, not to be a hero.

Inside the SSRI bunker

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SSRI withdrawal is a notoriously variable thing. For most people, the symptoms vary from day to day, even hour to hour. This variability makes planning a day in withdrawal very difficult and leads to a general fear of the future and an inability to plan ahead because of anxiety about which “me” will show up tomorrow. Withdrawal also breeds a profound desire to withdraw from life and other people. It’s sometimes hard to deal with your own internal state, let alone social interactions.

It’s still important to try to push the boundaries of personal comfort during withdrawal. One of the strange aspects of withdrawal is that it’s very hard to tell when symptoms are improving. Often, the best way to gauge progress is during a social interaction. You may notice that today’s trip to the market didn’t produce as much stress as last week. Even though your internal state may feel the same, having a successful trip outside can show you subtle signs of progress. Getting out can also be a way to “make” progress happen. Powering through an encounter can provide confidence going forward.

Withdrawal is not just an emotional or intellectual problem, though. It’s also an imbalance of neurotransmitters. After having Serotonin levels managed artificially by the SSRI, it takes a while for the brain to find a new balance. serotonin is intimately involved in our emotional state. As much as we would like to believe that we can control our emotional state, our minds are much more complex than that. The mind has intellectual and instinctual elements. It’s important to heal both aspects during withdrawal. Just as you wouldn’t “walk off” a broken leg, you can’t push through some of the symptoms of withdrawal. The broken bone analogy is apt when discussing withdrawal. When recovering from a broken bone, it’s important to exercise to speed healing, but over doing it can actually set back recovery. The same applies to SSRI withdrawal. Pushing the emotional boundaries of withdrawal can speed healing and make for a stronger internal mental state. Likewise, pushing through social interactions that produce a lot of fear or stress can set back recovery.

It’s important to manage stress during withdrawal. It’s hard to apply general principles to it because each person’s tolerance to stress is different. An individual’s stress tolerance can change over time, too. Since withdrawal follows a chaotic pattern, it’s hard to manage. The only way to manage stress is to take it day by day, even interaction by interaction. You may reach your stress limit after one trip to the market. Tomorrow, though, you may be able to go to a movie theatre. Try to be flexible and only retreat when you feel you need to. Don’t hesitate to retreat a bit if you become overwhelmed, but also don’t hesitate to jump out there again.

Emotional Biases in SSRI Withdrawal

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If you flip a coin 4 times, and the first three come up heads, there is a built in human bias to assume that the next flip will be tails. Even though the coin has no memory of previous throws, the human mind still assigns a bias to the series as a whole. Similarly, withdrawal symptoms create their own momentum. The timeline of withdrawal is much longer than a short series of coin flips, but the principle can still apply.

For many people, withdrawal occurs in windows and waves. It oscillates between times when symptoms are lighter and times when they are more severe. Since the mind always seeks to find or create patterns in what it experiences, it’s natural to try to anticipate the next cycle, and predict what it will be like. This can be good and bad. In the middle of a wave, it gives the mind something to look forward to. Instead of being mired in a wave, the mind can anticipate the symptoms improving. Likewise, a window can be seen as an opportunity to consolidate gains and take stock of overall progress towards recovery.

The relief that you get from lighter symptoms can be squandered by anticipating the next wave, though. In many ways, it’s a one sided bias. There is fear of slipping into a wave during windows, but no anticipation of a new window during a wave. There is an emotional weight associated with each stage.  It’s like our perception of a coin flip instead of the actual binary nature of the flip. While you’re in a wave, that negative feeling gains a sense of permanence that it shouldn’t. Even though waves inevitably give way to windows, except in the case of a chronic conditions (withdrawal is usually episodic, not chronic), there’s no anticipation, just suffering in the moment. That fear persists into the next window, coloring our interpretation of the window. Instead of recognizing it as an improvement, it’s seen as a brief respite or interlude before the next wave.

One of the big mental tasks in making progress during withdrawal is to separate waves and windows. Instead of viewing them as two sides of the same coin, inevitable partners, they should be viewed in the larger context of recovery. The window/wave pattern is a sign that the brain is recovering. Once the symptoms begin to break up, the waves should get shorter/milder and the windows should get longer/better. Waves and windows should also be viewed in isolation from each other, like a coin flip. Feeling better is not the cause of the next wave, just as feeling bad is not the cause of the next window. Those cycles are signs of deeper restructuring taking place in the brain. There are things that you can do to mitigate waves and extend windows. Mindfulness can help.  Being aware of the cycle between waves and windows can mitigate the bad, and extend the good.  It’s important not to obsess about your emotional state, but be cognizant of the ebb and flow of emotions.  At the same time, waves and windows need to be dealt with individually.  You can’t always be looking forward to the next change. At first glance, a window seems like an easy thing to deal with.  You’re feeling better! Normal!  What’s to do?  Actually, windows are opportunities to take stock.

Windows

Windows represent your progress towards normalcy during withdrawal.  It’s very hard to compare your mid window state with “normal”, though.  We all live in a relative mental state.  It’s very hard to step outside yourself and compare the way you are now with the way you’ll be after recovery.  It is possible to perceive changes from one window to another, though.  Keeping a journal can help quantify your well being during a window.  It’s human nature to avoid dwelling on negative emotions when we’re feeling good, so it takes a bit of discipline to go back to your journal during a window.  Many people post on withdrawal sites until they start to feel better, then only come back when they experience a wave.  Just like a course of antibiotics, it’s important to keep the mindfulness momentum going during a window, even if you feel better.

Waves

Dealing with waves is a defensive thing.  Being mindful that the symptoms of a wave are not a normal part of your mental makeup is a good strategy.  In normal thought, we only consciously perceive a small portion of what happens in the depths of our minds.  Our cultural and mental makeup parses most thoughts, and they don’t become conscious thoughts.  Anger, fear, anxiety, even psychosis, are all parts of everyday thought.  We only see the small part that our conscious mind actively thinks about, though.  Psychotic, angry, and fearful thoughts are normally not part of our daily interactions, so we don’t give them much “processor time” in our active minds.  We present the side of our minds that we want to the outside world.  In a wave, the normal checks and balances are suppressed.  Instead of automatically suppressing thoughts we don’t want, the mind presents everything all at once.  It’s important to actively take over the parsing role until that automatic system has a chance to re establish itself.

So, in a strange way, waves and windows should be seen in the larger context of overall recovery and also viewed as binary things (heads or tails).  It’s not easy to take the long view of withdrawal while still dealing with each individually.  One of the symptoms of withdrawal that makes it particularly hard is the suppression of cognition.  We simply don’t think as quickly or deeply as we normally would.  It creates a vulnerability to the symptoms that makes the waves more powerful and the windows less satisfying.  Even if you fail to have much of an effect on the cycles in the beginning, that effort will pay dividends over time.  It’s hard to keep trying through multiple “failures”, but you’re building a mental reserve that will eventually have an effect on the whole process of recovery.

Psychology of Abilify Commercials

 

The psychology used to make Abilify commercials effective marketing tools is rather remarkable.  The goals for the advertisement are to generate a positive feeling towards the product in the consumer, minimize the effect of negative connotations, and ultimately sell the product.  In this series of commercials, Abilify is being marketed as an additional drug that existing users of antidepressants can take to enhance the effectiveness of the primary drug.  The process begins with the choice of an animated commercial with a very soft color palette.  The pastel colors used in the commercial serve to create a subtle undertone of calmness.  All of the colors are secondary colors rather than primary colors, which are meant to illicit both attention and emotion in the viewer.  The soft colors are in contrast to the primary colors used in most regular programming, which makes the commercial stand out in the broadcast.  In addition, secondary colors also create an emotional state in the viewer that makes the message of the commercial more effective.

The choice of a female narrator serves two purposes.  The majority of antidepressants are prescribed for female patients.  Some estimates claim that 1 in 5 women take an antidepressant.  In addition to marketing the product to the largest consumer base, a female narrator also touches on deep cultural biases concerning the role of women in society.  The traditional role of women in society is as protector and nurturer.  A female narrator touches on these biases to create a sense of safety in the viewer.  The intention is that this sense of safety will be transferred to the product in the mind of the viewer.

Anthropomorphizing depression serves several purposes in the commercials.  Creating a character for depression gives the viewer a way to focus their attention on depression, which is essentially a feeling that normally can’t be easily described.  It also removes depression from the main character, creating the idea that the protector/nurturer is being assailed by an external force.  Using depression as an external force, rather than an internal emotional state, gives the viewer a more concrete focus.  It also reinforces the struggle with depression visually as well as through dialog.  The narrator struggles with this external representation several times in the commercial.  After fighting the depression character, the narrator eventually succumbs, which sets the stage for the authority figure to enter the story.

As the narrator struggles to overcome her depression, a doctor comes and pulls her out of her pit.  Having the doctor save the patient serves to establish him/her as a protective figure and a source of relief for the problems that the narrator is having.  The doctor is also used to discuss the side effects of the drug.  When the doctor discusses side effects, s/he doesn’t do it personally.  Instead, the doctor uses a movie within the cartoon to list side effects.  This serves to remove the side effects from being a primary topic in the commercial.  All of the positive effects of the drug are delivered visually through the cartoon and through direct narration.  Side effects are delivered through a secondary image of the doctor which the doctor, narrator, and depression character watch.  This puts the positive and negative effects of the drug into different categories of awareness for the viewer.  The positive effects are made to be more prominent than the side effects, and minimizes the idea of side effects for the consumer.

This framework is used in several Abilify commercials.  The characters and dialog change, but the essential motif remains the same.  The same psychological methods are used.  It’s not manipulation, per see, but it is carefully designed to create emotion in the viewer rather than facilitate critical thinking.  That is the goal of all advertising, of course.  The difference in this case is that anti psychotics like Abilify were not intended to be used as mild boosters for other antidepressants.  Instead, they were intended to treat chronic and untreatable psychosis.  The way that the effects and side effects of these drugs are trivialized through these commercials is troubling to me.  Instead of prompting a serious discussion between patient and doctor over appropriate treatments, these commercials encourage patients to ask for a specific drug without really understanding the possible effects, positive or negative, of taking it.

Tapering off an SSRI

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Many people can wean off an SSRI very quickly.  Most doctor’s schedules last for a month or two and consist of skipping days and tapering by 20-25% every few days.  Some people cannot tolerate that fast schedule, though.  There is some speculation about the reasons why some people cannot tolerate a fast weaning schedule.  Without clinical studies of long term SSRI use and withdrawal, there is little official information about the proper method for sensitive patients to wean off the drug.  SSRI studies generally last 8-12 weeks and study the efficacy of SSRI versus placebo.  The goal of these studies is not to study the side effects of the drugs, but to gain FDA approval of the drug.  It’s ironic that these short term studies are then used to justify long term, even life long, prescriptions.  Since there is little information about the long term effects of SSRI on the brain, the reasons for some patients’ sensitivity to fast weaning is open to speculation.  Withdrawal is not a recognized problem with SSRI, though.  Most doctors will seek to diagnose a new or existing condition to explain the symptoms.  This is a delicate subject because there are cases where an existing condition will emerge as the drug is removed.  It can be very difficult to discern between existing symptoms and those caused by withdrawal.  Usually, if the symptoms can be closely tied to removal and reinstatement of the drug, that points strongly to a withdrawal problem.  The patient’s history can also be used to distinguish between withdrawal and existing illnesses.  A patient who does not have a history of psychosis or a severe anxiety disorder may exhibit symptoms of both during withdrawal.  Source.  The strongest link between cessation of an antidepressant and withdrawal are the initial symptoms.  Head zaps, dizziness, and electric sensations in the head are some of the first symptoms that most people experience if they are sensitive to fast weaning off an SSRI.  These initial physical symptoms are often followed by more severe symptoms that mimic other illnesses.  It is the similarity between withdrawal symptoms and other illnesses that cause the most confusion for doctors trying to diagnose the problems that their patients are exhibiting.  Since withdrawal is not an accepted part of the pharmacology of SSRI, doctors are left with few diagnostic tools to explain the symptoms that they see in their patients.  A doctor’s role in the prescribing of SSRI is not to break new ground in the diagnosing and treatment of withdrawal, but to use existing tools to describe and treat the symptoms that they see.  It’s incumbent on the patient to bring up the subject of withdrawal and work with their doctor to develop a weaning plan that serves both their needs.  A misdiagnosed case of withdrawal can lead to a spiral of new treatments which compound the problems for the patient.  Instead of treating the underlying withdrawal problem, the patient can be prescribed several drugs in succession to treat the symptoms caused by the previous drug/s.  As the cross prescriptions add up, it becomes more and more difficult to discern which drug is causing which symptoms.  Add in withdrawal from the original drug, and the diagnostic task quickly becomes overwhelming.

Once a patient recognizes that they are very sensitive to SSRI, the regular weaning schedule is not sufficient.  Weaning off an SSRI very quickly may seem like the best plan, like pulling a bandage off quickly to minimize the pain.  Withdrawal doesn’t work like that, though.  The brain combines mental and physical processes in a way that a sudden shock to the Serotonergic system can actually prolong symptoms rather than minimize them.  Once the patient realizes that they are dependent on the drug, it can be very tempting to get the drug out of their system as quickly as possible.  This feeling is compounded as the long term issues with SSRI use become more apparent in withdrawal.  The patient becomes more aware of the cognitive and emotional numbness that SSRI can cause.  The suppression of self awareness and inhibitions becomes more apparent as the SSRI dose goes down, too.  Things that seemed quite normal at the time become more inexplicable as self awareness returns.  Even though the emotional imperative is to wean off the drug very quickly, sensitive patients need to exercise patience.  The goal for a sensitive patient is to wean slowly rather than quickly.  Weaning at a very measured pace minimizes symptoms and actually shortens the overall length of withdrawal.  The goal of slow weaning isn’t just to stop taking the drug, but to maintain as much quality of life as possible while doing it.  It’s important to express that desire to wean slowly to your doctor.  S/he may maintain that a fast schedule is best, but you need to balance their diagnostic imperative with your own sense of well being.  Once you have divided symptoms into existing problems and withdrawal, you want to minimize the withdrawal issues as much as possible.

In sensitive patients, the weaning schedule can extend out to many months.  Instead of weaning off the drug in a month or two, it may take a year or more to fully stop taking the drug.  The best method to lower SSRI dosage is to do so at 4-6 week intervals.  This lets the brain adjust to the lowered dose in a measured way and minimizes the shock that the patient experiences.  Many symptoms of a lower dose are delayed by a few days or even weeks.  The brain has taken a great deal of time to adjust to the drugs presence, so it follows that it will take some time for it to readjust to a lowered dose of the drug.  A longer schedule also minimizes the build up of symptoms that can happen in fast schedules.  Since some symptoms are delayed during the weaning process, the patient can sometimes feel the effect of several dosage drops at once.  The longer schedule separates the onset of symptoms and allows the patient to consolidate each dosage drop before attempting another one.  It’s important to not attempt another dosage drop before you feel that you have stabilized at the new dose.  Instead of relying on a strict calendar schedule, base your decision to drop your dosage on how you feel.  There is no reward for dropping too quickly.  Again, the goal of a prolonged weaning schedule is to minimize withdrawal symptoms.

It is very important to take the drug each day.  Skipping days leads to off and on withdrawal symptoms, which can complicate the weaning process.  As an example, Paxil is metabolized by the body in about 22 hours.  Skipping a day leaves the body with no drug about half the time.  Consistency is the best way to minimize withdrawal symptoms.

The amount of each drop varies by individual.  Each person reacts to dosage drops differently.  Most people who are sensitive to SSRI can drop by 10% each time.  For example, a patient taking 40mg/day can initially drop to 36mg/day.  After an adjustment period, they can then drop to 32.4mg/day.  Each time you taper your dose, it’s important to drop it by 10% of your previous dose.  In the 40mg/day example, don’t drop by 4mg/day each time.  It’s a diminishing schedule that will slow down the dosage changes as weaning progresses.  It may seem like a schedule that will never end, but it is the best way to keep withdrawal symptoms manageable.  Here is an example of a weaning schedule from 20mg/day

20.0, 18.0, 16.2, 14.6, 13.1, 11.8, 10.6, 9.6, 8.6, 7.7, 7.0, 6.3, 5.6, 5.1, 4.6, 4.1, 3.7, 3.3, 3.0, 2.7, 2.4, 2.2, 2.0, 1.8, 1.6, 1.4, 1.3, 1.2, 1.0, 0.9, 0.8, 0.8, 0.7, 0.6

It can be very hard to measure dosages to the granularity that the 10% reduction schedule requires.  Small dosage drops like those described here are hard to accomplish with a pill splitter.  Again, it depends on the level of sensitivity that the patient has to dosage drops.  Some people will be able to estimate the drops, and the important concept is to wean more slowly.  Other people will be more sensitive to dosage drops.  Those people should ask their doctor about changing their SSRI prescription to the liquid form, which is easier to measure at precise dosages.  They can also purchase a jeweler’s scale which can measure pill fragments into very precise dosages.  Source.

The most important thing about developing an SSRI weaning schedule is to personalize it to your own needs.  It takes some time to do the introspection required to place yourself within the spectrum of sensitivity.  It also takes some time and experience to recognize which symptoms are caused by withdrawal, existing conditions, and normal day to day events.  Most people begin the weaning process on their doctor’s schedule and don’t realize that they are sensitive to dosage drops until the symptoms drive them to seek out more information.  In those cases, stay at the last dosage that you felt stable at, and continue from there using the 10% reduction method.  For more information about restarting an SSRI after weaning too quickly, see this post.

How SSRI work in withdrawal

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Neurons in the brain use both electrical and chemical signals to work.  When a neuron is stimulated, it fires electrically.  This stimulates the release of neurotransmitters at the end of the neuron.  These chemicals flow in the gap between neurons until they bind to receptors on another neuron.  Once enough neurotransmitters have attached to the next neuron, it stimulates that neuron to fire electrically, and the process continues.  SSRI affect the chemical part of this process.  Chemically, SSRI mimic the neurotransmitter Serotonin on one side of the molecule, but are different, otherwise.  When it binds to a receptor, instead of activating that receptor, it blocks it.  These receptors absorb excess Serotonin and store it in the neuron.  By blocking the absorption of Serotonin, more of this neurotransmitter stays in the gap between neurons.  The theory is that having more Serotonin available to stimulate new neurons improves mood.

As receptors that are stimulated by Serotonin are blocked, less of the neurotransmitter is absorbed back into neurons.  The brain responds to this lack of stored Serotonin by creating new networks of neurons in an attempt to reestablish the old state of function.  These new receptors are in turn blocked by the SSRI.  As the process continues, the dosage of an SSRI prescription may be increased to counteract the brain’s attempts to restore the old functional state.  Patients refer to this as “poop out”.  It’s similar to the tolerance that other drug users experience.  The difference is that most illegal drugs act on a wide range of neurotransmitters, whereas SSRI target Serotonin specifically.

In withdrawal, the blocking action of the SSRI is removed, and the excess networks of neurons are able to absorb Serotonin again.  Since the brain has been trying to balance against reduced absorption capacity, the result is over absorption.  Serotonin is closely linked to emotions and mood.  The over absorption of Serotonin can lead to extreme fluctuations in mood and even create symptoms in the patient that mimic serious mental illnesses.  Psychosis, anxiety, fear, and even suicidal thoughts are not uncommon.  It takes a long time for the brain to re balance to the new amount of Serotonin.  The brain once again rewires itself and reduces its capacity to absorb Serotonin.  During this rewiring, moods and emotions can fluctuate.  Many patients withdrawaling from an SSRI report that their mood can be different from day to day.  This most likely reflects the fluctuations in available Serotonin.

Serotonin doesn’t just exist in the brain.  There are neuron like cells throughout the body.  Some have described the neurons in the gut as a belly brain.  They’re not as organized as the neurons in the brain and serve different purposes, but the analogy is fairly accurate.  Serotonin is produced in the gut and migrates to the brain where it is used as a neurotransmitter.  The same Serotonin balancing process that occurs in the brain happens in other parts of the body.  SSRI withdrawal can have impacts on many parts of the body.  Along with mood fluctuations, it can cause muscle twitching, stomach aches, gastrointestinal problems.  The effect of blocking Serotonin in the gut may also be linked to weight gain, which is a very common side effect of SSRI use.

SSRI withdrawal can present symptoms that are very close to other diseases.  Doctors who see these symptoms often misdiagnose withdrawal as a new illness or the re emergence of an existing illness.  The diagnostic problem is one of scale.  Anxiety, fear, anger, and even psychosis are present in all human emotions to a small degree.  In withdrawal, these emotions become unnaturally amplified.  An event that would normally produce mild anxiety produces debilitating anxiety in withdrawal.  It’s not until the brain has completed balancing for the new state of Serotonin absorption and release that emotions once again return to the normal baseline.  This problem is further complicated in patients who have pre existing conditions that affect these emotions.  Often, doctors will prescribe new drugs that compound the problems of withdrawal.  Instead of allowing the brain to balance itself, a new chemical is introduced, with new effects and changes to the brain.  Introducing new changes to the brain while it is trying to deal with existing changes can cause a spiral of new symptoms and diagnoses that put the patient on a tract to taking a cocktail of drugs, each meant to treat the effects of the previous drug.

The safest way to stop taking an SSRI is to do so very slowly.  By slowly weaning off an SSRI, the brain has enough time to consolidate the changes in Serotonin absorption and production.  Instead of absorbing the majority of Serotonin in a short time, the brain has the opportunity to deactivate the excess receptors that cause a lack of available Serotonin.  Most doctors and drug manufacturers recommend reducing SSRI dosages by large amounts.  Most tapering schedules only last a month or two.  This time frame is too short for the brain to adjust.  It took a long time for neurons to extend themselves into new areas in the attempt to absorb Serotonin.  Likewise, it takes a long time for the brain to change the structure of neurons so that the old functional state is achieved.  The tapering period doesn’t have to last as long as the original treatment, but it does need to be longer than most recommendations.  10% reductions in dosage each 4-6 weeks is usually sufficient to allow the brain to adjust slowly.  For example, a patient taking 40mg/day would reduce to 36mg/day in the first month, then 32.4mg/day in the second month, continuing to reduce 10% from the last dose.  It’s difficult to measure pills to this granularity, but being as precise as possible is important to reducing withdrawal symptoms.