Discussion: Comparing the Pros and Cons of Daily Microtapering and Cut-and-hold Schedules

If you have a supportive prescriber or pharmacist who understands truly slow, responsible psychiatric drug tapering, it may be helpful to think through together which schedule might be best for you. Below is further information gathered from anecdotal reports from the layperson withdrawal community to help with personal decision-making.

 

Which is the “smoothest ride”?

Because the dose changes are being made in such a gradual fashion, many in the withdrawal community have found Daily Microtapering to be a “smoother ride” with fewer and less intense uncomfortable experiences coming down off a drug than seem to happen with larger, less-frequent cuts. While many people have used a Cut-and-hold schedule with success, others report that this type of schedule has been difficult for them to tolerate –  among certain circles, the method has earned the nickname “cut and suffer”.

 

Which is considered to be the schedule that is the gentlest on the central nervous system?

Though there is no formal clinical research to our knowledge that explicitly supports these assertions, many laypeople in the withdrawal community believe that Daily Microtapering is a way to “trick” the brain into not noticing that the original dosage size that it has become acclimated to is actually becoming progressively smaller, similar to how the brain may not notice very subtle, gradual changes in temperature over time. Some even believe that by avoiding more substantial disruptions, the central nervous system can remain more “comfortable” and better able to progressively re-acclimate itself to the drug reductions during the taper.

 

Which is the faster schedule over the long term?

According to people’s anecdotal reports, neither Daily Microtapering nor Cut-and-hold is necessarily faster over the long term – it all depends on which approach a person’s own central nervous system becomes comfortable enough with so that the person is able to taper relatively continually without significant setbacks along the way.

 

Which one is more complicated? 

Laypeople have found that both taper schedules require learning and doing some basic math, measurements and/or chemistry to calculate exactly what their cuts will be and to carefully their drug amounts. (Step 18 breaks down various approaches that people use to make these calculations and adjustments.) Many people find that both approaches become very easy with practice. However, a Daily Microtaper requires more frequent calculations and dose adjustments than a Cut-and-hold approach.

 

Which is better for tracking the emergence and disappearance of withdrawal symptoms?

There is no built-in “hold” time as part of a Daily Microtapering schedule, and because laypeople have found that there can be a delay (sometimes as long as 2-4 weeks) in the body’s response to cuts of a drug, some people using this schedule report getting ahead of their ideal tapering rate without realizing it. It can then become difficult to figure out when it was that problems really started and at what dose level it would have made sense to hold steady for a while. For this reason, some people prefer a Cut-and-hold schedule because it involves regularly holding a dose for a period of time, which they find allows them some time to monitor if and when withdrawal symptoms are emerging, and how long it takes for those symptoms to resolve after each cut. They often report this can be an empowering way to closely track the stability of their central nervous system by noticing any symptoms and adjusting their taper accordingly. Nevertheless, neither approach is perfect because withdrawal symptoms can emerge at unpredictable times in unpredictable ways.  

 

Which is better for tweaking a taper rate to find the personal “sweet spot”?

When following a taper rate aligned with their bodies’ limitations, and when their withdrawal experience is going smoothly, people often report that the teeny-tiny daily cuts in a Daily Microtaper schedule allow for more “wiggle room” to carefully and cautiously increase a taper rate by extending the time window in which a particular daily cut size is being made past a calendar month. For example, if during the previous month they were cutting 0.16mg more each day from their dose, they might continue at that same pace into the next month. Sometimes, this window of opportunity lasts for a few days, but other times, people report being able to stick with the same size daily micro-cut for an additional number of weeks or even months before noticing new symptoms and needing to recalculate their cut size. On the other hand, people using a Cut-and-hold schedule sometimes find that they become so familiar and comfortable with the patterns of symptom emergence and resolution following each cut that they feel able to carefully experiment with slightly speeding up their monthly taper rate by testing out slightly-higher cut sizes. However, comparatively speaking, many report that this type of Cut-and-hold acceleration of a taper rate still feels more disruptive than accelerating with the tiny tweaks of a Daily Microtaper.

 

Which schedule gives more options for choosing a taper method?

It’s generally believed that a Cut-and-hold schedule gives a person more flexibility for choosing a taper method. And in particular, it's important to note that certain taper methods necessitate diluting dosages with pharmaceutical grade-powder filler or a liquid diluent in order to be able to reliably measure the relatively tiny daily cuts required for Daily Microtapering. (These and related issues are discussed in more detail in later steps.)

 

Have there been any formal scientific studies to support one type of schedule over the other?

Clinical studies have consistently shown that abrupt discontinuation of psychiatric drugs is far more disruptive than tapering at a slow rate. Unfortunately, these studies have almost always involved taper rates that in the opinion of the layperson withdrawal community are still far too rapid (usually just a few weeks to a few months in length), so they do not shed much further light on optimal taper schedules or methods. The FDA-approved drug labels for many psychiatric drugs now include mentions of the risk of “discontinuation syndrome” (in other words, psychiatric drug withdrawal), and sometimes even state the importance of tapering “gradually”. But as is the case with the clinical studies mentioned above, the notion of “gradual” is rarely defined and, when defined at all, it is typically a rate that is considered by the layperson withdrawal community to be far too fast. (Read TWP’s "How Slow is Slow When It Comes to Psychiatric Drug Tapering?" for more information.)

In summary, to our knowledge, there has been no formal, clinical research conducted on either the Daily Microtaper or Cut-and-hold schedules when performed at reasonably responsible rates. The best “evidence” we currently have, therefore, seems to be the shared anecdotal wisdom of people in the withdrawal community who’ve tried these approaches themselves. 

 

Does it really have to be either/or?

It is important to keep in mind that at no point in time does a person have to decide to stay using one and only one taper schedule. People often pause a Daily Microtaper for a time to “hold” at one dosage level if things get bumpy, and then decide how to proceed again after they’re feeling restabilized. Or, during a Cut-and-hold schedule, people may choose to start to decrease the size of their cuts while increasing their frequency, keeping in sync with their overall monthly taper goal, and gradually make their Cut-and-hold schedule more similar to a Daily Microtaper if their chosen taper method allows that. Indeed, some people successfully use a Cut-and-hold schedule until they’re down to a relatively low daily dose, at which point they will deliberately switch to a Daily Microtaper schedule in order to make the final stages feel like a ‘smoother, steadier’ ride off the rest of their medication. What laypeople say to one another is that the most important thing is to always make the adjustments to a schedule that are needed to best meet one’s own comfort levels and goals. At the end of the day, your own body will tell you what’s working and what isn’t.