Is it hard to stop taking nortriptyline or amitriptyline?
Nortriptyline and amitriptyline are tricyclic antidepressants, a class of drugs that was in wide use decades before Prozac existed. Their labels list one approved use in the United States, the relief of symptoms of depression. Yet, many of the people taking them today were never treated for depression at all, and were handed a small bedtime dose for a reason that appears nowhere on the label.
Is it hard to stop? For some people, no. For others, stopping a pill they took every night for ten years brings on days or weeks of nausea, headache, poor sleep, and a general feeling of being unwell that they never connect to the pill.
Dr. Leeds, an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida, helps patients taper off of these older antidepressants, and the questions they bring are always the same three. Why does stopping feel this way? How slowly should the dose come down? And, how do you know whether it is the drug or the depression?
The label itself says this is not addiction.
Both labels carry the same short warning about stopping. Abrupt cessation of treatment after prolonged therapy, each label says, may produce nausea, headache, and malaise, and each adds, in so many words, that these symptoms are not indicative of addiction. The nortriptyline prescribing information and the amitriptyline prescribing information use nearly identical language.
That sentence deserves more attention than it gets. A United States Food and Drug Administration (FDA) label for an antidepressant from an earlier era states plainly that stopping the drug abruptly can make a person ill, and that this is not addiction. Dependence is not addiction. A person who took amitriptyline every night as prescribed did nothing but follow a prescription, and the discomfort of stopping is a medical matter, handled by a slower exit.
Unfortunately, neither label says how to taper. Each names the symptoms of stopping too fast, and then it stops. So, what does a slower exit look like?
What does the amitriptyline label say?
Amitriptyline, once sold under the brand name Elavil, is the more sedating of the two, and its label describes it as an antidepressant with sedative effects. It comes as tablets, and the smallest tablet is 10 milligrams. There is no commercial liquid form in the United States, which matters a great deal at the end of a taper.
The amitriptyline label goes one step further than the nortriptyline label. It notes that even gradual dosage reduction has been reported to produce transient symptoms within two weeks, including irritability, restlessness, and dream and sleep disturbance, and it repeats that these symptoms are not indicative of addiction. In other words, the label itself expects a taper to be felt, which is exactly why the taper needs holds.
In the body, amitriptyline is partly converted into nortriptyline, so a person taking amitriptyline is, in effect, taking both drugs. Neither label gives a half-life figure, but in Dr. Leeds’ experience neither drug clears quickly, and the symptoms of stopping may not show up until several days after the last dose, by which time the person has already decided the drug was doing nothing.
What does the nortriptyline label say?
Nortriptyline, sold under the brand name Pamelor, carries the same single approved use, the relief of symptoms of depression. It comes as capsules and, unlike amitriptyline, as an oral solution. The nortriptyline label also discusses measuring the level of drug in the blood at higher doses, and it notes that some people, because of how their bodies break the drug down, carry much higher blood levels than expected on usual doses.
That variation is worth remembering during a taper. Two patients on the same capsule may be carrying very different amounts of drug, so the same cut may feel like nothing to one and like a cliff to the other. Nobody can predict in advance who will taper off of a tricyclic in a few months and who will need a year, and the honest answer is that it varies.
Why does the last part of the taper feel harder than the first?
An analogy that may help is a dimmer switch on a wall. Turn a dimmer down from full brightness, and the first quarter turn barely changes the room. The last quarter turn takes the room from lit to dark.
Antidepressants behave much like that dimmer. At a full dose, the drug’s effect on its targets in the brain is close to saturated, so trimming a quarter of the dose removes very little effect. At the low end, a small cut removes a large share of the effect the brain has adapted to. While this is not a perfect analogy, it explains why so many people sail through the first cuts and then hit a wall at the smallest doses.
This is why the Maudsley Deprescribing Guidelines, which cover tricyclic antidepressants along with the newer classes, describe reductions that get smaller as the dose gets smaller. Each cut is a proportion of the current dose, not a fixed number of milligrams, and the final doses sit far below the smallest tablet. The method is known as hyperbolic tapering, and it applies to an older antidepressant just as well as to a modern one.
What does a taper with holds actually look like?
The shape is simple to describe and slow to live through. The dose comes down by a modest proportion, and then it holds at that level until the body has settled, which may take a couple of weeks or longer. Only then does the next cut come, and it is smaller in milligrams than the last cut, because it is the same proportion of a smaller number.
Holding is not failure, and it is not weakness. Symptoms after a cut are information, the body reporting that the step was too large or too soon, and the answer is to wait, or to go back up a little, not to push through. Faster is not stronger.
Near the bottom, tablets and capsules run out of useful sizes. Nortriptyline’s oral solution helps, and for amitriptyline a compounding pharmacy can prepare a liquid or precisely measured capsules, so that the last reductions can be fractions of a milligram. None of this is a schedule to copy from a website. It is a shape, and the numbers belong to you and your prescriber.
Is it withdrawal, or is the depression coming back?
This is the question that ends most tapers too early. A person cuts the dose, feels worse within days, and is told that the original condition has returned and the drug is clearly needed. Sometimes that is true. Often, it is not.
Timing is the best clue. Withdrawal tends to arrive within days of a cut and to ease when the dose is held or nudged back up. A return of the original condition tends to build over weeks and does not care much about last Tuesday’s dose.
Symptoms that never existed before the drug point toward withdrawal rather than toward the old illness. Patients describe stomach cramps, sweating, vivid dreams, and a flu-like feeling that no depression of theirs ever produced. The guide to surviving antidepressant withdrawal on this site goes through those symptoms in more detail.
Unfortunately, many patients have been told that a withdrawal reaction is all in their head, or that a drug this old could not possibly cause one. The labels say otherwise, and so does the Maudsley text. If you are told to stop a tricyclic tomorrow and simply see how it goes, it is not a bad idea to ask for the slower plan instead.
If at any point during a taper you have thoughts of harming yourself, call or text 988, the 988 Suicide & Crisis Lifeline, and call 911 or go to the nearest emergency room for any medical emergency.
What should have been said on day one.
A conversation about tapering usually reveals a conversation that never happened. Informed consent for an antidepressant means the risks first, including the possibility that stopping will be uncomfortable, then the benefits, then the alternatives, including no medication at all. It also means an exit plan from the beginning, how long the drug is expected to be used and how you will eventually come off of it, and the right to decline or to change your mind later.
Medicine handed these drugs out for decades with no exit plan, and most people taking a tricyclic were never given that conversation. That is not a reason for shame. It is a reason to insist on the conversation now, before the first cut, with a doctor who treats you as a partner rather than as a chart.
This is the principle Dr. Leeds’ practice is built around. Patients meet with him by telemedicine anywhere in Florida, weekly and often for up to an hour, with text access between visits for the question that comes up at eleven at night after a cut. There is no substitute physician, no fixed timeline, and no cut the patient did not agree to.
The taper rate is patient directed. If a step is too fast, the doctor must slow it down. If a step is too slow, patient and doctor may agree to go a bit faster, as tolerated.
If you are taking nortriptyline or amitriptyline and want to come off of it without the nausea, headache, and malaise the labels warn about, a slow, proportional taper with holds is the way to do it. Contact Dr. Leeds today to talk about a taper plan built around your dose, your history, and your pace.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
