How to Taper Psychiatric Medications Safely: Expert Advice on Med Management with Dr. Lori Calabrese

Lori: 
Depakote is a really common medicine that we use in psychiatry. And you can start someone on a ketogenic diet and they may say, I’m so tired, I can’t stand this. I’m falling asleep all the time. I can’t take this. It’s Depakote rising. You just need to know that. And again, conversely, when we talk about tapering, knowing some things are affected because they’re being absorbed more; some things are affected because a ketogenic diet affects how the liver processes the medicine.

Bret: 
Welcome to the Metabolic Mind Podcast. I’m your host, Dr. Bret Scher. Metabolic Mind is a nonprofit initiative of Baszucki Group where we’re providing information about the intersection of metabolic health and mental health and metabolic therapies such as nutritional ketosis as therapies for mental illness.

Thank you for joining us. Although our podcast is for informational purposes only and we aren’t giving medical advice, we hope you will learn from our content and it will help facilitate discussions with your healthcare providers to see if you could benefit from exploring the connection between metabolic and mental health.

Dr. Lori Calabrese is a psychiatrist at Innovative Psychiatry, and she has a tremendous amount of experience, not only with general psychiatric care, but now also with metabolic psychiatry, and it gives her a unique perspective on managing medications. How do we deal with potentiation, with tapering, with withdrawal?

She has a lot of clinical experience and a really good approach in terms of how we should see this. So let’s hear the general approach and some of the specifics about how Dr. Calabrese manages psychiatric medications with ketogenic and metabolic therapies.

Dr. Lori Calabrese, thank you so much for joining me here live at Metabolic Mind. 

Lori: 
Thank you for having me. 

Bret: 
Oh, of course. 

Lori: 
It’s a pleasure and really an honor. 

Bret: 
Yeah, and it’s so cool to be able to talk to you live in-person at this conference we’re having. And a lot of the discussion that comes up around ketogenic therapies, what do we do with the medications?

What do we have to do, but also what can we do? Because a lot of people are looking to taper down or get off their medications when they start a new therapy, like ketogenic therapy. So, first I want to rewind. Think back to your training, in your early days as a practicing psychiatrist, do you feel like you were trained or prepared to help get people off of their medications?

Lori: 
I know that I was trained to cross taper from one to another to start something. But the idea was never really about specific training in de-prescribing medications or in specifically looking at factors that helped do that successfully. No, I’d say no. That is just something that people develop.

Most psychiatrists develop it with experience over time because there are many patients in psychiatric practice who say, get me off. I can’t take this anymore.

Bret: 
Yeah, I think it’s clear when, and you talk about medications with side effects, psychiatric medications rank up there pretty high. So, how has your approach to tapering medication evolved over time before ketogenic therapy and then since you’ve come across metabolic ketogenic therapies? 

Lori: 
I think the biggest change is before I came across ketogenic therapies, what I was tapering was either to something else or to good luck. And it’s a scary thing to think about because many people will say, I would rather take my chances.

I would rather be ill. I would rather not have this. So tapering in that sense means really looking at the medicine very specifically and reducing it in the smallest possible way. And sometimes with things that have a quick washout, using a tail, a medicine with a longer tail or a longer half-life, to minimize drug side effects as a person tapers off.

Before using ketogenic metabolic therapies, it was using compounding pharmacies to taper benzodiazepines and other medicines that needed special doses. So, all of that becomes part of standard psychiatric practice. Ketogenic therapies changes everything.

And so I do that because ketones and fat trafficking, lipid trafficking with a ketogenic therapy, blows medication out of the water. And so really understanding what happens at the level of the gut, the liver, the blood-brain barrier within the brain itself and how all of those things are affected by the other things that patients are taking for management of hypertension.

Let’s say that then, get tapered, too, really requires, I think, a lot of thought. So, I think probably the first thing to recognize, or that I really started to recognize and then needed to learn, is that some medicines are automatically enhanced in terms of their absorption at the level of the gut when one enters ketosis.

And that’s because there’s a certain little protein called PGP. So, it’s P-glycoprotein that’s upregulated in ketosis. 

That protein is a barrier. Protein don’t get in, don’t get in, don’t get in to the brain and into so many other organs. It’s a membrane protein, and it’s a push out protein that pushes medicines or influxes them out of the brain.

So, when you have more of that, all of a sudden at the level of the gut, you are absorbing more things because P-glycoprotein is downregulated in a ketogenic diet. You don’t make as much of it. 

Bret: 
Oh, interesting. 

Lori: 
So, what happens is you get more things absorbed. Like what? Depakote. Depakote is a really common medicine that we use in psychiatry.

And you can start someone on a ketogenic diet and they may say, I’m so tired, I can’t stand this. I’m falling asleep all the time. I can’t take this. 

Bret: 
Yeah. 

Lori: 
It’s Depakote rising. You just need to know that. And again, conversely, when we talk about tapering, knowing some things are affected because they’re being absorbed more; some things are affected because a ketogenic diet affects how the liver processes the medicine.

I’ll give you an example: Xanax. A lot of patients are on Xanax. It’s processed through a certain liver enzyme system called CYP3A4. When you’re on a ketogenic diet, the rate of CYP3A4 production changes because the ketogenic diet changes the activity of that enzyme.

And so your Xanax levels change. They feel different, and you have to be aware of that as you taper. Want me to keep going? 

Bret: 
No, those are two fantastic examples, but it’s the good and the bad, right? It’s how your physiology changes. But the bad is, it makes it a little more complicated.

Because one of the things we always try to do is, how do we get this out to more clinicians so that they can be aware of this and do this? And I can see a lot of clinicians being like, “I don’t want to deal with that.” That’s a lot to have to think about. So what kind of advice can you give to other clinicians who want to help someone with ketogenic therapy and manage them, but still has to be aware of all these potentiation effects and the different medications?

Yeah, what kind of advice can you give for how to approach that? 

Lori: 
I think the first advice I would give is to really do everything to make sure that the patient is stable with their ketogenic therapy. 

Bret: 
Yeah. 

Lori: 
So, the most exciting thing to see is for your patient to get well. So, if your patient gets well all of a sudden. It’s, oh, they feel better in so many ways. And they might have a few other things that they weren’t expecting.

They might feel restless. They might have trouble sleeping. It may actually be because one of their medicines is rising quickly. We always say both before ketogenic treatment, taper very slowly, but there’s actually some things in psychiatry that you can hop right in and taper quickly because the medicine is being potentiated early.

Bret: 
Yeah. 

Lori: 
When? Like within the first week even. So, if you’re on board and listening for a side effect, that could be a medicine side effect that you don’t expect. You don’t expect your level of aripiprazole to rise, for example, or to feel more of it. But when you see it, if you are a thoughtful doctor, you’ll say, it sounds like an aripiprazole side effect.

I might not understand why, but maybe we can reduce the aripiprazole now instead of making you wait it out? So, listening for things that you know are true drug side effects, they belong to the drug. If those are amplified, you see it and you act on it early. 

Bret: 
Yeah. 

Lori: 
And if they could be something related to the ketogenic diet yourself or itself, you have to think about, oh, would we make a modification with more electrolytes? With more hydration? With something else?

Bret: 
Yeah, I think that’s a good point. I could see how a clinician would be like, oh, they’ve never had a side effect of Depakote before. So, why would they have one now? So, that you would almost dismiss it out of hand because it hasn’t been an issue before. But, so, you have to be aware of that.

So, you have to be aware of potentiation. And then if you do start to taper, you have to be aware of withdrawal effects versus a recurrence of symptoms. So, how do you then guide someone, or yourself clinically, to decide is this a withdrawal symptom from the medication or is it a recurrence of their symptomatology?

Lori: 
I think it takes us back to figuring out for the patient what their symptomatology was. So, many times someone’s episode of illness or their most recent episode of illness will be so long ago that we’ll have just cursory details about it. 

Bret:
It’s a good problem to have. 

Lori: 
So, it’s a good problem to have, right?

But when you really say, now, gee, as we begin to taper, what was it that you remember most? How did you go down the last time you went down? And those are going to be the salient things that we’ll look for specifically. But I’ll give you just a really good example of someone whom I’m tapering an antipsychotic for right now.

And he said, I just feel my head is not good; I’m getting psychotic again. And what he was really having was restlessness and akathisia. It was a potentiation; it wasn’t the psychosis. So, in a sense, having him trust me enough to say, can we just try, can we just try a little bit less? But don’t I need more?

No, I think you’d need less. 

Bret: 
Yeah, even he thought it was the psychosis just because. 

Lori: 
Even he thought it was because he felt so bad. And so when we actually reduced it just a little bit and he felt better, he couldn’t believe it himself. So listening, I think, closely is really what it’s about.

And then being willing to entertain, could it be the old stuff coming back? By knowing what that old stuff is by getting it? Or is it something new that you’ve never had before? 

Bret: 
Yeah, and then the other issue of tapering and withdrawing that we always hear is go slow. And even you’ve already said that once in this interview so far, go slow.

But go slow can mean a lot of different things to a lot of different people. So, how do you approach that to say, what is going slow? What does that mean? That’s a big question. 

Lori: 
I know. It’s a big question. So, I think, the way I think of it is in terms of what the primary diagnosis is that I’m treating. So, if I’m treating someone who very easily could get suicidal, who very easily flips into mania, whose OCD is so impairing that when we’re tapering things, they call out a work or they’re late at work. It’s the question of what level of risk can their lives afford?

So, an example of going slow might be, if I’m looking at something that has a medication side effect, I’ll really say, let’s take away a certain percentage of the dose. Call me in two days, email me in two days, let’s look at really what you’re doing in two days. For someone else where we are tapering something like carbamazepine, it’s very slow because we need to remove just a little bit of it. Sometimes, we do that by, if it’s a tablet, cutting a tablet into porters or having a compounding pharmacy do it.

And then waiting a long enough time to see if a symptom recurs. So, for someone who has panic disorder, or for someone who has psychosis, or for someone who has depression, we don’t know when their next symptom would otherwise normally occur. So, it’s a question of waiting for me, sometimes a month.

And sometimes a month isn’t long enough. Because if they’re having trouble just adjusting to the lower dose and wondering, then we want to say, are you good at that lower dose before we take it down? Sometimes tapering is really fast because it’s a med side effect. It’s a med that’s been potentiated. And so we take Olanzapine and cut the dose in half, sometimes in the first week. And for many doctors, that’s a scary thing to think about. They don’t ever want to be in the position where they could be doing something that might backfire. But many times, that’s exactly what needs to be done.

Bret: 
Yeah, and then I guess another question is, how do you set the expectation when you’re with a patient? If it’s a new patient or even a patient you’ve had for a while, how do you set the expectation of the goal of tapering? If someone comes in and says, I want to get off all my medications, let’s do it.

Or if someone says, what do I do with my medications? How do you set the goal of what the end point is? 

Lori: 
I think, I think the patient sets the goal. So, the patient will say, I just want to be better, or I just want to get off everything, or I don’t know that I want to get off my medicine, but I want to see if this helps me. They set that goal with me. And then, as we’re working together, I try to figure out if it’s a reasonable goal because that goal is always offset by the risk of your symptoms coming back. So, if you’re well, that’s great.

Then, you have a ketogenic diet and whatever you’re taking and you’re well or a little bit less than what you’re taking. And if the goal is to get rid of this medicine, let’s say that’s giving you side effects that you don’t want or the weight gain that you don’t want, then, the real exciting stuff starts to happen in the conversation. We talk about, for example, what would it look like if you started to get symptomatic again? What would be the worst symptoms?

When would you say stop? When would you be able to go back? And so those are nuanced conversations that take place over time. 

Bret: 
Yeah. 

Lori: 
And we have time with the ketogenic diet to have those conversations and to get people to begin to imagine a life with maybe less medicine. Sometimes the medicine that they want to get off of is their metabolic medicines. They’re anti-hypertensives or there are other medicines. So, it can expand beyond that. 

Bret: 
And we talked so much about the ketogenic diet, but what about other metabolic therapies? Lifestyle therapies? And how those may impact tapering of medications, be it sleep or exercise like?

How did those play into the picture for medicine withdrawal or medicine de-prescription or tapering? 

Lori: 
Let me start with exercise because I think that’s such an important part of the lifestyle changes that we want to have people undertake with the ketogenic diet. Exercise will change often ketone levels as people begin to adapt to or to invite exercise into their lives.

So, as their ketone levels change and they move more fat, whether it’s body fat or fat that they’re eating, those changing lipid levels, that changing lipid trafficking, will affect their medicines and may allow us to taper more quickly, right? Yeah. And in some cases, a little bit more slowly. So, what I say is exercise opens the door.

It may let us do more than you would otherwise be able to do. The other thing that really opens the door is circadian. Timing and circadian gating. So, we know that, for example, time-restricted eating with early hours of eating. Reset circadian clocks. So, that literally you’re going to, you’re sleeping better.

It will facilitate your sleep at night, and that will facilitate all of the clock genes around the body synchronizing in a good way. Will it help me with your taper? I’ll make the taper smooth. If you can do it, we’re smooth. If you’re all over the place, if you’re a nurse working shifts in the hospital, then all of a sudden things get a little bit more difficult because ketosis gets more difficult to sustain and maintain.

Bret: 
Yeah, that makes a lot of sense. You’re clearly a wealth of knowledge on this, and you’ve got the experience and the knowledge behind it. So I like how you really emphasize the potentiation, the withdrawal, the recurrence of symptoms. How do you differentiate between those? Setting the goals, let the individual set the goals, but then have it being an ongoing conversation throughout the process?

And, of course, how exercise and sleep play in. So, I think this has been a wonderful discussion. If people want to learn more about you and your work and everything you’re doing, where would you direct them to go? 

Lori: 
They can find me at loricalabresemd.com. Or they can google Touchpoints 180. They’ll find me there, too.

Bret: 
Great. Thank you so much. 

Lori: 
Thank you. 

Bret: 
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