As a nurse in the antidepressant 2.0 era, I'm teaching my patients to cut down their doses using jewelry scales

• Telehealth startup Outro has raised $7 million for its de-prescribing service.
• A nurse practitioner shares her experience weaning people off pills as this practice gains momentum.
• The US Department of Health is expected to release new deprescribing guidelines this year.

This as-told-to essay is based on a conversation with Kristen Massingill, a 36-year-old nurse practitioner working in psychiatry.

Massingill works at Outro, a de-prescribing startup that announced today that it has raised $7 million in pre-seed and seed funding. The conversation has been edited for length and clarity.

I've worked in healthcare for over 15 years. I started my career in the ER, and spent a long time working there, but I've also worked in hospice, palliative care, and electrophysiology.

My main focus right now is working with patients on de-prescribing and discontinuing antidepressants. It's not something we're taught much about in nursing school.

Coming off of antidepressants, especially if you've been on them for a while, can prompt serious withdrawal symptoms, including insomnia, brain fog, dizziness, appetite changes, and mood shifts. Many people end up going back on medication because the symptoms are so debilitating, or they're interpreted as a relapse.

I first got interested in de-prescribing when I was working with a couple of patients in the clinic who were really having a hard time getting off their medications. I thought, "There's got to be a way to do this."

Unfortunately, I think there's a lot of dismissiveness toward patients who experience withdrawal symptoms coming off antidepressants. My job is not to convince patients that they're not experiencing these symptoms. My job is to help them through them.

Some patients enjoy 'playing chemistry' in their kitchen, but it's not for everyone

I've learned all about how to draw down dosages of different medications, sometimes going as far as weighing the drugs with jewelry scales. Some medicines, especially SNRIs (serotonin and norepinephrine reuptake inhibitors), are really challenging to taper, but you can do bean weighing, breaking open the capsules, and measuring out smaller doses of the medication.

It kind of depends on where the patient is at. Do they want to play chemistry in their kitchen? Oftentimes, they do, and they do a wonderful job, but it's not always a good fit. Many of my patients travel, and they don't want to be carrying a jewelry scale around or carting a vial of liquid everywhere they go, so we'll get compounded tablets specially made for them, with the incremental dosages they need.

I'm always learning more about de-prescribing. We'll have rounds with the other practitioners each week where we'll discuss interesting cases. I've learned so much about tapering that way, in addition to the more formal education I got from Mark Horowitz.

A lot of what I do during the sessions is cheer on my patients. I have about a hundred total, but I get a lot more time with my patients than most practices offer. If it's a first evaluation, we'll spend up to an hour together. If it's a follow-up, we'll usually sit down together for 30 minutes or so, reassessing how things are going, and whether we need to slow down or speed up the tapering. I do a lot more patient education than I used to, and a big part of my job is encouraging people and figuring out how best to support them through the process.

Tapering is tailored to each patient

There isn't one set timeline for how long it takes to taper off an antidepressant. It is genuinely tailored to fit each patient. Sometimes that looks like holding a certain dose for a prolonged period of time. Maybe something happened in life, and it's just not a good time for them to potentially experience any kind of side effects with the taper. So they just want to hold where they're at because they're in a good spot. Sometimes it looks like slowing things down or just taking a different approach, maybe changing from a compounded tablet to a liquid, just depending on what life is like.

Oftentimes, what's challenging is that these patients are tapering and they're doing such a great job and tolerating the taper really, really well. So they want to speed it up, because they want to be done, but they also know that that is not a great approach — they've often tried that in the past and failed. Most of the people I work with have tried to come off their antidepressant medication before and had a hard time, and they're very nervous about trying again because they had such a bad experience.

Of course, tapering isn't right for everyone, and we do have to turn some patients away, but even from them, I hear constantly during evaluations that they appreciate finally feeling heard.

The culture around antidepressants is changing. A first set of evidence-based deprescribing guidelines is forthcoming in the US, probably later this year. Still, a lot of the focus in psychiatry really is spent heavily on prescribing, even today.