Hyperbolic Tapering: A Safer Offramp for Antidepressants?

Written by Evan Starkman
Medically Reviewed by Smitha Bhandari, MD on May 29, 2025
9 min read

Within weeks of cutting her 50-milligram pills of sertraline (Zoloft) in half, Morgan Stewart was besieged with mysterious symptoms – a fast heartbeat, a sense of spinning, dizziness, intense ringing in the ears, bad headaches, insomnia. 

A month or two after she had completely "tapered" off the medication, the wife and mother of two was in crisis. She paced a lot. She barely slept. She was horrified by violent, intrusive thoughts that popped into her mind – images of harming a loved one; images of killing herself.

"I was so desperate. I really felt like my life was kind of ending, and I was very afraid I was going to take my life," says Stewart, a 38-year-old digital production specialist in Boise, Idaho.

Months earlier, Stewart had decided to get off of Zoloft, a prescription SSRI medication she’d taken for about two years after seven years on a different SSRI. She felt that her depression was situational and had improved over time as her life changed. Her primary care doctor told her she could simply stop taking her medication. Or, just to be safe, she could gradually reduce the dose, also called tapering, to try to avoid the known possible side effects of stopping too quickly.

Stewart chose to taper. When things started going sideways, her doctor told her that her depression had simply come back worse than before. But Stewart was skeptical, and her symptoms were so bad that she checked herself into a psychiatric hospital for a few days. There, she and a psychiatrist found out her symptoms were due to withdrawal from SSRIs. (SSRI "withdrawal symptoms" are technically called "discontinuation symptoms.”) But no one seemed to have a solution outside of more medication.

A psychiatrist prescribed two other meds to combat her symptoms – clonazepam (Klonopin) and buspirone (BuSpar) – and Stewart soon found herself trapped on not just one, but now two medications with serious withdrawal risks.

Eventually, Stewart found her own way to a new science-backed tapering approach many U.S. doctors knew nothing about: hyperbolic tapering.

By some estimates, around 30% to 40% of people who get off an antidepressant may get some degree of withdrawal symptoms. "We know that after long-term use – more than a year – many more people will have severe withdrawal effects," says Mark Horowitz, MD, PhD, a clinician and clinical research fellow with the National Health Service in London.

In the U.S., over 15 million Americans have reportedly been taking antidepressants for more than five years. Yet most doctors rely on outdated guidelines designed for short-term users that are "irrelevant to long-term users," says Horowitz.

And it’s not just antidepressants. Anti-anxiety meds like the ones Stewart was taking – clonazepam and buspirone – can have similar effects. 

For many who have been on them for the long term, the common U.S. protocols for slowly reducing, or tapering, these medications don't work, according to some experts.

The problem lies in how most American doctors approach tapering. In linear tapering – the kind most common in the U.S. – a doctor reduces a drug's dose by even amounts – for instance, 10 milligrams (mg) per week. It’s often done over the course of just a few weeks.

That's too fast for someone who's been taking an antidepressant long-term, Horowitz says, especially toward the end of a taper, when the risk of withdrawal symptoms can increase.

"For a drug like Lexapro [escitalopram], going from 5 mg to 0 is like jumping off a cliff. It has about 20 times the effect of going from 20 to 15 mg," says Horowitz. "Many doctors regard 5 mg as a small dose because it is the smallest available tablet, but it is the effect on the brain that matters, not the size of the tablet."

So, the first few milligrams of linear taper are relatively easy to come off, Horowitz says. The last few milligrams, he says, can be "hell." 

"And when clinicians are not aware of this relationship, they can conclude, 'This person's fallen to pieces … they must be mentally ill.' "

Horowitz knows all too well. He was a 33-year-old psychiatry resident working on his doctoral degree when he started getting severe withdrawal symptoms, including suicidal thoughts, as he slowly tapered off of escitalopram (Lexapro), the antidepressant he'd taken for 12 years.

"It was the single scariest experience of my life. And that was what woke me up to this issue," he says.

 

Like Stewart, Horowitz sought information about his life-threatening symptoms online. He came across a peer support community where members shared tips on how they managed their antidepressant withdrawal symptoms – in most cases when they couldn't get a doctor's help, he says.

That inspired Horowitz to rethink the tapering methods he learned in medical school. Horowitz and co-researcher David Taylor, PhD, published in 2019 their first paper on hyperbolic tapering of SSRIs, a slower, personalized method geared toward people who take the most commonly prescribed type of antidepressant long-term.

In general terms, hyperbolic tapering means you lower your medication dose by smaller and smaller amounts, usually over several months (or, in some cases, years) before you stop the drug.

For example, some people might get their dose lowered by 10% each month, with the proportion worked out on their most recent dose so that reductions get smaller and smaller as the total dose gets smaller. There's flexibility for the percentage to go up or down, depending on how well the person who's tapering feels, says Horowitz.

Along with antidepressants, hyperbolic tapering has shown promise with other psychiatric drugs linked to withdrawal symptoms, like insomnia medications, antipsychotics, and some anti-anxiety medications. 

To do hyperbolic tapering safely, it's important to work with a psychiatrist or other health care provider who knows about the method and is able make a tapering plan tailored to your health needs and medication use, experts say – but such a provider is not easy to find in the U.S. 

You also need a way to get increasingly tiny doses, which many drug companies don't make in pill form. That often means switching to a liquid form of your drug, if one's available, or using a compounding pharmacy to get professionally made doses. Either option can be expensive.

One compounding pharmacy in the Netherlands actually makes hyperbolic tapering strips. The strips have small, numbered pouches that contain 28 daily doses of a person's antidepressant in increasingly small amounts.

Horowitz co-founded a system of virtual tapering clinics called Outro, which says it provides personalized hyperbolic tapering plans, close clinical supervision, and organizes for patients to receive custom doses of their antidepressant. As of May 2025, Outro was available in seven states.

Some people who lack an option like that try to make super-small doses using do-it-yourself tactics at home. For instance, they use a scale to measure crushed antidepressant tablets, or they try to count the correct number of medicated beads from a capsule.

Horowitz believes DIY tactics are reasonable to try, namely for people with severe withdrawal symptoms who can't find or afford professionally tapered doses. 

But not everyone thinks it's a good idea. There is a risk of making inaccurate doses, among other problems, says Jonathan Alpert, MD, PhD, chair of the American Psychiatric Association's Council on Research and chair of psychiatry at Montefiore Medical Center in New York. 

"Most people can't carry out that kind of very precise tapering, even if they're highly conscientious," he says.

Though hyperbolic tapering makes a great deal of "theoretical sense," most of the time withdrawal symptoms are mild and disappear on their own, Alpert says.

"It's simply not necessary except for the very small percentage of people who have more severe or protracted symptoms," he says.

Awais Aftab, MD, agrees. He’s a psychiatrist and a clinical assistant professor at Case Western Reserve University in Cleveland. "My impression is that linear [tapering] works well for most people. But there's a small number of people for whom it doesn't work well at all, and you end up needing hyperbolic."

"It's not a small number of people," Horowitz says. He recently did a study in which at least 1 in 7 people who'd taken an antidepressant for more than two years reported having severe symptoms when they tried to stop their medication.

Horowitz says a 2024 review of studies, which found that about 1 in 35 people get severe withdrawal symptoms, had drawbacks. He says it mostly looked at short-term antidepressant use and mainly included studies that weren't designed to assess withdrawal effects, among other limitations. Some experts agree that 1 in 35 is likely an underestimate.

In general, Horowitz says that far too many people with severe antidepressant withdrawal get left in the lurch when they try to get medical care. Doctors tell them, “This can't be withdrawal. Withdrawal is mild and brief. … You must be experiencing a return of your mental illness.” 

And then they put them back on the medication. 

The problem, says Aftab, is that so many doctors simply don’t have the training.

A lot of American primary care providers (PCPs) don't use any type of tapering with antidepressants, says Aftab. They simply stop the medication.

"We are in this situation where the average PCP has no idea about what's happening in the field regarding all of this," he says. "That's why I think so many people ended up creating these online self-health spaces, because their clinicians were just not taking them seriously."

If thousands of people are online trying to figure out tapering strategies for themselves to manage antidepressant withdrawal, “something has failed in the medical establishment,” Aftab says.

There’s more awareness in the U.K., he says. The Royal College of Psychiatrists in London has a patient information page on stopping antidepressants, and The Maudsley Deprescribing Guidelines (co-written by Horowitz) is a well-known handbook among medical professionals. 

"I think if medical and psychiatric associations come out and say, 'Hey, this is new guidance in the literature,' then people will pay attention. But if no one is issuing any official guidelines in the U.S., then it would be basically pure luck if a physician gets exposed," Aftab says.

Today, Stewart says, she feels like she's been "slowly waking up from a nightmare."

When her psychiatrist wouldn’t help with hyperbolic tapering, Stewart sought and found a medical professional with the right training who could help. She ordered a customized tapering plan to get off the clonazepam first.

Rather than use a compounding pharmacy to make her increasingly small doses, she followed a challenging DIY method. It involved dissolving her daily pill in water and using a syringe to take out the precise amount of liquified medicine that her plan called for each day.

She says she did that for 15 months and came off clonazepam with no new withdrawal effects. Now she's about two-thirds of the way through with a hyperbolic tapering plan to come off of BuSpar.

While she still has some lingering symptoms, like sleep issues and ringing in the ears, she says that her life is full of adventure and joy again.

"I'm free," she says. "And that's a miracle for where I came from."