For Clinicians | Psychiatric Medications in a Disaster

For Clinicians | Psychiatric Medications in a Disaster

Why Stopping and Restarting Are Two Different Hazards

By Dr. Jamie Wilkey, PharmD — Director of Clinical Strategy, Jase
Medically reviewed and edited by Kristen Carpenter, PA-C

Our last article ranked a patient’s Rx medicine cabinet so you could tell a patient which of their prescriptions genuinely can’t wait and are the most important. One row on that table needed a lot more room than we gave it. Disaster planning almost always lands on insulin and blood pressure medication, and that’s not anybody’s oversight. It’s where the evacuee data pointed, so it’s where the guidance went. We went looking for mental health medications on the standard kit lists and came up empty.

So this write up is only about mental health medications. Stopping them is one hazard and restarting them is a separate one. We’re covering two specific drugs, clozapine and lithium, and one whole class, the benzodiazepines, because all three fail in a different direction when access is disrupted with the rules of thumb that hold across the category.

Clozapine: the number of days decides the dose

When a patient on clozapine has had any gap in dosing, the first thing to establish is the date of the last dose.¹ The length of the gap is what sets the restart dose. Their maintenance dose is not the default answer.

The mechanism is loss of tolerance to clozapine’s hypotensive effect.² Current labeling puts orthostatic hypotension, bradycardia, syncope and cardiac arrest among the things that can happen “when restarting patients who have had even a brief interruption in treatment,” at doses as low as 12.5 mg a day.² The same labeling names dehydration as a predisposing condition, which is the state a lot of these patients are in during a natural disaster.

US labeling sets the restart by days missed:²

• One day missed: resume at 40% to 50% of the previous dose
• Two days missed: resume at roughly 25% of the previous dose
• Anything longer: restart at 12.5 mg once or twice daily, then climb back faster than a new start

Clozapine can drive down neutrophils, the white cells that fight bacterial infection, so these patients have to get regular blood draws to check the absolute neutrophil count (ANC). If that count falls far enough, an ordinary infection can turn life-threatening. A break under 30 days doesn’t change the ANC monitoring schedule. At 30 days or more, monitoring reverts to the weekly-for-six-months schedule of a new start.² A one-week outage changes the dose and leaves the bloodwork alone. Until February 2025, the Clozapine REMS made a pharmacy verify an ANC before dispensing, so the monthly refill didn’t go out without a current lab value on file, and a patient who had drifted out of monitoring hit a hard stop at the counter.³ That backstop is gone, so the extra eye on a clozapine patient has to be yours now.

Benzodiazepines: write the plan down while you still can

For any patient on a daily benzodiazepine, the contingency plan needs to be documented while they can still reach you. Labeling is really clear and tells us why: abrupt discontinuation or rapid dose reduction after continued use “may precipitate acute withdrawal reactions, which can be life-threatening,” seizures among them.⁴ The 2025 joint tapering guideline, ten societies including ASAM and the APA, says anyone past a month of use shouldn’t stop abruptly and should taper under supervision.⁵

Withdrawal symptoms start 2 to 10 days after the last dose and can run for weeks.⁶ This is exactly why it is important to have a plan ahead of time for these medications. Withdrawal in this class needs active treatment, and a disaster is when active treatment is hardest to reach.⁶ A patient in withdrawal during an evacuation is agitated, tremulous, and tachycardic, in a setting with nothing to manage it with. 

Controlled-substance prescribing follows the same federal and state rules during a declared emergency so there isn’t disaster wiggle room here. The built-in emergency provisions are narrow, and some states bar writing for a patient the provider hasn’t examined unless that rule gets waived.⁷ 

The biggest reason patients lose access to key medications like this is structural. That means no money, no services running, or no way to get there. After Katrina, that was the reason for 74% to 84% of the people who were already in mental health treatment and then cut back or stopped.⁸ So these are the patients whose plan you prioritize. Getting through a natural disaster on a stable regimen is hard enough. Doing it in withdrawal is worse, and that’s the part planning ahead can actually change.

Lithium: the risk shows up without a missed dose

The conversation for a lithium patient is particularly interesting because in a disaster it isn’t about the medication itself that we have to worry about so much. It’s more about what the patient taking lithium is exposed to: heat, fluids, salt, and what pain medication they are using.

The kidney handles lithium a lot like sodium, so sodium or volume depletion drives reabsorption up and excretion down.⁹ Serum levels climb on an unchanged dose. Dehydration, vomiting, diarrhea, fever, and a low-sodium intake all contribute. So does a week of heat with no air conditioning, which is how a power outage affects a lithium level.

Then there’s the part that comes from the medicine cabinet instead of the weather. NSAIDs and ACE inhibitors both raise lithium levels by changing how the kidney handles sodium.⁹ A patient with a sprained ankle and a bottle of ibuprofen in a house with no power has assembled a lithium problem out of ordinary decisions.

The counseling point is early toxicity: a new tremor, GI upset, feeling unsteady.⁹ Those are vauge-ish symptoms that a patient may very well shake off as just being part of living through a natural disaster and miss them as warning signs. If these warning signs manifest then that’s a call to the prescriber, not a dose the patient adjusts on their own.

Everything else on the list

Clozapine, benzodiazepines, and lithium are the high-alert three. Most of your patients are on something else and the risk on those is different. A gap produces withdrawal symptoms, and over a longer stretch relapse, rather than the acute physiologic events the first three carry.

Two things predict how hard your patients will be hit. The first is half-life, which is just how long the drug is still doing its job after the last dose. Nobody has these memorized, and looking one up takes awhile, so here they are.¹⁰

The second is how long they’ve been on it. Someone a few weeks into an SSRI is at low risk of serious withdrawal. Someone eight years in certainly is at a much, much higher risk of withdrawal.¹¹

Half-life is a first pass, not a verdict. Sertraline’s half-life sits above paroxetine’s, and it made almost no difference: after 5 to 8 days off, withdrawal showed up in 60% of patients taking sertraline and 66% on paroxetine, against 14% on fluoxetine.¹² The table sorts the extremes reliably. In the middle it’s a rough guide.

Oral antipsychotics and mood stabilizers don’t sort this way. Their gap risk is relapse over weeks to months rather than withdrawal over days, so half-life doesn’t predict it.

Restarting is simpler here than with clozapine. Nothing has lost tolerance, so a short gap generally resumes at the prior dose. A long one doesn’t. Reinstating a drug months after stopping it can behave unpredictably, including symptoms worsening rather than settling.¹¹

One thing not to counsel: stretching the interval. Spacing doses to every other day is the intuitive way to make what’s left go further, and for most of this list it’s the wrong move. Because so many of these half-lives run under a day, every-second-day dosing swings concentrations up and down and can precipitate severe withdrawal, which is the outcome the patient was trying to avoid.¹¹ If someone is going to run short, the prescriber reduces the dose rather than widening the interval.

Two halves of preparation

We want patients protected in a disaster, and the ones on mental health medications have been left out of many disaster preparation conversations.

Appropriate medical preparation here comes in two halves. The first is clinical, and it’s the whole article above: knowing which of your patients has no buffer, knowing that the restart is a prescriber decision rather than the patient’s, and having that decision on paper before anything happens. That first half is not a quantity, and for this class it can’t be, since controlled substances like benzodiazepines have so much red tape around dispensing them.

The second half is boring, and it’s the one that gets skipped. The formal, active, updated medication list that travels with the patient. In one Japanese flood study, 48% of evacuees left their medication behind and 88% left their prescription records behind.¹³ People remember the pills more reliably than the paper, and the paper is what lets any pharmacist or any prescriber anywhere pick up the thread.

None of this replaces primary care. It’s the layer that helps prepare a patient well with your help ahead of if/when primary care isn’t reachable.

Jase Daily: extends the list, not the benzodiazepines

Jase Daily extends a stable, existing prescription up to a 12-month supply for a patient your practice has seen within the past 6 months. That covers lithium and most of the SSRIs and SNRIs above. It doesn’t cover benzodiazepines. Jase’s pharmacy doesn’t dispense controlled substances, so a benzodiazepine patient’s continuity still runs through the written plan, not a supply workaround.

Sources

1. ACLP How To Guide: Clozapine Consultation. Academy of Consultation-Liaison Psychiatry, 2024. Directs clinicians to determine the patient’s last clozapine dose as soon as possible, and gives a re-initiation schedule that differs from US labeling: no re-titration up to 48 hours, half the previous total daily dose then 75% then full dose over three days for a 48 to 72 hour break, 12.5 mg once or twice daily from 72 hours to one week, and titration as a new patient beyond a week. http://clpsychiatry.org/wp-content/uploads/ACLP-How-To-Guide-Clozapine-2025.pdf 
2. Clozaril (clozapine). FDA prescribing information, revised June 2025. Identical language across Clozaril, clozapine tablets, and clozapine orally disintegrating tablets. Warnings state that orthostatic hypotension, bradycardia, syncope, and cardiac arrest have occurred, and that these reactions can occur with the first dose, at doses as low as 12.5 mg per day, or when restarting patients who have had even a brief interruption in treatment; dehydration is named among predisposing conditions. Section 2.6 sets the restart at 40% to 50% of the previous dosage after one missed day, roughly 25% after two, and 12.5 mg once or twice daily for longer gaps. ANC testing continues at the previous frequency for interruptions under 30 days and reverts to the initiating-treatment schedule, weekly for months 1 through 6, at 30 days or more. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=90876802-0e3a-44c9-9ff7-1754dfbe736a 
3. Clozapine REMS has ended. National Community Pharmacists Association, 2025. The program ended effective February 24, 2025; pharmacies no longer need ANC results before dispensing, and FDA continues to recommend prescribers monitor ANC at labeled frequencies. The current labeling contains no REMS references while retaining the ANC monitoring table. https://ncpa.org/newsroom/qam/2025/03/31/clozapine-rems-has-ended 
4. Xanax (alprazolam). FDA prescribing information, revised April 2024. Boxed Warning states that continued use may lead to clinically significant physical dependence, and that abrupt discontinuation or rapid dosage reduction after continued use may precipitate acute withdrawal reactions, which can be life-threatening; section 5.3 names seizures as an example. Dependence risk is greater above 4 mg daily and beyond 12 weeks but exists after shorter use at lower doses. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=bb5cf72e-3a41-41a8-9a38-80f974eca33f 
5. Brunner E, et al. Joint Clinical Practice Guideline on Benzodiazepine Tapering: Considerations When Risks Outweigh Benefits. Journal of General Internal Medicine, 2025;40(12):2814-2859. Sponsored by ten organizations including ASAM, the AAFP, and the APA. Patients taking benzodiazepines longer than a month should not abruptly discontinue and should taper under clinical supervision. https://www.asam.org/quality-care/clinical-guidelines/benzodiazepine-tapering 
6. Regina AC, Gokarakonda SB, Attia FN. Withdrawal Syndromes. StatPearls, NCBI Bookshelf. Benzodiazepine withdrawal develops 2 to 10 days after discontinuation and can last weeks; seizures are named among the physical signs; benzodiazepine and barbiturate withdrawal are described as potentially life-threatening and requiring aggressive management. https://www.ncbi.nlm.nih.gov/books/NBK459239/ 
7. Rutkow L, et al. Prescribing authority during emergencies: challenges for mental health care providers. Journal of Legal Medicine, 2011. Providers must follow the federal and state laws regulating prescribing during an emergency, the emergency provisions in those laws are limited, and some states do not permit prescribing for a patient the provider has not examined unless that provision is waived during a declared emergency. https://pmc.ncbi.nlm.nih.gov/articles/PMC3229266/ 
8. Wang PS, et al. Disruption of existing mental health treatments and failure to initiate new treatments after Hurricane Katrina. American Journal of Psychiatry, 2008;165(1):34-41. Among survivors with a pre-hurricane mental disorder, 12.7% terminated and 10.2% reduced treatment, 22.9% combined. Barriers involving enabling factors, meaning financial barriers and unavailability of services plus transportation problems outside the New Orleans metro subsample, were the most commonly reported reasons for reducing or terminating treatment, at 84.0% and 74.0% across the two subsamples. https://pmc.ncbi.nlm.nih.gov/articles/PMC2248271/ 
9. Slubicki M, et al. Lithium Toxicity. StatPearls, NCBI Bookshelf. Because the kidney handles lithium similarly to sodium, sodium or volume depletion increases renal lithium reabsorption and decreases excretion; precipitants include dehydration, vomiting, diarrhea, fever, and low-sodium diets. NSAIDs and ACE inhibitors alter renal hemodynamics or sodium handling, increasing reabsorption or reducing clearance. https://www.ncbi.nlm.nih.gov/books/NBK499992/ 
10. Keks N, Hope J, Keogh S. Switching and stopping antidepressants. Australian Prescriber, 2016;39(3):76-83, which tabulates elimination half-lives: fluoxetine 4 to 16 days including norfluoxetine, vortioxetine 2.4 to 2.8 days, citalopram and escitalopram 1.5 days, sertraline 1.1 to 1.3 days, paroxetine 1.0 day, mirtazapine 0.8 to 1.6 days, amitriptyline 0.2 to 1.9 days, venlafaxine 0.6 days including desvenlafaxine, fluvoxamine 0.6 days, duloxetine 0.5 days, desvenlafaxine 0.4 days. https://pmc.ncbi.nlm.nih.gov/articles/PMC4919171/ Bupropion is not in that table: 21 hours, with erythrohydrobupropion about 33 and threohydrobupropion about 37 hours, from Wellbutrin XL prescribing information, https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=a435da9d-f6e8-4ddc-897d-8cd2bf777b21 Trazodone is biphasic, 3 to 6 hours initial and 5 to 9 hours terminal, from Cuomo A, et al., A narrative review on trazodone as a multimodal and multifunctional antidepressant, Annals of General Psychiatry, 2026;25:32, https://pmc.ncbi.nlm.nih.gov/articles/PMC13112903/ 
11. Therapeutics Letter 157: How to stop antidepressants. Therapeutics Initiative, University of British Columbia, 2025. Because the elimination half-life of many antidepressants is under a day, every-second-day dosing can produce wide fluctuations in drug concentrations and precipitate severe withdrawal effects. Patients on an antidepressant for only several weeks are at low risk of serious withdrawal compared with those with years of exposure, and resuming a withdrawn drug at a low dose months after stopping can have unpredictable effects including paradoxical worsening. https://www.ncbi.nlm.nih.gov/books/NBK618767/ The alternate-day modelling it draws on is O’Neill JR, et al., Alternate-day dosing to taper antidepressants risks severe withdrawal effects: an in silico analysis, Journal of Affective Disorders, 2026;392:120084, https://pubmed.ncbi.nlm.nih.gov/40848773/ 
12. Therapeutics Letter 156: Antidepressant withdrawal syndrome, update. Therapeutics Initiative, University of British Columbia, 2025. After 5 to 8 days of discontinuation, withdrawal occurred in 14% of patients taking fluoxetine against 60% taking sertraline and 66% taking paroxetine. Paroxetine, duloxetine, and venlafaxine/desvenlafaxine are disproportionately represented in WHO withdrawal reporting. https://www.ncbi.nlm.nih.gov/books/NBK618768/ 
13. Ochi S, et al. Disaster-Driven Evacuation and Medication Loss: a Systematic Literature Review. PLoS Currents Disasters, 2014. Seventy articles covering 27 events across 9 countries. Following Japan floods, 48% of evacuees left their medication behind and 88% left their prescription records behind. The 5.7x prepared-emergency-pack finding also comes from a single Japanese flood study inside this review rather than pooled across its 27 events. https://pmc.ncbi.nlm.nih.gov/articles/PMC4169391/