The ability to tolerate the dysphoric moods and physical symptoms associated with psychotropic medication withdrawal is undoubtedly linked to a patient’s baseline psychological resilience and the strength of his or her support system. Therapies targeted at bolstering psychological resilience such as cognitive behavioral therapy (CBT) can be useful in helping patients cope with withdrawal. For instance, CBT might be useful in challenging patients’ beliefs that discontinuation symptoms are a sign that they are incapable of coping without the medication. CBT could transform this self-belief to the more accurate understanding that these symptoms are common and often time limited.
A systematic review by Fava8 highlights 3 main complexities in managing antidepressant withdrawal. First, no clear sociodemographic and clinical characteristics appear to be associated with increased vulnerability to severe withdrawal; second, although gradual tapering of antidepressants is a reasonable clinical strategy, it often will not prevent the onset of severe withdrawal symptoms; and third, antidepressant withdrawal appears to be associated with a variety of other iatrogenic complications such as the onset of hypomania/mania and other persistent mood instabilities.
Similarly, Lader and Kyriacou5 discuss the difficulty of managing benzodiazepine withdrawal. Three of these difficulties are illustrative:
1 The onset of severe withdrawal symptoms sometimes does not respond to re-initiation of medication.
2 Persistent withdrawal reactions can last years.
3 Unavoidable severe withdrawal symptoms may occur despite slow withdrawal over several months or years.
When the risks of treatments are not identified in the clinical trials that bring them onto market, these risks are not cautioned against in widely circulated medication guidelines. As a result, the prescribing physician will overestimate potential benefits and neglect patients’ vulnerabilities to the adverse effects of treatment. Expert commentaries in psychiatric journals are available to help clinicians correctly weigh the risks and benefits of using benzodiazepines and antidepressants in the management of depression and anxiety disorders.8,9
Although many people do not have substantial difficulties withdrawing from these medications, it is clear that withdrawal syndromes are not rare. Reports of withdrawal syndromes are becoming increasingly common on patient websites, and the widespread use of these types of medications poses a substantial public health concern.
The ubiquity of social media in the past 10 years and informal online communities have led adolescents to utilize these as the most likely forums in which to seek mental health advice.10 As young patients continue to turn to these sources for mental health guidance, mental health professionals need to familiarize themselves with and interface with these online communities.
An important ethical issue to consider is who should conduct research into drug-related problems that emerge following licensing? Burdening pharmaceutical companies to conduct such research before granting them license to sell would certainly slow down the development of many new and helpful medications. Yet, who is responsible for conducting the urgent and resource-heavy research needed to help guide clinicians in managing the variety of unexpected iatrogenic complications of these medications?
Given the current state of our understanding of complex withdrawal syndromes, increased awareness of these syndromes among providers is of utmost importance. These syndromes need further research, or more patients will continue to turn away from the medical establishment to look for support from other patients on the internet.
Mr. Witt-Doerring is a PGY 3 Psychiatry Resident; Dr. Shorter is Assistant Professor of Psychiatry, and Director, Psychiatry Residency Program; and Dr. Kosten is Professor of Psychiatry, Neuroscience, Pharmacology, Immunology, and Rheumatology, and Vice-Chair, Psychiatry for Research, Baylor College of Medicine, Houston, TX.
1. SimilarWeb. Antidepressants; 2017. https://www.similarweb.com/website/survivingantidepressants.org#overview. Accessed December 13, 2017.
2. SimilarWeb. Benzodiazepines; 2017. https://www.similarweb.com/website/benzobuddies.org#referrals. Accessed December 13, 2017.
3. Belaise C, Gatti A, Chouinard V, Chouinard G. Patient online report of selective serotonin reuptake inhibitor-induced persistent postwithdrawal anxiety and mood disorders. Psychother Psychosom. 2012;81:386-388.
4. Nielsen M, Hansen E, Gøtzsche P. What is the difference between dependence and withdrawal reactions? A comparison of benzodiazepines and selective serotonin re-uptake inhibitors. Addiction. 2012;107:900-908.
5. Lader M, Kyriacou A. Withdrawing benzodiazepines in patients with anxiety disorders. Curr Psychiatry Rep. 2016;18:9.
6. Haddad P, Lejoyeux M, Young A. Antidepressant discontinuation reactions. BMJ. 1998;316:1105-1106.
7. Wilson E, Lader M. A review of the management of antidepressant discontinuation symptoms. Ther Adv Psychopharmacol. 2015;5:357-368.
8. Fava G. Rational use of antidepressant drugs. Psychother Psychosom. 2014;83:197-204.
9. Baldwin D, Aitchison K, Bateson A, et al. Benzodiazepines: risks and benefits; a reconsideration. J Psychopharmacol. 2013;27:967-971.
10. Oldt A. Adolescents turn to social media when in need of mental health care; 2017. https://www.healio.com/psychiatry/suicide/news/online/%7B3af3e975-2bc3-4069-b96f-bc60551bae48%7D/adolescents-turn-to-social-media-when-in-need-of-mental-health-care. Accessed December 13, 2017.