Dr Pies is Professor in the psychiatry departments of SUNY Upstate Medical University, Syracuse, NY and Tufts University School of Medicine, Boston. He is Editor in Chief Emeritus of Psychiatric Times (2007 to 2010). Dr Osser is Associate Professor of Psychiatry, Harvard Medical School, Boston. He is an Editorial Board member of Psychiatric Times.
Consider the following vignettes and what they might teach us regarding so-called “antidepressant withdrawal.”
Mr A is a 40-year-old technician who has a diagnosis of MDD. He has been successfully treated with supportive therapy and 75-mg sertraline daily for the past 9 months. He has been in full remission for the past 6 months and asks his psychiatrist about “getting off the meds.” Since this is Mr A’s first episode of MDD, he and his psychiatrist decide that a cautious trial off the sertraline is reasonable.
The dose is reduced to 50 mg daily for 2 weeks; then 25 mg daily for 2 weeks; then 12.5 mg daily (1/2 of a scored 25-mg tablet) for 2 weeks. The patient is seen twice during this period and monitored carefully for any discomfort. Mr A tolerates the taper well, although he does report some mild nausea, occasional headaches, and hypersensitivity to sound, on 12.5 mg daily. Accordingly, the tapering is extended another 2 weeks (for a total of 8 weeks). The medication is then discontinued without difficulty.
Ms B is a 30-year-old financial manager with a history of three episodes of severe MDD over the past 10 years. She has been stable and doing well on paroxetine (60 mg/d) for the past 3 years, prescribed by her family physician, and is now strongly considering having a child. After discussing the risks of continuing an antidepressant during pregnancy, she and her doctor decide to discontinue the paroxetine. The dose is decreased to 40 mg daily for 2 weeks; then 20 mg daily for 1 week; then discontinued. During the first 2 weeks, the patient complains of occasional mild nausea, occasional abdominal cramping, and mild dizziness. However, Ms B is determined to “push ahead” with the tapering process and the schedule is maintained. On 20 mg daily, the patient reports no new or bothersome symptoms, and the paroxetine is stopped after a week.
Within 3 days, the patient calls her physician and complains of intense anxiety, insomnia, restless legs, diarrhea, dizziness, and what she describes as “brain zaps” (“like an electric shock to my head”). The paroxetine is immediately re-started at 20 mg daily, and the patient’s symptoms abated slowly over the next month.
These two vignettes—based on many patients we have encountered over a combined 70+ years of clinical experience—represent two possible outcomes of discontinuing serotonergic antidepressants (SSRIs and SNRIs). In our experience, the first scenario is far more common, and represents sound medical management of the tapering process. The second scenario is not one we have seen in our practice but is commonly reported among the “layperson withdrawal community.”1 Anecdotal reports of the second type—some with much worse outcomes—have led to extreme claims in the lay media that SSRIs and SNRIs are addictive, and ought to be grouped with known drugs of abuse.2 One website run by a psychiatrist (who will not prescribe antidepressants) declares that these medications “. . . are habit forming, so withdrawal can be excruciating.”3
While we do not deny that severe reactions can and do occur when antidepressants are stopped suddenly (or the dose reduced too rapidly), we also believe that fears of such “excruciating” experiences are greatly overstated, in the context of proper psychiatric care. At the same time, we acknowledge that many “prescribers” of antidepressants—nearly 80% of whom are primary care physicians—discontinue antidepressants much too rapidly.4 Moreover, as critics of these drugs rightly point out, it is very hard to find detailed, professionally approved guidelines for tapering and discontinuation of antidepressants.1
1. The Withdrawl Project. https://withdrawal.theinnercompass.org. Accessed January 15, 2019.
2. New York Times Exposes Antidepressant Scandal: Antidepressants are Addictive. Citizens Commission on Human Rights Florida. https://www.cchrflorida.org/new-york-times-exposes-antidepressant-scandal-antidepressants-are-addictive. Accessed January 15, 2019.
3. Brogan K. Saying no to antidepressants. Kelly Brogan, MD. https://kellybroganmd.com/saying-no-to-antidepressants. Accessed January 15, 2019.
4. Barkil-Oteo A. Collaborative care for depression in primary care: how psychiatry could “troubleshoot” current treatments and practices. Yale J Biol Med. 2013;86:139-146.
5. Jha MK, Rush AJ, Trivedi MH. When Discontinuing SSRI Antidepressants Is a Challenge: Management Tips. Am J Psychiatry. 2018;175:1176-1184.
7. Rosenbaum JF, Fava M, Hoog SL, et al. Selective serotonin reuptake inhibitor discontinuation syndrome: a randomized clinical trial. Biol Psychiatry. 1998;44:77-87.
8. Fava GA, Benasi G, Lucente M, et al. Withdrawal Symptoms after Serotonin-Noradrenaline Reuptake Inhibitor Discontinuation: Systematic Review. Psychother Psychosom 2018;87:195-203.
9. Viguera AC, Baldessarini RJ, Friedberg J. Discontinuing antidepressant treatment in major depression. Harv Rev Psychiatry. 1998;5:293-306.
10. Davies J, Read J. A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based? Addict Behav. 2018 Sep 4. [Epub ahead of print].
11. Calls for guidelines to be revised over antidepressant withdrawal symptoms. NHS. October 3, 2018. https://www.nhs.uk/news/medication/calls-for-guidelines-be-revised-over-antidepressant-withdrawal-symptoms. Accessed January 15, 2019.
12. Antidepressant withdrawal “hits millions.” BBC News. October 2, 2018. https://www.bbc.com/news/health-45717465. Accessed January 15, 2019.
13. Targum SD. Identification and treatment of antidepressant tachyphylaxis. Innov Clin Neurosci. 2014;11:24-28.
14. Solomon DA, Leon AC, Mueller TI, et al Tachyphylaxis in unipolar major depressive disorder. J Clin Psychiatry. 2005;66:283-290.
15. Zimmerman M, Thongy T. How often do SSRIs and other new-generation antidepressants lose their effect during continuation treatment? Evidence suggesting the rate of true tachyphylaxis during continuation treatment is low. J Clin Psychiatry. 2007;68:1271-1276.
16. Trevisan LA, Boutros N, Petrakis IL, et al. Complications of alcohol withdrawal: pathophysiological insights. Alcohol Health Res World. 1998;22:61-66.
17. Qadir A, Haider N. Duloxetine withdrawal seizure. Psychiatry (Edgmont). 2006;3:10.
18. Pies R. Are antidepressants effective in the acute and long-term treatment of depression? Sic et non. Innov Clin Neurosci. 2012;9:31-40.