Coming off antidepressants

In recent times the prescription of antidepressant medication has become almost epidemic. Many people who are struggling with a crisis in their lives go to their GP feeling low and having poor sleep and come away with a prescription for antidepressants after a 10 minute consultation.
Often people find they get some initial benefit but of course drugs don’t fix life problems and soon they feel the same as they did initially. With other supports and time the issues resolve and the person feels better or they just don’t like being on the drugs and wish to stop taking them.
After short-term use, particularly if life problems have remitted, it is relatively easy to come off antidepressant drugs and frequently they can be discontinued without any difficulty.
However, for people who have been on these drugs for a long time it is important that they are tapered slowly, preferably under the guidance of a co-operative doctor.
The standard definition of an addictive substance requires three characteristics: tolerance (effect wears off with time, higher dose required), withdrawal syndrome and cravings for the substance. Antidepressants rarely give rise to cravings for them when not taken but they frequently show the other two characteristics of an addictive substance.
When a drug affects the chemistry of the brain, the body reacts by modifying the natural chemical balance in the brain. When the drug is no longer provided the brain chemistry is out of balance and this gives rise to “withdrawal syndromes”. These are very common with antidepressants, especially when used for more than a few weeks.
A survey of over 800 people who had discontinued antidepressants was conducted by the Royal College of Psychiatrists’ in the UK on anti-depressant withdrawal and the findings are very interesting.
Survey findings
36% of people stopped their antidepressant suddenly. Males were more likely to do this (m=44%, f=34%). Younger people were also more likely to stop suddenly (59% of 18-24 yr olds compared with just 20% of the over 65s).
512 (63%) people in the survey experienced withdrawal when stopping their antidepressants.
Some drugs were more likely to cause withdrawal than others. In the table below we have split the drugs into 3 groups (high, medium and low withdrawal).
High                                              Medium                                    Low
% with withdrawal        % with withdrawal            % with withdrawal
Venlafaxine 82%                    Sertraline    62%                   Fluoxetine      44%
Escitaloprm 75%                    Citalopram 60%                   Mirtazepine   21%
Paroxetine   69%
Duloxetine   69%

A further 43 people were on Tricyclic antidepressants, such as amitriptyline. 53% of them had withdrawal.

Common withdrawal symptoms
Overall, the most common symptoms were:
 anxiety (70%)
 dizziness (61%)
 vivid dreams (51%)
 electric shocks / head zaps (48%)
 stomach upsets (33%)
 flu like symptoms (32%)
 depression (7%)
 headaches (3%)
 suicidal thoughts (2%)
 insomnia (2%).
Anxiety was the most common symptom for every antidepressant except Duloxetine, for which ‘dizziness’ was the most common. The least common symptoms across all types were stomach upsets and flu-like symptoms. These patterns were the same for men and women. Considering anxiety is frequently the person’s reason for starting the drugs it is easy to see why people who discontinue antidepressants feel that their symptoms have returned and they then feel they have to go back on the drugs.

Why do people stop?
The people in the survey decided to stop for a number of reasons:
Reason for stopping Number of people %
Felt better 219 31%
Side-effects 213 30%
Didn’t help 175 25%
Wanted to try without. 45 6%
Pregnant 39 5%
On advice of doctor. 21 3%

When to stop?

Deciding when to stop is really important.

Medical opinion would advise that if you have had one episode of depression, you are should stay on antidepressants for 6 months to 1 year after you feel better. If you stop too soon, your depression may come back. This, of course, has to be viewed with caution. As we have seen above anxiety, which is a key component of depression is the most common symptom of antidepressant withdrawal syndrome.

It is important to be aware of two things if you do stop:
 You may get withdrawal, which can be minimized by slow discontinuation
 The condition for which you were taking your antidepressants may come back, which may be a symptom of the withdrawal syndrome.
As people often feel that antidepressants do not actually help (many studies show they are no better than placebo in mild to moderate depression), they seek alternative ways of dealing with their problems and realise that as they develop life skills they are better positioned to manage difficulties in their lives without the crutch of antidepressant medication.

Seeking advice
It is probably best to discontinue antidepressants under medical supervision, especially if they have been used for a prolonged period. However, it may be difficult to get co-operation from doctors to discontinue these drugs. In these circumstances, a person may have to “go it alone”. In this situation it is important to be aware of how to withdraw the drugs and what to expect along the path.

What is withdrawal like?
People in the survey mentioned above reported that the symptoms generally lasted for up to 6 weeks. A small percentage of symptoms lasted longer than this. A quarter of the group reported anxiety lasting more than 12 weeks.
Of the common symptoms reported, the one rated severe by most people was anxiety. The symptoms that were rated moderate by most people were stomach upsets, flu-like symptoms, dizziness, vivid dreams and electric shocks/brain zaps. The less common symptoms were reported as severe: returning depression, headache, suicidal thoughts, insomnia, fatigue and nausea.
These symptoms can be minimised by gradually withdrawal of the drugs, the longer the duration of use the more gradual the withdrawal should be. It is very important not to abruptly withdraw the drugs, except under medical supervision in cases where it is essential.

I want to stop – how should I go about it?
The following strategy will help reduce the risk of withdrawal and increase the likelihood of successful discontinuation.

BEFORE
 Make an informed decision
 Discuss the options with your doctor/pharmacist/counsellor
 Be aware of possible withdrawal or return of depression
 Make a plan
 Choose a good time – life going well
 Decide the speed of reduction (see below)
 Plan what to do if there are problems?
 Seek support from friends and family
 Support is critically important during discontinuation
 Work – hopefully this will provide support and time off if required
During the withdrawal process a person may encounter life stresses that they imagine they would be better able to handle if they were still taking the drug, prompting them to re-commence the medication. It is important, therefore, to have strategies in place to manage stressful events. This could include relaxation practice, talking to friends/family/counsellor, distraction methods, etc. It is often useful to actually document the strategies as this makes it easier when an event arises unexpectedly – there is a definite thing to do rather than panic making the situation worse.

DURING
 Reduce slowly. Research suggests that if treatment has lasted less than 8 weeks, stopping over 1-2 weeks should be OK
 After 6-8 months treatment, taper off over 6-8 weeks
 If you have been on maintenance treatment, taper more gradually: e.g. reduce the dose by not more than ¼ every 4-6 weeks.
 Be prepared to stop the reduction or increase your dose again if needed
 Keep a diary of your symptoms and drug doses.
Dose reduction
Time extension can also be used in reducing dose. This is especially useful for drugs that cannot be obtained in lower doses. For instance, if someone is taking fluoxetine 20mg daily in the morning, the dosage interval could initially be extended to 36 hours – that is, take a dose on day one in the morning, then at night on day 2, then morning again on day 4. When the person feels comfortable, the interval can then be further extended to 48 hours, 60 hours, etc until the drug is no longer taken at all.
If a person is on more than one drug, the drugs should be discontinued one at a time, with a gap between totally stopping one and starting to reduce the next one. The more drugs a person is on the more difficult it is to withdraw, as they will have had very complex impacts on brain chemistry. Again, the longer the use the more gradual the withdrawal should be. It would probably be best to discontinue the most recently started drug first.
 Go slowly – reduce by small amounts.
 See if there is a liquid presentation of the drug – this makes it easier to gradually reduce the dose.
 Increase your dose temporarily to control symptoms if needed, then taper more slowly once stabilised.
 Be aware that symptoms may come back, at any time, if the dose is reduced further or too rapidly.
 Don’t feel bad if you can’t come off at your 1st or 2nd attempt, it may take some time to achieve your goal. The stronger the persons coping skills the better their chances are – it may take some time to fully develop these skills.

AFTER
 Keep an eye on your mood – develop and practice skills to improve mood – aerobic exercise has been shown to elevate mood.
 It may take some time before mood fully stabilises – have a safe place and support to manage mood variation and stress
 It is important you look after yourself and keep active, eat well and get sufficient sleep.
 Learn and practice relaxation techniques
 View it like recovery from an operation. Be good, focussed and approach it in a lifestyle change sort of way – be gentle on yourself.
 Go back to see your doctor is you are worried about how you feel. It is not failure if you don’t succeed in discontinuing the drugs. It may not be the right time for you.

By  Charles O’Connell based in DUBLIN and ASHBOURNE