A review of the management of antidepressant discontinuation symptoms

Abstract

Strong evidence supports the existence of a discontinuation syndrome following the withdrawal of antidepressant medication, particularly second-generation antidepressants. The syndrome is a common phenomenon and guidance as to best avoid the symptoms is essential for both practitioners and patients. The current study reviewed the available literature on the best methods of discontinuation for antidepressants in order to avoid or prevent the occurrence of any unpleasant side effects associated with antidepressant withdrawal. Accordingly, an electronic search of the PubMed/MedLine database and Google Scholar was conducted to find relevant literature published within the last 10 years. From this, 18 related articles were identified; five clinical studies, one case series, one consensus panel's recommendations and 11 literature reviews. Of the articles reviewed there is a general consensus as to tapering the drug slowly over a period of weeks or months. Also, in those patients who experience severe symptoms the drug should be reinstated and discontinued more gradually. The discontinuation syndrome does not occur as frequently or severely with longer-acting agents such as fluoxetine and therefore it is recommended that switching to this drug prior to withdrawal may be advisable. The articles reviewed also emphasize the need for patient education and reassurance throughout the discontinuation process. One in particular adds that cognitive behavioural therapy may be a useful tool in easing the patients' distress. However, this review highlights the lack of controlled data to support the available guidelines. Furthermore, the guidance which is available is somewhat conflicting. Research approaches should address this issue as well as develop appropriate methods of withdrawal for specific drugs.

The Safety, Tolerability and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature

“…Alternative strategies for the management of antidepressant-related withdrawal syndrome are scarce, and the quality of the evidence is limited [189]. A combination of cognitive behavior therapy and well-being therapy has been reported to be successful in a case series for managing persistent postwithdrawal disorders [195].…”

“…An often underappreciated clinical problem associated with the use of almost all SSRIs and SNRIs is the emergence of withdrawal symptoms of varying degrees of severity upon treatment discontinuation and/or interruption [189,190]. These symptoms include flu-like symptoms, tremors, tachycardia, shock-like sensations, paresthesia, myalgia, tinnitus, neuralgia, ataxia, vertigo, sexual dysfunction, sleep disturbances, vivid dreams, nausea vomiting, diarrhea, worsening anxiety and mood instability [190].…”

Discontinuing Psychotropic Drugs from Participants in Randomized Controlled Trials: A Systematic Review

“…Controlled evidence has not yet provided decisive findings on the merits of gradual versus abrupt discontinuation [13] and withdrawal symptoms accompany gradual tapers [38]. Nonetheless, good justifications exist for gradual discontinuation when drug use has lasted over 3 months unless frank toxicity is present [39, 40]. The lack of consensus about what constitutes gradual discontinuation within each drug class, and the rarity of such discussions from a patient-centered perspective [41, 42] may explain why most RCTs chose to give no justification for their withdrawal strategy.…”

Discontinuing Antidepressant Drugs: Lesson from a Failed Trial and Extensive Clinical Experience

“…There have been several reviews on the management of antidepressant discontinuation symptoms, such as the ones by Lejoyeux and Ades [27], Haddad [28], Schatzberg et al [29], Warner et al [30], and Wilson and Lader [31]. In these papers, recommendations about treatment discontinuation apply to the "average" patient and are rather general.…”

“…There is consensus in the literature [27][28][29][30], as summarized by Wilson and Lader [31], that AD should be tapered as slowly as possible, over at least 4 weeks or longer, and the same AD should be reinstated if withdrawal symptoms occur. Another suggested procedure is to switch to fluoxetine, which is less likely to induce discontinuation problems [34].…”