Discontinuing antidepressants: Pearls and pitfalls

Abstract

A n ever-increasing number of patients are prescribed antidepressant medications, most often by primary care physicians, 1 with approximately 12.7% of the adult population in the United States prescribed a daily antidepressant. 2 Antidepressants are used to treat a variety of conditions other than mood and anxiety disorders, such as chronic pain syndromes, tobacco use disorder, and obsessive-compulsive disorder. Common scenarios prompting discontinuation of an antidepressant include the following: • The condition for which the antidepressant was started is in remission for an appropriate maintenance period • The antidepressant does not achieve a satisfactory effect 3,4 • Intolerable side effects emerge • New drug-drug interactions occur due to additional medication the patient must take • The patient's prescription drug insurance coverage changes. In the case of insurance coverage, clinicians are encouraged to advocate for the patient whenever a coverage issue arises in order to avoid changing antidepressants. Additionally, patients may choose to stop an antidepressant of their own accord.Stopping antidepressants can be challenging because of the frequency of antidepressant discontinuation syndrome (ADS). Discontinuation symptoms occur commonly and vary in severity. 5 Symptoms will often surprise and frighten patients who are not forewarned, leading them to seek emergency medical care. Discontinuation symptoms include insomnia, fl u-like symptoms, mood disturbances, dizziness, paresthesias ("brain zaps"), and a broad array of other adverse effects. 6,7

Alliance for Sleep Clinical Practice Guideline on Switching or Deprescribing Hypnotic Medications for Insomnia

“…[ 102 ]. More recently, a review on antidepressant discontinuation syndrome noted that key symptoms that may last days to months include insomnia, flu-like symptoms, mood disturbances, and paresthesia [ 103 ]. The authors also state that discontinuation of TCAs and atypical antidepressants can result in sleep disturbances, nightmares, and vivid dreams, and they note an intermediate risk of antidepressant discontinuation syndrome with amitriptyline and trazodone and a low risk for mirtazapine.…”

“…When any of these medications have been prescribed to treat insomnia symptoms, clinical decision making about discontinuation should take into consideration whether deterioration in sleep or new-onset withdrawal symptoms might be anticipated. Though a paucity of evidence exists regarding deprescribing or switching from these medications to other treatments in individuals with insomnia, abundant literature endorses gradual dose reductions rather than abrupt discontinuation, in order to mitigate withdrawal effects of these medications in individuals with non-insomnia-related indications for treatment [ 102 , 103 ].…”

Development and acceptability of a decision aid for major depressive disorder considering discontinuation of antidepressant treatment after remission

“…Advantages include that the individual no longer has to take medication every day, meaning that any side effects of the medication can be avoided, and the patients no longer need to worry about avoiding other medications because of possible drug interactions, 24 or about any concerns with pregnancy and breastfeeding 25 . The disadvantages of discontinuing medication include the risk of MDD relapse and potential withdrawal symptoms, such as flu‐like symptoms or dizziness 26,27 . Accordingly, when considering the treatment strategy after MDD remission, patients may feel conflicted regarding the advantages and disadvantages described above.…”

“… 25 The disadvantages of discontinuing medication include the risk of MDD relapse and potential withdrawal symptoms, such as flu‐like symptoms or dizziness. 26 , 27 Accordingly, when considering the treatment strategy after MDD remission, patients may feel conflicted regarding the advantages and disadvantages described above. Our DA, which is designed for individuals who are taking antidepressant monotherapy, allows patients to compare the advantages and disadvantages of continuing and discontinuing antidepressant treatment.…”

Antidepressant discontinuation and the role of the pharmacist

“…Although duration of treatment varies depending on the clinical situation or remission maintenance period, generally antidepressant treatment is recommended to cease after a certain length of time. 1,4 Canadian guidelines recommend that clinicians discuss discontinuation with their patients after 6 to 9 months of clinical remission, but in some patients (such as those with frequent, recurrent or severe episodes or other comorbidities), treatment may be suggested for at least 2 years. 5 There can be significant withdrawal risks when discontinuing an antidepressant too quickly, including mania, hypomania, suicide and suicidal ideation; withdrawal symptoms of restlessness and panic may worsen suicidal ideation, and patients should be monitored closely.…”