Safely and Successfully Stopping Antidepressants

Ready to Stop Antidepressants?

The decision to stop antidepressants is individual and should involve and be supervised by the prescribing provider whenever possible. There are several factors that can help make the decision or weigh into the decision if it is a good time to taper. Some factors include how well the medication is working or effectiveness, how well tolerated the medication is (side effects), symptom history, sensitivity to withdrawal, life-timing and ongoing stressors, personal growth and development, as well as therapeutic support and planning.

A Growing Problem: Long-Term Antidepressant Use

Antidepressants were designed and originally studied for the treatment of major depressive disorder, which is characterized by episodes of depression. While some persons do feel depressive symptoms chronically and may benefit from continuous therapy, most persons experience discrete episodes. Therefore, antidepressants were never designed to be used as chronic maintenance medications. Rather, they were designed to be used over the course of an episode, which typically lasts 9-12 months.

Since the approval of the first selective serotonin reuptake inhibitors (SSRI) Prozac in 1988 there has been a steady increase in the number of antidepressant prescriptions. At this point around 13% of the US adult population takes antidepressant medication, with whites, females, and persons over 60 seeing the most dramatic rises in use. It is mostly long-term use prescribed by general practitioners that account for the increasing number of antidepressant users [1]. Unfortunately, many prescribing providers are unprepared to help their patients discontinue antidepressants [2, 3]. In the US, around 2/3 antidepressant users have been taking the medication longer than 2 years and it’s estimated that 30-50% of long-term users have no evidenced based indication to continue them [3].

Roadblocks to Stopping Antidepressants

There are many potential obstacles to stopping antidepressants, although a few themes emerge when browsing the literature. One is confidence and knowledge in ability to safely discontinue antidepressants. Patients often look to their providers for this information, however treatment-guidelines as well as manufacturer prescribing information lack evidence-based recommendations on how to discontinue antidepressants. Subsequently and unfortunately, it’s an area that providers often do not feel confident in themselves.

An interrelated theme are fears of antidepressant withdrawal syndromes. Persons may at time forget to take their antidepressant with them on vacation or attempt tapering or discontinuation of antidepressants themselves and run into bothersome and sometimes destabilizing withdrawal symptoms. Antidepressants work over a period of weeks to months to improve mood and likely induce neuroadaptation events that leave the user with a physical (and at times psychological) dependence on the medication.

Another common fear is return of original illness. This occurs commonly and may be expected given antidepressants rarely treat the etiology of mental illness. Return of symptoms of the original illness occurs in many persons that stop antidepressants within a year, thus requires close attention and an alternative therapeutic plan is reasonable to be developed ahead of time. In this vein, persons are less likely to discontinue antidepressants when they’re working well, however treatment-refractory depression (defined as failing therapy with at least 2 antidepressants) is prevalent at around 30%.

Essentially, users find themselves ‘trapped’ on antidepressants due to mediocre efficacy, presence of significant withdrawal, and lack of knowledge as to how to taper and discontinue them [2,3].

Antidepressant Withdrawal Reactions

Much can happen in the time immediately after stopping or decreasing the dose of an antidepressant, creating confusion as to what the correct course of action is. Antidepressant Discontinuation Syndrome (ADS) has been defined by symptoms such as fatigue, insomnia, nausea, feeling off-balance or dizzy, sensory disturbances such as feeling abnormal sensations or ‘brain zaps’, as well as anxiety and irritability [4]. Beyond symptoms of ADS which may be distinct and recognizable compared to symptoms of original illness, persons can also experience ‘rebound symptoms’ [5]. Rebound symptoms are similar to those of original illness, however they are experienced almost immediately upon dose decrease and occur with greater intensity than those of original illness. Additionally, rebound symptoms resolve as the antidepressant withdrawal reaction completes itself whereas return of original symptoms may arise more slowly and after a longer time period from stopping or decreasing the dose of antidepressants. The diagram below depicts temporal differences in rebound symptoms vs. return of original symptoms.  

Providers and persons taking antidepressants may take a dose step down, experience lower moods or increased anxiety almost immediately, and falsely conclude there was a return of original illness and reinstate the antidepressant. When symptoms rapidly resolve after reinstating or increasing the dose of an antidepressant it is a helpful sign in understanding that the user was having trouble related to withdrawal of medication rather than exacerbation mental illness.

Timeline and Severity of Antidepressant Withdrawal Reactions

There are considerable amounts of variability in the types of reactions persons experience when lowering their dose of antidepressant. Persons using longer than the minimum 6 weeks required to understand if the antidepressant will have a therapeutic effect are at risk for antidepressant withdrawal. Persons taking higher doses, agents with shorter-half lives (paroxetine, venlafaxine), or use of an antidepressant for a condition such as panic disorder can increase risks of withdrawal syndromes. It is reasonable to believe withdrawal symptoms emerge as the antidepressant leaves the users system. For most SSRI and related serotonin reuptake blocking antidepressants (SNRIs) onset of withdrawal occurs within 2-5 days of a dose decrease or stopping use. Withdrawal symptoms typically peak within 5-14 days and gradually resolve over 2-3 weeks in most users. Depending on the sensitivity of the individual to withdrawal and the size of the dose decrease severe symptoms (e.g. suicidality) or reactions that last longer are possible [6, 7].

Rate of Antidepressant Taper

Current or ‘normal’ recommendations for antidepressant tapering in persons with major depression suggest ‘tapering slowly over 2-4 weeks’ [8]. This rate of taper is too fast for most antidepressant users resulting in intolerable withdrawal syndromes and reinstatement of antidepressant use. Ideally, the rate of taper would be slow enough that the antidepressant user does not notice that they are tapering or withdrawal symptoms are limited to being mild and not bothersome. For most persons tapering over a period of 2-3 months is reasonable, although for some 4-6 months may be necessary. Antidepressant tapers are traditionally accomplished with linear step-down dosing of the antidepressant (e.g. a 25% decrease in dose every 3 weeks). Persons may find that they need smaller dose decreases the closer they get to being completely off the medication or that subsequent step downs are more difficult than initial ones. Alternative and emerging tapering strategies involve tiny decreases of the antidepressant on an almost daily basis (microtapering) or decreasing rapidly initially and slowing down as the taper progresses (hyperbolic dose reduction) [9]. There is no data to clarify if one method works better than another.

One difficulty that persons may face is finding step-down doses of their antidepressant small enough that the dose reduction doesn’t result in moderate-severe withdrawal syndromes. Antidepressants in immediate-release tablet forms can be cut using pill splitters to create smaller doses. Antidepressants in capsules or extended-release tablets cannot but cut, crushed, or chewed because it will destroy the extended-release mechanism and result in unwanted spikes and crashes and blood levels of antidepressant during the taper phase. Extended-release capsules can often be opened, contents weighed, and an amount discarded to create a smaller dose. The user should swallow extended-release beads whole in a spoonful of applesauce. Obviously, this type of solution is imprecise, tedious, and involves tampering with the medication thus is far from ideal and not recommended by most sources due to these factors. Some antidepressants are available in liquid formulations which can be used to create customized doses. One helpful solution are ‘tapering strips’ which involve custom compounded blister packs of antidepressants that have smaller and smaller doses as the taper progresses. Tapering strips can be customized depending on sensitivity to withdrawal and desired rate of step-down. 

Monitoring the Taper

Due to the variability in individual responses to tapering antidepressants as well as confusion between rebound symptoms or original illness it clarifies the pattern of withdrawal and planning subsequent step-down doses to monitor the taper closely. Monitoring parameters may include depression (mood), anxiety, sleep, as well as symptoms specific to antidepressant discontinuation syndrome. It is reasonable to record other interventions used or a short journal entry about the days events or other stressors that are influencing the picture. By doing this daily one can then plot their antidepressant withdrawal reaction and see it as a predictable pattern. By knowing the pattern, subsequent steps are easier as alternative interventions and support can be planned for times predicted to be rough.

To help with antidepressant tapers I created an Antidepressant Monitoring and Support Kit. The Antidepressant Monitoring and Support Kit allows persons taking antidepressant to clearly track themselves over the course of a month and plot their individual withdrawal reaction. They can then share the results with their provider to plan the next step of their taper.

Click and opt-in below to receive the Kit in your inbox

Managing Original Illness: Emerging Treatments with Psychedelics

Antidepressants treat symptoms of depression as well as other psychiatric conditions which can increase a user’s functionality and significantly improve their quality of life. However, antidepressants are not thought to treat the underlying etiology and it is realistic of users stopping antidepressants to expect that they will need to grapple with symptoms of their illness once more. For some, antidepressants were effective for some time although waned in benefit over time and they are already managing illness that could be compounded by withdrawal. Identifying alternative interventions and gathering resources to treat symptoms of illness prior to tapering is a sage choice.

One emerging strategy for management of depression, anxiety, PTSD and other disorders that antidepressants are currently used for is psychedelic-assisted psychotherapy. Psychedelic therapies are intermittent and do not involve regular use.  They are conducted in supervised settings and involve extensive therapy outside of psychedelic use. There is no data to support that psychedelics are helpful with antidepressant withdrawal syndromes, however there is increasingly supportive high-quality data suggesting psychedelic therapies to have high rates of success where antidepressants have previously failed. Therefore, particularly if you have tried several antidepressants without helpful effects or know you will need to treat your original illness it may be prudent to explore their healing potentials. 

Summing Up

Antidepressant withdrawal reactions and tapering can be complex, and many persons find it much more challenging than they had expected. Learning about withdrawal and how to manage it as well as planning, monitoring, and supporting antidepressant tapers are key ingredients for success.

Additional Resources and Help

If you found this article to be of help, I’d highly recommend my courses or services. I’m passionate about helping persons successfully and safely taper antidepressants as well as psychedelic therapies and have much more to offer as far as help and resources!

I know my course has the ability to help safely transition from their antidepressants to therapies healing and directive for the soul. Check it out below:

References

1.            Mojtabai, R. and M. Olfson, National trends in long-term use of antidepressant medications: results from the U.S. National Health and Nutrition Examination Survey. J Clin Psychiatry, 2014. 75(2): p. 169-77.

2.            Scholten, W., N. Batelaan, and A. Van Balkom, Barriers to discontinuing antidepressants in patients with depressive and anxiety disorders: a review of the literature and clinical recommendations. Therapeutic Advances in Psychopharmacology, 2020. 10: p. 2045125320933404.

3.            Maund, E., et al., Barriers and facilitators to discontinuing antidepressant use: A systematic review and thematic synthesis. J Affect Disord, 2019. 245: p. 38-62.

4.            Warner, C.H., et al., Antidepressant discontinuation syndrome. Am Fam Physician, 2006. 74(3): p. 449-56.

5.            Henssler, J., et al., Antidepressant Withdrawal and Rebound Phenomena. Dtsch Arztebl Int, 2019. 116(20): p. 355-361.

6.            Fava, G.A., et al., Withdrawal Symptoms after Serotonin-Noradrenaline Reuptake Inhibitor Discontinuation: Systematic Review. Psychother Psychosom, 2018. 87(4): p. 195-203.

7.            Fava, M., Prospective studies of adverse events related to antidepressant discontinuation. J Clin Psychiatry, 2006. 67 Suppl 4: p. 14-21.

8.            American Psychiatric Association (APA), Practice Guideline for the Treatment of Patients With Major Depressive Disorder. 3rd edition. Arlington (VA); 2010 Oct. 152 p. [1170 references], 2010.

9.            Horowitz, M.A. and D. Taylor, Tapering of SSRI treatment to mitigate withdrawal symptoms. Lancet Psychiatry, 2019. 6(6): p. 538-546.