AMA, 2009 The long goodbye: The challenge of discontinuing antidepressants

[Altostrata]

As we know, withdrawal syndrome is not psychological trauma, as Dr. Shelton would have it, but real neurological dysregulation.

 

The long goodbye: The challenge of discontinuing antidepressants

 

http://www.amednews.com/article/20090309/health/303099976/4/

Tapering slowly is the mantra for pruning these regimens, but some patients may still experience withdrawal symptoms.

By Victoria Stagg Elliott March 9, 2009 American Medical Association Web site

 

....

For various reasons, patients often are eager to discontinue antidepressants. Some stop or reduce dosages on their own because of side effects, the expense, a desire not to take pills anymore or as a response to perceived stigma. Dr. [Thomas C.] Bent's protocol is to reduce the dosage slowly over several weeks. This approach is the widely accepted way to transition patients off these drugs. The labels of antidepressants warn of symptoms that can occur with sudden discontinuation, and physicians often use this as a motivator for adherence.
....

The why and the how
It's not entirely clear why, but discontinuing antidepressants can be very difficult for some patients. Studies suggest about 10% to 20% of patients on these medications will experience symptoms of what's been coined "the antidepressant discontinuation syndrome" when they try to stop. Experts theorize the adjustment of the serotonin receptors in the brain can cause flu-like feelings and electric shock sensations, among other complaints. Most cases will be mild. Symptoms are lessened by tapering, but the Internet is filled with horror stories written by people who feel they cannot get off these drugs no matter what they do.

 

Experts believe these situations most likely are created by a convergence of three factors.

 

"There are the discontinuation symptoms, the possible relapse into the original condition and then patients may have an anxious response to both the return of the symptoms and the discontinuation effects," said Richard Shelton, MD, professor in the department of psychiatry and pharmacology at Vanderbilt University in Tennessee. He has published several papers on this subject. "Some patients may be traumatized by the discontinuation attempt."

 

Experts suspect some of those having the hardest time stopping still need the medications. Many also speculate that the need to taper slowly may not be widely known by both physicians and patients, in part because of the history of antidepressants.

 

"For a while, it wasn't that obvious that this phenomenon was happening," said Jerry Rosenbaum, MD, chief of psychiatry at Massachusetts General Hospital. He co-authored some of the earliest studies documenting the discontinuation syndrome.

For instance, it was well known that discontinuing old tricyclic drugs could be thorny. But fluoxetine (Prozac), the first widely used selective serotonin reuptake inhibitor, did not come with most of these adverse effects. Its long half-life created a built-in taper, and it took a while to realize that slow discontinuation would be needed for the drugs that followed. Fluoxetine is the only modern antidepressant most experts would consider safe to stop abruptly. The same cannot be said for some newer drugs the body metabolizes more quickly. These include paroxetine (Paxil) or venlafaxine (Effexor), which several studies have shown are more difficult to stop.

 

"It's about five weeks until [fluoxetine] is out of your blood stream entirely," said Dr. [Patrick J. McGrath]. "It doesn't cause much in the way of withdrawal. The shorter half-life drugs -- they're all much more prone to cause problems."

 

A spokesman for Wyeth Pharmaceuticals Inc., maker of Effexor, had no comment on whether the discontinuation symptoms were more common in this drug. But, he said, discontinuation symptoms in general occur in a minority of patients and can be minimized by tapering. Paxil maker, GlaxoSmithKline, did not respond to requests for comment.

 

But while tapering is the widely accepted discontinuation method, there is little data to define what that means. Numerous papers have documented that the antidepressant discontinuation syndrome exists, and can last for weeks or months. Children and adolescents seem to have a harder time than adults, and those who have problems while starting these drugs may be more likely to experience issues when stopping. Also, patients who are taking them longer at higher doses seem to be most at risk, but research has not examined the best way to minimize these symptoms.

 

"With most antidepressants, if they are discontinued suddenly, you do run the risk of a withdrawal syndrome, but there's no science on the best way to stop antidepressants," said David W. Price, MD, national clinical head for depression at Kaiser Permanente's Institute for Health Research in Denver and lead author on the organization's depression treatment guidelines.

Customizing the taper
Expert opinions, including the results of two consensus panel deliberations on the syndrome, were published as supplements to the Journal of Clinical Psychiatry in 1997 and 2006. The earlier document was funded by an educational grant from Eli Lilly and Co., the manufacturer of fluoxetine. The latter was financially supported by Wyeth. In addition, the popular health book, The Antidepressant Solution, was published in 2005 as a guide for discontinuing these drugs.

 

"The key is really customizing it for every patient," said Joseph Glenmullen, MD, the book's author and a clinical instructor of psychiatry at Harvard Medical School in Boston. He wrote it because a chapter on this subject in his previous book, Prozac Backlash, triggered a large number of information requests.

 

Experts suggest waiting until patients have been well for several months before moving toward discontinuation. Patients should be counseled that these types of symptoms are possible as the drugs are tapered. They also should be informed that other medications can cause discontinuation syndromes as well and that having these kind of symptoms does not mean they are addicted. With the patient's permission, a family member or a friend can be involved.

 

Physicians and patients should be alert for signs of a relapse, something more likely to happen to those who have had more episodes of major depression. And, although the science is lacking, specialists have devised several strategies for patients who have the most difficult time, including ways to taper as slowly as necessary.

 

"The rules are -- there are no rules. There's no magic period of time. But in most circumstances, there is no reason to be in a hurry," Dr. Shelton said.

 

For patients attempting to discontinue short half-life drugs, briefly switching to other medications with a longer half-life may ease the transition. More problems seem to occur the closer a patient gets to zero than at the beginning at higher dosages, so tapering needs to proceed more slowly at the end than at the beginning. Patients can split pills, if need be, or open up capsules to divide the medication when small enough doses are not readily available. Many antidepressants also come in liquid form, which can make dosing more precise.

"If we're trying to get them off these drugs, we can do it, but for some people it is painstakingly slow," said Scott Haltzman, MD, clinical assistant professor of psychiatry and human behavior at Brown University in Rhode Island.

....
 

---

Effects of stopping meds
Approximately 20% of patients who taper off antidepressant medications experience signs of withdrawal. These include:

• Flu-like symptoms
• Headache
• Fatigue
• Nausea
• Insomnia
• Nightmares
• Dizziness
• "Electric shock" sensations
• Irritability

Source: "Antidepressant Discontinuation Syndrome," American Family Physician, Aug. 1, 2006 (link)

---

External links
"Antidepressant Discontinuation Syndrome: Current Perspectives and Consensus Recommendations for Management," Journal of Clinical Psychiatry, 2006, supplement index (link)
"Safety and Efficacy of Serotonin Reuptake Inhibitors (SSRIs) in Children and Adolescents," American Medical Association's Council on Science and Public Health, June 2005 (link)

[nz11]

When i click on the link it comes up blank

[nz11]

As we know, withdrawal syndrome is not psychological trauma, as Dr. Shelton would have it, but real neurological dysregulation.

I think we can all relate to the psychological trauma view.

 

Tapering slowly is the mantra for pruning these regimens,......Dr. [Thomas C.] Bent's protocol is to reduce the dosage slowly over several weeks. This approach is the widely accepted way to transition patients off these drugs.

This is not very informed.

 

Experts believe these situations most likely are created by a convergence of three factors.

"There are the discontinuation symptoms, the possible relapse into the original condition and then patients may have an anxious response to both the return of the symptoms and the discontinuation effects," said Richard Shelton, MD, professor in the department of psychiatry and pharmacology at Vanderbilt University in Tennessee. He has published several papers on this subject.

Question: Who is providing Sheltons bread and butter??

 

Later...did a google and guess what i found..i went full circle ...

 

Dr. Shelton got on the pharma gravy train:...

 

http://survivingantidepressants.org/index.php?/topic/778-shelton-2006-correspondence-from-dr-richard-shelton-about-prolonged-withdrawal-syndrome/?p=49950

 

 

Experts believe.....

Experts suspect....

Experts theorize...

Experts suggest....

Expert opinions.....

 

So who are these experts?...puppets?

Expert opinions, including the results of two consensus panel deliberations on the syndrome, were published as supplements to the Journal of Clinical Psychiatry in 1997 and 2006. The earlier document was funded by an educational grant from Eli Lilly and Co., the manufacturer of fluoxetine. The latter was financially supported by Wyeth.(Effexor.).

 

Just found a great statement:

"One hallmark of rationalization in the service of cognitive dissonance is a lack of logical coherence and a reliance on blither. Do you think that's what's going on here?"

 

A spokesman for Wyeth Pharmaceuticals Inc., maker of Effexor, had no comment on whether the discontinuation symptoms were more common in this drug. But, he said, discontinuation symptoms in general occur in a minority of patients and can be minimized by tapering. Paxil maker, GlaxoSmithKline, did not respond to requests for comment.

GSK suffering some cognitive dissonance perhaps? One other hallmark i have found in the service of cognitive dissonance is a deafening silence. Perhaps thats what is going on here.

 

 

That last one on 'effects of stopping meds' is so understated its a joke.

[nz11]

The good thing i guess is they actually acknowledge albeit sheepishly that withdrawal exists.

 

This was interesting

It's not entirely clear why, but discontinuing antidepressants can be very difficult for some patients. Studies suggest about 10% to 20% of patients on these medications will experience symptoms of what's been coined "the antidepressant discontinuation syndrome" when they try to stop.

 

They also mention Glenmullen as well in this article.

Wonder why they didnt quote his assessment of how many suffer withdrawal symptoms because in this article he says 66%

http://www.lawyersandsettlements.com/articles/drugs-medical/paxil-00172.html#.VjwlI2vr2h4

 

Last two sentences:

"Research has shown that when patients stop antidepressants cold turkey they can have high rates of withdrawal reactions," Dr Glenmullen advises, "which vary depending on the particular drug."

"In studies involving hundreds of patients, 66 percent of patients stopping Paxil," he says, "have withdrawal reactions."

 

I suppose this relates to paxil only but im sure it is the same across the board.

[ChessieCat]

Hi LeslieBarnes,

 

I can see from your profile that you have already started an introduction in the Intro & Updates thread.

 

It might be helpful if you copy and paste this post into that thread, as it seems to be more of a question relating to yourself.  That way it will keep it altogether and other members will be more likely to find and answer you question.

 

All the best,

CC

[Altostrata]

Thanks, Chessie. I moved Leslie's post.

[westcoast]

(a window into doc-think (when they know their conversation isn't private, that is.)

 

How to taper long-term, low-dose Seroquel user

 

Discussion in 'Psychiatry' on studentdoctor.net started by novopsych, 01.17.14.

Link is below. These two excerpts.

 

 

"I'm also not understanding why someone would want a slow taper unless they have some type of psychological obsession with it. Per all the guidelines you could taper it much faster than people here are writing. I'm not saying the people here are wrong, just that I don't understand their logic. Please inform me what your train of thought is."

 

 

 

"Anxious people frequently require approaches that make no sense to anyone else. Giving an anxious person a perception of control and gradualness might be key for successful taper. Of course it doesn't "make sense," but if we expect our patients to "make sense," we might be expecting a bit too much!"

 

http://forums.studentdoctor.net/threads/how-to-taper-long-term-low-dose-seroquel-user.1050727/

[nz11]

Westcoast ..that link seems a bit odd.

 

Wow is that a doctor you have quoted there...gee, how arrogant and ignorant!

Thats a person treating someone like an idiot ...oh yeah it must be a doctor then.

 

Notice he says 'per all the guidelines' .

 

Personally if this is from an internet thing then who knows who that person could be ...they may be holding themselves out as a doctor but could simply be a pharmaceutical worker.

[compsports]

Here is the direct link to the thread:

 

http://forums.studentdoctor.net/threads/how-to-taper-long-term-low-dose-seroquel-user.1050727/

 

Only the moderator cautioned about tapering too quickly.    

 

NZ11, they all unfortunately sound like real psychiatrists judging from their disrespectful remarks about patients being anxious regarding withdrawal symptoms.

 

CS

 

PS - It looks like I put in the same link as WC.  But when I clicked on the first one, the page didn't load.   Weird.

[cymbaltawithdrawal5600]

 

But when I clicked on the first one, the page didn't load.   Weird.

 

That's because her link had something hidden at the start of it. My ad and/or script blocker didn't load the site either:

http://www.http.com//forums.studentdoctor.net/threads/how-to-taper-long-term-low-dose-seroquel-user.1050727/

See the 'www.http.com'? That's the site it linked to. I am too lazy to see what kind of cr@p site 'http.com' is.

[Dawes1b]

 

Since those of us withdrawing from ADs are up against a multi billion assembly of Psychiatrists, pharm companies, government social agencies, and the media. I imagine the doctors wont probide much help since they are taugnt by drug reps and paid shills from their own profwssion. Perhaps famous people, celebrities who are withdrawing might help to publicize. SA needs a Betty Ford. Finding long-term withdrawing users of ADs is difficult though. Benzo withdrawers are plentiful, Stevie Nicks is a Klonipin veteran and advocates against it regularly. I can think of one famous long term ssri user who came off but he is back on. I myself "switched,"from an SSRI to Lamictal, I am also not famous and struggle !

[btdt]

Westcoast ..that link seems a bit odd.

 

Wow is that a doctor you have quoted there...gee, how arrogant and ignorant!

Thats a person treating someone like an idiot ...oh yeah it must be a doctor then.

 

Notice he says 'per all the guidelines' .

 

Personally if this is from an internet thing then who knows who that person could be ...they may be holding themselves out as a doctor but could simply be a pharmaceutical worker.

Notice he says 'per all the guidelines' .

translate my ass is covered I don't need to think for myself somebody else will be accountable... but nobody ever is.