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Bhat, 2017 Recognition and management of antidepressant discontinuation syndrome.


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ADMIN NOTE I don't know how this slipped by me. The DSM-5 contains a new diagnosis code. See topic

 

 

I wrote the DSM-5 committee repeatedly begging them to add a diagnosis code, I was told no can do. But there it is.

 


J Psychiatry Neurosci. 2017 Jun;42(4):E7-E8.

Recognition and management of antidepressant discontinuation syndrome.

Bhat V1, Kennedy SH1.

 

No abstract. Pubmed entry and free full text https://www.ncbi.nlm.nih.gov/pubmed/28639936

 

From the paper:

....

Antidepressant discontinuation syndrome (ADDS) is a new entity in DSM-5 in the category of medication-induced movement disorders and other adverse effects of medication. Symptoms generally begin 2–4 days after abrupt discontinuation of anti-depressants taken continuously for at least 1 month. ADDS is often seen during taper or after missed doses with short half-life agents, such as paroxetine and venlafaxine.

 

Up to 70% of patients prescribed antidepressants occasionally skip doses. For diagnosis, ADDS symptoms should not be present before dose reduction and should not be better explained by another psychiatric disorder. Symptoms that fit the FINISH mnemonic (flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, hyperarousal), can be experienced by up to 40% of patients upon abrupt antidepressant discontinuation., The Discontinuation Emergent Signs and Symptoms Scale (DESS) can be used to quantify symptoms. ADDS can also include worsening symptoms of the original illness and can be mistaken for a relapse., In addition, mis-diagnosing the physical symptoms of ADDS can lead to unnecessary medical and laboratory workup.

 

Patients must be informed of ADDS when starting treatment and of the differences between ADDS and withdrawal associated with addiction. Although withdrawal symptoms and ADDS could have neurobiological similarities, such as a “receptor rebound” phenomenon upon sudden discontinuation,,,, there are important differences. Unlike antidepressants, use of drugs of abuse include reinforcing/euphoric effects of the drug and associated drug-seeking behaviour. Symptoms of ADDS are associated with short half-life agents, and symptoms are usually mild and short-lived.

 

Risk for ADDS is highest with short half-life agents, high doses and rapid taper., The risk also appears to be higher for those who have taken anti-depressants for 8 weeks or longer, experience anxiety symptoms when starting a selective serotonin reuptake inhibitor (SSRI), are taking other centrally acting medications (e.g., anti-psychotics, antihypertensives, antihistamines), are children/adolescents, or have a history of ADDS episodes., ADDS has been reported with all monoamine oxidase inhibitors (MAOIs) and commonly presents with agitation, movement disorders, and sleep and speech problems. ADDS has most commonly been reported for amitriptyline and imipramine among tricyclic antidepressants (TCAs) and paroxetine and venlafaxine among SSRIs. Neonatal venlafaxine discontinuation syndrome upon maternal venlafaxine discontinuation before childbirth has been reported. ADDS with TCAs and SSRIs commonly presents with flu-like symptoms, insomnia and vivid dreams, and with additional “shock-like” sensations with SSRIs. Movement disorders have occasionally been reported with both TCAs and SSRIs. Symptoms of ADDS have not been reported with abrupt discontinuation of agomelatine,, or vortioxetine.,

Prevention of ADDS, particularly for short half-life agents, includes a gradual discontinuation over 4 weeks with a slow rate of taper at the end,,, and a longer taper for those on MAOIs. Importantly, patients need reassurance that ADDS is common, self-limited and often mild. If symptoms are severe, restarting the original antidepressant or another antidepressant with a long half-life in the same class can be followed by gradual taper. When ADDS symptoms persist despite slow taper, abrupt withdrawal options could be considered, particularly when patients prefer a short period of intense symptoms to a longer period of mild symptoms associated with a gradual taper. Importantly, there is limited evidence on ADDS management; some studies suggest benefits with fluoxetine for ADDS associated with venlafaxine or clomipramine and anticholinergic agents in TCA withdrawal. Although one recommendation is to switch patients to long-acting antidepressants like fluoxetine before withdrawal of venlafaxine, there are no controlled studies to identify the best option (taper v. substitution).

 


WARNING: Despite the comment in this paper, please DO NOT suddenly quit your drug thinking you can trade "a short period of intense symptoms" instead of going to the trouble of gradual tapering. (Maudsley Prescribing Guidelines is wrong about this.) We have many people on this site who have tried that short cut and found a "short period of intense symptoms" lasts months or years.

If you get symptoms while tapering, your tapering reductions are too large. to a longer period of mild symptoms associated with a gradual taper

Edited by Altostrata
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This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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18 minutes ago, Altostrata said:

For diagnosis, ADDS symptoms should not be present before dose reduction and should not be better explained by another psychiatric disorder.1 Symptoms that fit the FINISH mnemonic (flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, hyperarousal), can be experienced by up to 40% of patients upon abrupt antidepressant discontinuation.2,68The Discontinuation Emergent Signs and Symptoms Scale (DESS) can be used to quantify symptoms.2 ADDS can also include worsening symptoms of the original illness and can be mistaken for a relapse.1,2

 

Great find, Alto.

 

I always get nervous when I read "should not be better explained by another psychiatric disorder" because the DSM keeps getting larger as more and more psychiatric disorders are "discovered". I so hope this doesn't feed into that narrative.

 

I looked up the reference for "The Discontinuation Emergent Signs and Symptoms Scale" and found the full text of the reference here:

 

Withdrawal Symptoms after Selective Serotonin Reuptake Inhibitor Discontinuation: A Systematic Review

 

And this is a screenshot of the symptoms listed. 

 

journalScreenshot.png.019c4690cbdeb7bccc0588d6b78ccccb.png

 

 

I hope doctors are forced to pay attention to this list. 

 

It's great to see this in the medical literature, including the DSM 5. 

 

34 minutes ago, Altostrata said:

I wrote the DSM-5 committee repeatedly begging them to add a diagnosis code, I was told no can do.

 

I think somebody was listening. Thank you for all you do! 

 

 

 

Drug free May 22, 2015 after 30 years of neuroleptics, benzos, z-drugs, so-called "anti"-depressants, and amphetamines 

 

My Success Story:  Shep's Success: "Leaving Plato's Cave"

 

And what is good, Phaedrus, and what is not good — need we ask anyone to tell us these things? ~ Zen and the Art of Motorcycle Maintenance


I am not a medical professional and this is not medical advice, but simply information based on my own experience, as well as other members who have survived these drugs.

 

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This recognition in the DSM is significant.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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Great work, Alto! 

Pristiq tapered over 8 months ending Spring 2011 after 18 years of polydrugging that began w/Zoloft for fatigue/general malaise (not mood). CURRENT: 1mg Klonopin qhs (SSRI bruxism), 75mg trazodone qhs, various hormonesLitigation for 11 years for Work-related injury, settled 2004. Involuntary medical retirement in 2001 (age 39). 2012 - brain MRI showing diffuse, chronic cerebrovascular damage/demyelination possibly vasculitis/cerebritis. Dx w/autoimmune polyendocrine failure.<p>2013 - Dx w/CNS Sjogren's Lupus (FANA antibodies first appeared in 1997 but missed by doc).

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Patients must be informed of ADDS when starting treatment and of the differences between ADDS and withdrawal associated with addiction.10 Although withdrawal symptoms and ADDS could have neurobiological similarities, such as a “receptor rebound” phenomenon upon sudden discontinuation,2,7,11,12 there are important differences. Unlike antidepressants, use of drugs of abuse include reinforcing/euphoric effects of the drug and associated drug-seeking behaviour.1 Symptoms of ADDS are associated with short half-life agents, and symptoms are usually mild and short-lived.1

 

Happy for the code .... very small start...but a start.  

 

 

-Nardil 1976 < year, stopped. React to AD's. Klonopin .5BID 1990, 2.5mg til 2016

-Klonopin doubled Jan '16. Taper to 2.25mg May to Nov '16. Bad react to Lexapro, stop. React to Prevacid too, taper off. 

-November '16 Tapered .25mg Klonopin in hospital. Jan '17 started Viibryd, 20mg from Feb to June '17,     

-20mg to 10mg Viibryd from 3/25 to 6/10 2017, 12/15 10% Viibryd taper...back up next day

-Clonazepam 2mg to 1.85mg 4/14 '17 to end November; taper to 1mg Clonazepam in hospital 9/1 tp 9/14 '17

-Feb '18 Amiloride .25mg  5/18 off Amiloride d/t react. Clonaz compounded  

-4/27 '18 Viibryd 9.5mg, 6/11 9.0 mg, 1/27 '19 Viibryd 8.75mg, ; Clonazepam .2mg 530pm and .7mg 1130pm, Premarin .3mg 830PM CARAFATE QID 2/27/19 to 3/5/19

-July 6'19 1/2 10mg Claritin 230pm, stopped it about July 18, started Oct 11 '19, 

-7/27 Viibryd 8.5, 8/29 8.25, 10/24 8.0, 12/19 7.75, Feb '20 7.50, 3/20 7.25, 5/20 7.0, 6/20 6.75, 7/20 6.5, 8/20 6.25, 10/2 20 6.0, 11/25'20 5.75, 1/9/21 5.5, 2/23 5.25

-1015 AM Viibryd, vit D 4,000IU 130, 415 Clonazepam .2mg, 815 Premarin .3mg, 1015 Clonaz .7mg,

  1115 3t fish oil+D 1145 Castor Oil 650mg(4) 1230 Carafate 1/2GM,Methylated B Vit  1/week,Reacted Mag prn

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It’s great to have the code and I was thinking of copying  Altostrata’s summary to show to the unbelieving doctors I have to visit. However I still don’t feel they understand the syndrome as well as they should. There are a lot of people having trouble with fluoxetine withdrawal  and many others are taking a long time to get of these drugs. Altostrata really needs to educate these people! 

 

 

Edited by Bunyapine
Posted it before I finished it.

1987 Anafranil

1987-1989 Prothiaden

1990-Jan 2015 Prozac 40mg Feb-Mar Prozac 30mg Ap-Nov Prozac 20mg (+10mg Zoloft for 1 week in Sept) Dec Prozac 10mg 2016 Jan-2017 Oct Prozac 15mg  Nov Prozac 14mg  Nov Prozac14.5mg

Other drugs Humira and Methotrexate for rheumatoid arthritisSupplements :Magnesium and calcium.Folic acid 5mg.

Inderal 10mg (stopped 2018 Dec).        

2018 Nov Quetiapine fumarate 25mg Dec 150-125mg 2019Jan 125-25mg Feb 25-12.5mg

2018 Dec Sertra 25-150-125mg

2018 Dec Pregabalin 75-150mg                                                                                                  

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10 hours ago, Bunyapine said:

Altostrata really needs to educate these people! 

 

I and others have been working on this for 14 years.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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Quote

 

Antidepressant discontinuation syndrome (ADDS) is a new entity in DSM-5 in the category of medication-induced movement disorders and other adverse effects of medication.1

 

 

 

 

I am mildly concerned that this is included with movement disorders. I know it also says "and other adverse effects of medication" but I wonder if the second part will be lost if there are no movement disorders apparent. Still, an entry is good news - it must surely be easier to correct an entry than get a whole new one included.

 

Quote

Prevention of ADDS, particularly for short half-life agents, includes a gradual discontinuation over 4 weeks with a slow rate of taper at the end,2,6,7 and a longer taper for those on MAOIs. Importantly, patients need reassurance that ADDS is common, self-limited and often mild.2

 

This part is dreadful, and IMO only applies to the FINISH symptoms. It also doesn't allow for the honeymoon period we often see here - where the person feels okay for a few weeks or so, and then crashes.

 

I think this is a step forward in recognizing the acute phase of WD, but unfortunately they're reinforcing the "mild and short-lived" narrative, and also the terrible advice to do a "gradual  discontinuation over 4 weeks with a slow rate of taper at the end". I guess the next stage is to get acknowledgement of the more chronic phase.

 

It is one step forward though, and @Altostrata - well done for your perseverance! I'm immensely grateful for all of your hard work.

2005 St John's Wort / 2006-2012 Lexapro 20mg, 2 failed attempts to stop, tapered over 4.5 months in early 2012

January 2013 started Sertraline, over time worked up to 100mg

July 2014 Sertraline dropped from 100mg to 75mg, held for six months, slower tapering until 2019 22 Dec 3.2mg

2020 Sertraline 19 Jan 3.1mg, 26 Jan 3.0mg; 1 Mar 2.9, 7 Mar 2.8, May (some drops here) 24 May 2.5, May 29 2.4, June 21 2.3, June 28 2.2mg,  July 4 2.1mg, July 24 (or maybe a bit before) 2mg, early Nov switched to home made suspension; 29 Nov 1.8mg; approx 25 Dec 1.6mg)

2021 Some time in about Jan/Feb realised my dosing was off and as probably on more like 1.8mg and possible mixing error in making suspension; doses after 10 Feb accurate; 10 Feb 1.6mg; 7 Mar 1.4

 

My thread here at SA: https://www.survivingantidepressants.org/topic/1775-bubbles/page/17/

CurrentSertraline: 7 Mar 1.4mg / Armour Thyroid / endless allergy meds, erg

 

 

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@Altostrata forgot to send the second part of my message above....bless you for all the time and effort to help make this happen! It is a milestone!

@Bunyapine I agree with you...Alto does need to educate these people!  Even with the code and my taking things from here to my doctor...they dont really seem to believe this can be true.  

Sometimes I think part of that is doctors starting people on these drugs, making changes, increasing doses or making rapid tapers but not seeing the results of their actions because it is an inpatient setting, or they are covering for someone else, etc.  They dont see the results of their actions, and if they do simply feel it is further symptoms.

Thank you to all!!! 

-Nardil 1976 < year, stopped. React to AD's. Klonopin .5BID 1990, 2.5mg til 2016

-Klonopin doubled Jan '16. Taper to 2.25mg May to Nov '16. Bad react to Lexapro, stop. React to Prevacid too, taper off. 

-November '16 Tapered .25mg Klonopin in hospital. Jan '17 started Viibryd, 20mg from Feb to June '17,     

-20mg to 10mg Viibryd from 3/25 to 6/10 2017, 12/15 10% Viibryd taper...back up next day

-Clonazepam 2mg to 1.85mg 4/14 '17 to end November; taper to 1mg Clonazepam in hospital 9/1 tp 9/14 '17

-Feb '18 Amiloride .25mg  5/18 off Amiloride d/t react. Clonaz compounded  

-4/27 '18 Viibryd 9.5mg, 6/11 9.0 mg, 1/27 '19 Viibryd 8.75mg, ; Clonazepam .2mg 530pm and .7mg 1130pm, Premarin .3mg 830PM CARAFATE QID 2/27/19 to 3/5/19

-July 6'19 1/2 10mg Claritin 230pm, stopped it about July 18, started Oct 11 '19, 

-7/27 Viibryd 8.5, 8/29 8.25, 10/24 8.0, 12/19 7.75, Feb '20 7.50, 3/20 7.25, 5/20 7.0, 6/20 6.75, 7/20 6.5, 8/20 6.25, 10/2 20 6.0, 11/25'20 5.75, 1/9/21 5.5, 2/23 5.25

-1015 AM Viibryd, vit D 4,000IU 130, 415 Clonazepam .2mg, 815 Premarin .3mg, 1015 Clonaz .7mg,

  1115 3t fish oil+D 1145 Castor Oil 650mg(4) 1230 Carafate 1/2GM,Methylated B Vit  1/week,Reacted Mag prn

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Wow, this is progress. I wonder how many doctors out there are aware of this.  All of the psychiatrists and neurologists that I saw for my severe myoclonus told me that there is no way that this was a side effect of Neurontin (Gabapentin). They all said that it was Psychogenic and stemmed from my anxiety.  The fact that I still have it 3 years later despite being back on an antidepressant for 3 years and off Neurontin, which I was on only for 3 weeks, kind of proves them right, doesn't it?

But they also failed to recognize that I was going through protracted withdrawal  for over a year and suffering a complete dysregulation of my nervous system.   I was a mess, but it wasn't until I started taking Neurontin that the jerking in my spine started with four days of starting it.   But Neurontin usually causes mild jerking in one limb, nothing like what I was experiencing. The jerks were so violent that they could knock me off my feet even while standing.  I couldn't like still even for one minute, because as soon as I would start to relax, my body would jerk violently every 10 seconds.   Over 3 years as my nervous system healed, it would happen less and less.  But it still happens on days when I've been exposed to any kind of emotional stress but only when I lie down to sleep at night. The jerks seem to stem from within the base of my spine, and are still strong enought to violently jerk my entire body.  Thankfully the jerking subsides pretty quickly though and I'm able to fall asleep.

 

2005-2008: Effexor; 1/2008 Tapered 3 months, then quit. 7/2008-2009 Reinstated Effexor (crying spells at start of new job.)
2009-3/2013: Switched to Pristiq 50 mg then 100 mg
3/2013: Switched to Lexapro 10mg. Cut down to 5 mg. CT for 2 weeks then reinstated for 6 weeks
8/2013-8/2014: Tapering Lexapro (Lots of withdrawal symptoms)
11/2014 -8/2015: Developed severe insomnia and uncontrollable daily crying spells
12/2014-6/2015: Tried Ambien, Klonopin,Ativan, Lunesta, Sonata, Trazadone, Seroquel, Rameron, Gabapentin - Developed Anxiety disorder, PTSD, and Psychogenic Myoclonus
7/2015-1/2016: Reinstated Lexapro 2 mg (mild improvement, but crying spells still present)

1/2016-5/2017: Lexapro 5 mg ( helped a lot, but poor stress tolerance & depressive episodes)

5/20/2017 - Raised dose to Lexapro 10 mg due to lingering depression(Total of 2 failed tapers & severe PAWS)

9/11/2018 - Present: Still on 10 mg Lexapro and mostly recovered.(Extremely sensitive to stress which triggers Myoclonus.)

Intro page: http://survivingantidepressants.org/index.php?/topic/4149-lilu-depression-worsened-by-meds/

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......just a huge thank you Alto.  It IS significant.

I've almost got the code memorized!!!

 

🖤B)😻

Started with psycho meds/psychiatric care circa 1988.  In retrospect, and on contemplation, situational overwhelm.

Rounding up to 30 years of medications(30 medication trials, poly-pharmacy maximum was 3 at one time).

5/28/2015-off Adderal salts 2.5mg. (I had been on that since hospital 10/2014)

12/2015---just holding, holding, holding, with trileptal/oxcarb at 75 mg. 1/2 tab at hs.  My last psycho med ever!  Tapered @ 10% every 4 weeks, sometimes 2 weeks to

2016 Dec 16 medication free!!

Longer signature post here, with current supplements.

Herb and alcohol free since 5/15/2016. 

None of my posts are intended as medical advice.  Please discuss any decisions about your medical care with a knowledgeable medical provider. manymoretodays

 

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Seeing an increasing number of influential organizations and publications acknowledge the evidence of SSRI withdrawal is satisfying. The consequences I hope will include preventing further harm and compensating those who were harmed by professionals prescribing rapid tapers or sudden discontinuations.

 

Thanks to Altostrata, the moderators, and the SA community for your pioneering work by supporting sufferers, advocacy, research, and raising awareness. 

2012: 2 weeks of paroxetine, I cannot recall the dose. Strong side effects, stopped cold turkey, had intense, horrible withdrawal thereafter

2012 to 2016: Fluoxetine 40mg daily, sometimes 20mg daily, a couple of bad tapers under doctor's advisement, increasingly bad withdrawal symptoms with each major dose change

Oct 2016 to June 2017: 10-month reinstatement of 20mg fluoxetine daily to stabilize. A very difficult period but withdrawal gradually improved

July 2017: At 20mg (100%), started a linear tapering regimen using water titration (20mg fluoxetine into 300ml of water).

June 2019: Currently at 0.200mg (1.00%). I have many symptoms, most I attribute to fluoxetine, some to withdrawal, and the rest to hypothyroidism. Continuing to reduce anyway.

July 2019: Jumped from 0.066mg (0.33%) to 0.000mg (0.00%); I'm now free of the poison.

 

My introduction thread: https://www.survivingantidepressants.org/topic/14226-kittygiggles-generic-prozac-fluoxetine-stabilization/

 

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