Bhat, 2017 Recognition and management of antidepressant discontinuation syndrome.

[Altostrata]

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

 

DSM-5 Diagnosis Code: Antidepressant Discontinuation Syndrome DSM 995.29 (T43.205A)

 

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

 

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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.¹ Symptoms generally begin 2–4 days after abrupt discontinuation of anti-depressants taken continuously for at least 1 month.¹ ADDS is often seen during taper or after missed doses with short half-life agents, such as paroxetine and venlafaxine.^2–4

 

Up to 70% of patients prescribed antidepressants occasionally skip doses.⁵ 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.^2,6–8 The 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 In addition, mis-diagnosing the physical symptoms of ADDS can lead to unnecessary medical and laboratory workup.⁹

 

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

 

Risk for ADDS is highest with short half-life agents, high doses and rapid taper.^1,10 The risk also appears to be higher for those who have taken anti-depressants for 8 weeks or longer,¹³ 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.^2,10 ADDS has been reported with all monoamine oxidase inhibitors (MAOIs) and commonly presents with agitation, movement disorders, and sleep and speech problems.¹⁰ ADDS has most commonly been reported for amitriptyline and imipramine among tricyclic antidepressants (TCAs) and paroxetine and venlafaxine among SSRIs.¹⁰ Neonatal venlafaxine discontinuation syndrome upon maternal venlafaxine discontinuation before childbirth has been reported.¹⁴ ADDS with TCAs and SSRIs commonly presents with flu-like symptoms, insomnia and vivid dreams, and with additional “shock-like” sensations with SSRIs.¹⁰ Movement disorders have occasionally been reported with both TCAs and SSRIs.¹⁰ Symptoms of ADDS have not been reported with abrupt discontinuation of agomelatine^10,15,16 or vortioxetine.^10,17

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 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.² When ADDS symptoms persist despite slow taper,¹⁸ 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.¹⁰ Importantly, there is limited evidence on ADDS management; some studies suggest benefits with fluoxetine for ADDS associated with venlafaxine¹⁹ or clomipramine²⁰ and anticholinergic agents in TCA withdrawal.²¹ 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).²²

 

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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 September 10, 2018 by Altostrata
Updated admin note

[Shep]

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.^2,6–8The 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. 

 

 

 

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! 

 

 

 

[Altostrata]

This recognition in the DSM is significant.

[Barbarannamated]

Great work, Alto! 

[Rabe]

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.  

 

 

[Bunyapine]

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 September 9, 2018 by Bunyapine
Posted it before I finished it.

[Altostrata]

10 hours ago, Bunyapine said:

Altostrata really needs to educate these people! 

 

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

[bubbles]

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.

[Rabe]

@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!!! 

[Lilu]

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.

 

[manymoretodays]

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

I've almost got the code memorized!!!

 

🖤😻

[Kittygiggles]

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.