Guides to tapering off psychiatric medications

[Altostrata]

ADMIN NOTE Also see

 

Icarus Project Harm Reduction Guide To Coming Off Psychiatric Drugs (patient-produced, compiled by Will Hall)

 

Other peer-produced guides

 

NMSIS Tips to manage and prevent discontinuation syndrome

 

Harvard Women's Health Watch 2010 Going off antidepressants

 

Dose Equivalents for Second-Generation Antipsychotics

____________________________________________________

 

From GPnotebook.co.uk, a widely used UK medical site for general practitioners:

 

Stopping antidepressant treatment

 

• the timing of when to stop antidepressant treatment is discussed...below (length of antidepressant treatment)
• patients should be advised not to stop treatment suddenly or omit doses - patients should also be forewarned about possible symptoms that may occur when treatment is discontinued
• Drug and Therapeutics Bulletin (1) advises:
  • [*] after a 'standard' 6-8 months treatment it is recommended that treatment should be tapered off over a 6-8 week period
  • if the patient has been on maintenance therapy then an even more gradual tapering e.g. by 1/4 of the treatment dose every 4-6 weeks, is advised
  • if a treatment course has lasted less than 8 weeks then discontinuation over 1-2 weeks is considered safe
• this contrasts with the Maudsley prescribing guidelines (2) which recommend that antidepressants should be withdrawn slowly, preferably over four weeks, by weekly increments for example,

   

   

   

   

  Drug	maintenance dose (mg/day)	dose after 1st week (mg/day)	dose after 2nd week (mg/day)	dose after 3rd week (mg/day)	dose after 4th week (mg/day)
  amitriptyline	150	100	50	25	Nil
  paroxetine	30	20	10	5 (liquid)	Nil
  trazadone	450	300	150	75	Nil

  If withdrawal symptoms occur then the rate of drug withdrawal should be slowed or (if the drug has been stopped) the patient should be given reassurance that symptoms rarely last more than 1-2 weeks (2).

• NICE also suggest a four week period for withdrawal of antidepressant

  treatment (3):

  • stopping or reducing antidepressants

     

  • advise people that discontinuation symptoms may occur on stopping,

    missing doses or, occasionally, reducing the dose of the drug. Explain

    that these are usually mild and self-limiting over about 1 week, but

    can be severe, particularly if the drug is stopped abruptly

  • normally, gradually reduce the dose over 4 weeks (this is not necessary

    with fluoxetine). Reduce the dose over longer periods for drugs with

    a shorter half-life (for example, paroxetine and venlafaxine)

  • advise the person to see their practitioner if they experience significant

    discontinuation symptoms. If symptoms occur:

     

  • monitor them and reassure the person if symptoms are mild
  • consider reintroducing the original antidepressant at the dose

    that was effective (or another antidepressant with a longer half-life from the same class) if symptoms are severe, and reduce the dose

    gradually while monitoring symptoms

  [*]for detailed guidance then consult the full guideline (3)

Swapping antidepressant treatment (2):

• when swapping from one antidepressant

  to another, abrupt withdrawal should usually be avoided. Cross-tapering is preferred, where the dose of the ineffective or poorly tolerated drug is slowly reduced while

  the new drug is slowly introduced for example,

  		week 1	week 2	week 3	week 4
  withdrawing dosulepin	150 mg od	100mg od	50 mg od	25 mg od	Nil
  introducing citalopram	Nil	10 mg od	10mg od	20 mg od	20 mg od

Antidepressant

use: swapping and stopping

The table below has been adapted from the

Maudsley prescribing guidelines (2). However it is recommended that local prescribing guidelines and/or specialist psychiatric advice must be consulted when swapping antidepressant medication. Also the specific summary of product characteristics for each of the antidepressants involved should be consulted. It has been noted that there are no clear guidelines on switching antidepressants, so caution is required (2).

 

 

changing from	to tricyclics	to citalopram	to fluoxetine	to paroxetine	to sertraline	to venlafaxine
tricyclics (TCA)	cross taper cautiously	halve dose and add citalopram then slow withdrawal	halve dose and add fluoxetine then slow withdrawal	halve dose and add paroxetine then slow withdrawal	halve dose and add sertraline then slow withdrawal	cross taper cautiously starting with 37.5 mg per day
citalopram	cross taper cautiously		withdraw citalopram then start fluoxetine	withdraw citalopram and then start paroxetine at 10 mg per day	withdraw citalopram and then start sertraline at 25 mg per day	withdraw and then start venlafaxine at 37.5 mg per day. Increase very slowly
fluoxetine	stop fluoxetine. Start tricyclic at very low dose and increase very slowly	stop fluoxetine. Wait 4-7 days; start citalopram at 10mg per day and increase slowly		stop fluoxetine. Wait 4-7 days; start paroxetine at 10mg per day and increase slowly	stop fluoxetine. Wait 4-7 days; start sertraline at 25 mg per day and increase slowly	stop fluoxetine. Wait 4-7 days; start venlafaxine at 37.5 mg per day. Increase very slowly
paroxetine	cross taper cautiously with very low dose of tricyclic	withdraw paroxetine then start citalopram	withdraw paroxetine then start fluoxetine		withdraw paroxetine then start sertraline at 25 mg per day	withdraw paroxetine. Start venlafaxine at 37.5 mg per day. Increase very slowly
sertraline	cross taper cautiously with very low dose of tricyclic	withdraw sertraline then start citalopram	withdraw sertraline then start fluoxetine	withdraw sertraline then start paroxetine		withdraw sertraline then start venlafaxine at 37.5 mg per day
venlafaxine	cross taper cautiously with very low dose of tricycli	cross taper cautiously. Start with citalopram 10 mg per day	crosss taper cautiously. Start with 20 mg every other day	cross taper cautiously. Start with 10 mg per day.	cross taper cautiously. Start with 25 mg per day
stopping	reduce over four weeks	reduce over four weeks	at 20mg per day - just stop at 40 mg per day, reduce over four weeks	reduce over four weeks, or longer if necessary *	reduce over four weeks	reduce over four weeks or longer if necessary

NICE guidance regarding switching antidepressants is less detailed (3):

• do not switch to, or start, dosulepin
  • because evidence supporting its tolerability relative to other antidepressants

    is outweighed by the increased cardiac risk and toxicity in overdose

• when switching to another antidepressant, which can normally be achieved

  within 1 week when switching from drugs with a short half life, consider the

  potential for interactions in determining the choice of new drug and the nature

  and duration of the transition.

  Exercise particular caution when switching:
  • from fluoxetine to other antidepressants, because fluoxetine has a long

    half-life (approximately 1 week)

  • from fluoxetine or paroxetine to a TCA, because both of these drugs

    inhibit the metabolism of TCAs; a lower starting dose of the TCA will

    be required, particularly if switching from fluoxetine because of its

    long half-life

  • to a new serotonergic antidepressant or MAOI, because of the risk of

    serotonin syndrome

  • from a non-reversible MAOI: a 2-week washout period is required (other

    antidepressants should not be prescribed routinely during this period).

Notes:

Do not co-administer clomipramine and SSRIs or venlafaxine

When switching between one SSRI and another, cross-tapering the doses is generally not considered necessary. The effects of the first SSRI are likely to be so similar

to that of the second one, that the second SSRI will reduce the discontinuation effects of the first (2). The abrupt switch between SSRIs may still produce discontinuation

symptoms, and vigilance is still advised. In cases where discontinuation symptoms

arise a short period of dose tapering is recommended before starting a different SSRI.

* withdrawal effects may be more pronounced. Slow withdrawal over 1-2 months may be necessary.

 

Reference:

• Drug and Therapeutics Bulletin (1999); 37 (7):49-52.
• The Maudsley Prescribing Guidelines 2001; 6th Ed, p64 - 65.
• NICE (October 2009). Depression

Edited November 19, 2018 by Altostrata
edited admin note

[alexjuice]

NICE's advice to taper 50% a week over four weeks to d/c paxil is very bad advice. And, I feel confident in asserting, not the advice that would be offered by any of the posters on this site.

 

I thought pointing this out was worthwhile considering the possibility that a new visitor first could land on the instructions and decide to follow them.

 

Alex.i

[Altostrata]

You could also use this as a start to educate your doctor about the most recent advice from the conservative wing of psychiatry.

[Neuroplastic]

My doctor had always this advice; cut the pill in half, wait two weeks, then get rid of the rest. Yes, after eight years on it.

[Altostrata]

....

When switching between one SSRI and another, cross-tapering the doses is generally not considered necessary. The effects of the first SSRI are likely to be so similar to that of the second one, that the second SSRI will reduce the discontinuation effects of the first (2). The abrupt switch between SSRIs may still produce discontinuation symptoms, and vigilance is still advised. In cases where discontinuation symptoms arise a short period of dose tapering is recommended before starting a different SSRI.....

 

Note the conflicting and confusing advice regarding switching.

[Altostrata]

From advice given to U.S. family practitioners. Note reference is from 1997:

 

Antidepressant Withdrawal

Aka: Antidepressant Withdrawal, Antidepressant Discontinuation Syndrome, SSRI Discontinuation Syndrome

 

Pathophysiology

• Occurs with sudden Antidepressant Withdrawal
  • Selective Serotonin Reuptake Inhibitor (SSRI)
  • Tricyclic Antidepressant
  • MAO inhibitor
• Symptom onset occurs within 24 hours to 2-3 weeks
• Likely results from cholinergic overdrive

  Symptoms similar to Organophosphate Poisoning

• Most common with Paxil
• Least common with Prozac (naturally tapers)

Symptoms

• Cholinergic rebound (See Cholinergic Toxicity)
  • Diaphoresis
  • Nausea or Vomiting
  • Diarrhea
• Non-specific Withdrawal symptoms
  • Dizziness
  • Anxiety
  • Headache
  • Malaise
  • Myalgias
  • Weakness
  • Sleep Disturbance
• Extrapyramidal effects
  • Paresthesias
  • Restless legs

Differential Diagnosis

Bipolar Disorder with Antidepressant-induced mania

 

Management: Approach

• Mild Symptoms: Resolve spontaneously
  • Withhold treatment
  • Reassurance and observe
• Moderate to severe symptoms
  • Restart medication and then slowly taper
  • See specific medications for taper schedule
  • Symptoms abate soon after restarting medication

Management: Specific Withdrawal Symptoms

• Cholinergic rebound symptoms (See above)
  • Atropine 0.8 mg PO tid to qid
  • Cogentin 0.5 to 4 mg PO qd
  • Artane 1-4 mg PO tid to qid
  • Donnatal 2 tablets PO tid-qid
• Anxiety
  • Lorazepam 0.5 to 1 mg PO tid prn
• Dizziness
  • Antivert 12.5 to 25 mg PO q6 hours prn
  • Dramamine 50 mg PO q6 hours prn

Reference

Wolfe (1997) Am Fam Physician 56(2):455-461

 

 

http://www.fpnotebook.com/psych/pharm/antdprsntwthdrwl.htm

[Altostrata]

Also see About discontinuation from US APA Practice Guidelines

[Altostrata]

This is from www.nelm.nhs.uk/ and the UK's NHS UK Medicines Information (UKMi) pharmacists for NHS healthcare professionals (Expires 31 August 2011) about cross-tapering.

 

It is appalling.

 

QA150_2_v5_switching_antidepressants_SSRIs_TCAs_and_related.doc

[Altostrata]

Also see NICE antidepressant discontinuation guidelines for UK doctors

[Barbarannamated]

What do you make of the reference from 1997? I've noted trends in literature... info ceased in early 2000s or thereabouts.

[Altostrata]

New-generation antidepressant withdrawal syndrome became recognized in the late 1990s -- the initial hype from pharma was, as opposed to the tricyclics, there were no withdrawal difficulties -- and there was a burst of research that ended in the early 2000s.

[jr1985]

My psychiatrist told me I could just stop taking Effexor at 75mg, as it was a "small dose". But I knew from past experience that missing a single dose would cause me horrible w/d symptoms the next day (depression, anxiety, diahorrea, nausea, etc). I decided to taper over a month, based on the official guidelines, and I thought by doing so I was playing it safe.

 

After I had terrible w/d symptoms, I saw a different psychiatrist and told her I'd tapered over a month, she nodded and said, "yes, that's what we recommend" and that it was "your old symptoms returning". Even though I was put on it for social anxiety, not horrific morning anxiety with restlessness, burning nerves, tremors, diahorrea, loss of appetite, etc.

 

So now I think they're all a bunch of idiotic quacks, and wouldn't dare trust them with my life/wellbeing again. The info I've found online has been much more reliable and helpful, as sad as that sounds.

[Altostrata]

Yes, unfortunately that's true. Doctors are not well informed about getting people off psychiatric drugs.

[Rhiannon]

My psychiatrist told me I could just stop taking Effexor at 75mg, as it was a "small dose". But I knew from past experience that missing a single dose would cause me horrible w/d symptoms the next day (depression, anxiety, diahorrea, nausea, etc). I decided to taper over a month, based on the official guidelines, and I thought by doing so I was playing it safe.

 

After I had terrible w/d symptoms, I saw a different psychiatrist and told her I'd tapered over a month, she nodded and said, "yes, that's what we recommend" and that it was "your old symptoms returning". Even though I was put on it for social anxiety, not horrific morning anxiety with restlessness, burning nerves, tremors, diahorrea, loss of appetite, etc.

 

So now I think they're all a bunch of idiotic quacks, and wouldn't dare trust them with my life/wellbeing again. The info I've found online has been much more reliable and helpful, as sad as that sounds.

 

If doctors in general and psychiatrists in particular knew how much psych med withdrawal experiences are undermining their credibility and authority I think they might take the problem more seriously.

 

I'm not the only person around who will never trust medical advice again. About ANYthing. Especially prescriptions or expensive testing.

[Barbarannamated]

RE: testing - I have several tests and scans ordered but wondering "what info will this test yield?" and "what is/are the treatment/s" Inevitably, it's more drugs and that's where I get stuck wondering what's reasonable and worth doing.

[Aria]

My former pdoc used to titrate my doses by 25% a week and got me off each drug within one month. Of course he had me start another one after that. My body was on a "continuous merry go round of stop this -- start this" for too long.

 

I last time I took his advice was when he told me it was OK to stop the Seroquel due to profound Akathisia. "You're not on much of it so it's no big deal to just stop it". It was 300mg of Seroquel and my body howled. When I called his office his nurse told me to go to the ER. I knew better.

 

I successfully tapered off all of the psych drugs on my own.

[meistersinger]

My former pdoc used to titrate my doses by 25% a week and got me off each drug within one month. Of course he had me start another one after that. My body was on a "continuous merry go round of stop this -- start this" for too long.

 

 

In a footnote under tips for quitting psychiatric drugs on www.crazymeds.us, there is a citation for Julien--A Primer of Drug Action. The calculation there is take the half-life of the drug, multiply by 5 and round up to the nearest day. Anyone ever hear of this tome?

[tezza]

My GP said " T, most people have no problem coming off Risperdal ". He, now, knows that I do.

[Altostrata]

Many guides to tapering off psychiatric medications have been published. Some are more specific than others about the amount of reductions and rate of taper.

 

Gradual tapering is generally accepted medical practice, it's not controversial at all. Cold turkey is universally condemned as dangerous.

 

NONE of these guides suggest alternating or skipping doses to taper.

 

2010 APA Practice Guidelines

Practice Guideline for the Treatment of Patients With Major Depressive Disorder Third Edition

From the American Psychiatric Association

Selection and discussion: http://survivingantidepressants.org/index.php?/topic/372-2010-apa-practice-guidelines-about-discontinuation/

 

National Institute for Health and Clinical Excellence (NICE) guidelines (UK)

PDF: CG90 Depression in adults: full guidance 28 October 2009

Selection and discussion: http://survivingantidepressants.org/index.php?/topic/2448-nice-antidepressant-discontinuation-guidelines-for-uk-doctors/

 

US National Guidelines

For all US medical professionals, derived from APA practice guidelines.

Discussion: http://survivingantidepressants.org/index.php?/topic/1177-us-national-guideline-discontinue-antidepressants-after-4-9-months/

Icarus Project Harm Reduction Guide *

For tapering off psychiatric drugs, 2012 edition

PDF: http://www.theicarusproject.net/downloads/ComingOffPsychDrugsHarmReductGuide2Edonline.pdf

Selection and discussion: http://survivingantidepressants.org/index.php?/topic/207-icarus-project-harm-reduction-guide/

Mind UK's Making Sense of Coming Off Psychiatric Drugs *

An excellent summary of tapering.

Selection and discussion: http://survivingantidepressants.org/index.php?/topic/2331-mind-uks-making-sense-of-coming-off-psychiatric-drugs/

Dr. Peter Breggin's 10% taper method *

From Your Drug May Be Your Problem: How And Why To Stop Taking Psychiatric Medications by Peter R. Breggin and David Cohen

Selection and discussion: http://survivingantidepressants.org/index.php?/topic/803-dr-peter-breggins-10-taper-method/

 

Ashton Manual for benzodiazepine withdrawal

Also applies to "Z" drugs for sleep. Information on antidepressants is poor. 2002 version. Be sure to read 2011 update.

Discussions:

http://survivingantidepressants.org/index.php?/topic/206-2002-2011-ashton-manual-for-benzodiazepine-withdrawal/

http://survivingantidepressants.org/index.php?/topic/1510-ashton-manual-recommendation-of-antidepressants/

http://survivingantidepressants.org/index.php?/topic/1516-ashton-on-ssri-discontinuation-and-drug-development-2007/

NHS Advice: Benzodiazepine and z-drug withdrawal - Management *

Current NHS advice to doctors, informed by research by Ashton and Lader.

Discussions:

http://survivingantidepressants.org/index.php?/topic/2931-current-nhs-advice-for-doctors-about-benzo-tapering/

 

Gianna Kali's Withdrawal 101 on BeyondMeds.com *

 

NMSIS Tips to manage and prevent discontinuation syndromes

Circa 2005 from a physician education group, the Neuroleptic Malignant Syndrome Information Service. As usual, potential severity and possibly frequency of withdrawal are understated and descriptions of symptoms are incomplete. Recommends tapers of 10% per week, with close monitoring.

Selection and discussion: http://survivingantidepressants.org/index.php?/topic/2965-nmsis-tips-to-manage-and-prevent-discontinuation-syndromes/

Withdrawing Safely from Psychiatric Drugs *

by psychologist Maureen B. Roberts, Director, Schizophrenia Drug-free Crisis Centre

http://www.jungcircle.com/schiznatural.htm (Caution: We've found some of the supplements aggravate withdrawal symptoms, and have found orthomolecular physicians are not particularly knowledgeable about tapering or withdrawal.)

 

Drug package inserts (US)

In the US, each of the newer antidepressants and many other psychiatric drugs comes with an FDA-mandated package insert advising something like this:

Discontinuation of Treatment with Lexapro

During marketing of Lexapro and other SSRIs and SNRIs (serotonin and norepinephrine reuptake inhibitors), there have been spontaneous reports of adverse events occurring upon discontinuation of these drugs, particularly when abrupt, including the following: dysphoric mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesias such as electric shock sensations), anxiety, confusion, headache, lethargy, emotional lability, insomnia, and hypomania. While these events are generally self-limiting, there have been reports of serious discontinuation symptoms.

 

Patients should be monitored for these symptoms when discontinuing treatment with Lexapro. A gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose but at a more gradual rate....

 

(There is no more detail than this about tapering.)

 

UK psychologist Mick Bramham summarizes other tapering guides here http://www.mythsandrisks.info/coming-off-psych-drugs.html#Slow_taper 

 

*Recommends decreases of 10% or less

Edited February 10, 2014 by Altostrata
updated

[GiaK]

I've got a (relatively) short piece that's an intro to withdrawal...with links to other sources of info etc:

 

I've alternately called it a Beginner's Guide to Psychiatric Drug Withdrawal and Withdrawal 101.

 

I also refer to "safer" withdrawal practices and point out elsewhere that withdrawing from psych drugs always presents some risk.

 

anyway, when I was withdrawing I found it helpful to read as many sources of info as possible...it's like I needed to hear stuff over and over again...of course there is more available now then there was then.

 

http://beyondmeds.com/withdrawal-101/

[Rhiannon]

Excellent collection of resources. I recommend printing out this list and taking it with you when you go to the doctor and giving it to your doctor. If they seem open and interested and willing to check it out, that's a good sign. If they act angry or resentful that you're trying to inform them and take control of your own taper, you may need to do some doctor-shopping.

 

You can also print out a guide in full and take it with you. But I think this extensive list is even better.

[Rhiannon]

I've got a (relatively) short piece that's an intro to withdrawal...with links to other sources of info etc:

 

I've alternately called it a Beginner's Guide to Psychiatric Drug Withdrawal and Withdrawal 101.

 

I also refer to "safer" withdrawal practices and point out elsewhere that withdrawing from psych drugs always presents some risk.

 

anyway, when I was withdrawing I found it helpful to read as many sources of info as possible...it's like I needed to hear stuff over and over again...of course there is more available now then there was then.

 

http://beyondmeds.com/withdrawal-101/

 

Want to mention that this guide of G's has been recommended by John Grohol of the Psych Central website...

[primrose]

Here's a link all about psych drug withdrawal.

I havent read it yet, but thought I would share before reading as I tend to be forgetful.

Enjoy http://beyondmeds.com/withdrawal-101/

[Altostrata]

Thanks, Primrose. The author is one of our esteemed members, GiaK, who posted above.

[dalsaan]

The [2012] Maudsley prescribing guide in psychiatry claims to be the leading clinical reference guide in the UK. It is associated with the Maudsley hospital which is described as an international leader and ground breaker in mental health care

 

On page 276 of their latest guide they give the following advice:

 

'Many people suffer symptoms despite slow withdrawal and even if they have received adequate education regarding discontinuation symptoms. For those patients, the option do abrupt withdrawal should be discussed'.

 

Why is that you may ask. The answer lies in the next piece of prescribing advice

 

'Short life antidepressants should not generally. Be stopped abruptly, although some patients may prefer to risk a short period of intense symptoms rather than a prolonged period of milder symptoms'

 

 

Can you believe that! If your having trouble on a slow taper, cease them abruptly instead. We're not pulling of bandaids here, this is our nervous system we are talking about.

 

Perhaps we should have a thread that names and shames this baseless advice

Edited May 31, 2018 by Altostrata
merged related topics

[Altostrata]

This is a measure of the cluelessness out there about withdrawal.

 

Do they give any citations for this? (Link, please!)

 

I wonder what they've seen in terms of success, doing this.

[GiaK]

http://books.google.com/books?id=KY_2Qk4LqVYC&pg=PA276&lpg=PA276&dq=Many+people+suffer+symptoms+despite+slow+withdrawal+and+even+if+they+have+received+adequate+education+regarding+discontinuation+symptoms.&source=bl&ots=um3o36_4La&sig=fI_YQtH1h9a8hYuqk1oZ3QzbTiQ&hl=en&sa=X&ei=jsSaUJH8BPKw0AHgxYHgBQ&ved=0CDwQ6AEwAQ#v=onepage&q&f=false

[Barbarannamated]

http://books.google.com/books?id=KY_2Qk4LqVYC&pg=PA276&lpg=PA276&dq=Many+people+suffer+symptoms+despite+slow+withdrawal+and+even+if+they+have+received+adequate+education+regarding+discontinuation+symptoms.&source=bl&ots=um3o36_4La&sig=fI_YQtH1h9a8hYuqk1oZ3QzbTiQ&hl=en&sa=X&ei=jsSaUJH8BPKw0AHgxYHgBQ&ved=0CDwQ6AEwAQ#v=onepage&q&f=false

 

Last bullet point in shaded box on page:

"A very few patients experience a pre-dose discontinuation symptoms which provoke the taking of the antidepressant at an earlier time each day."

 

Tolerance??

[Altostrata]

Thanks, Gia. I was very interested to look at the references they have for this odd technique to get people off antidepressants with only a couple of weeks of intense suffering.

 

As I recall from the papers cited, none of them suggest "abrupt withdrawal" when patients experience difficulty tapering. It must be a Maudsley innovation.

 

From Google Books

 

The Maudsley Prescribing Guidelines in Psychiatry

edited by David Taylor, Carol Paton, Shitij Kapur

 

John Wiley & Sons, Jan 25, 2012 - 584 pages

 

http://books.google.com/books?id=KY_2Qk4LqVYC&pg=PA276&lpg=PA276&dq=Many+people+suffer+symptoms+despite+slow+withdrawal+and+even+if+they+have+received+adequate+education+regarding+discontinuation+symptoms.&source=bl&ots=um3o36_4La&sig=fI_YQtH1h9a8hYuqk1oZ3QzbTiQ&hl=en&sa=X&ei=jsSaUJH8BPKw0AHgxYHgBQ&ved=0CDwQ6AEwAQ#v=onepage&q&f=false

 

page 276

 

How to avoid (16,17,18)

Generally, antidepressant therapy should be discontinued over at least a 4-week period (this is not required with fluoxetine).(10) The shorter the half-life of the drug, the more important it is that this rule is followed. The end of the taper may need to be slower. as symptoms may not appear until the reduction in the total daily dosage of the antidepressant is (proportionately) substantial. Patients receiving MAOls may need to be tapered over a longer period. Tranylcypromine may be particularly difficult to stop. At-risk patients (see section on ‘Who is most at risk?‘ in this chapter) may need a slower taper.

 

Many people suffer symptoms despite slow withdrawal and even if they have received adequate education regarding discontinuation symptoms.(8,21) For these patients, the option of abrupt withdrawal should be discussed. Box 4.9 lists the key points about which patients should be aware. Some may prefer to face a week or two of intense symptoms rather than months of less severe discontinuation syndrome.

 

How to treat (16,17)

There are few systematic studies in this area. Treatment is pragmatic. If symptoms are mild, reassure the patient that these symptoms are common after discontinuing an antidepressant and will pass in a few days. If symptoms are severe, reintroduce the original antidepressant (or another with a longer half-life from the same class) and taper gradually while monitoring for symptoms.

 

Some evidence supports the use of anticholinergic agents in tricyclic withdrawal(25) and fluoxetine for symptoms associated with stopping clomipramine(26) or venlafaxine(27); fluoxetine, having a longer plasma half-life, seems to be associated with a lower incidence of discontinuation symptoms than other similar drugs.(28)

---

Box 4.9 Key points that patients should know about antidepressant discontinuation syndromes

 

• Antidepressants are not addictive (a survey of 1946 people across the UK conducted in 1997 found that 74% thought that antidepressants were addictive(1)). Note, however, that the semantic and categorical distinctions between addiction and the withdrawal symptoms seen with antidepressants may be unimportant to patients.

• Patients should be informed that they may experience discontinuation symptoms (and the most likely symptoms associated with the drug that they are taking) when they stop their antidepressant.

• Short half-life antidepressants should not generally be stopped abruptly, although some patients may prefer to risk a short period of intense symptoms rather than a prolonged period of milder symptoms.

• Discontinuation symptoms can occur after missed doses if the antidepressant prescribed has a short half-life. A very few patients experience pre-dose discontinuation symptoms which provoke the taking of the antidepressant at an earlier time each day.

---

From References p. 277

8. Tint A et al. The effect of rate of antidepressant tapering on the incidence of discontinuation symptoms: a randomised study. J Psychopharmacol 2008; 22:330-332.

 

9. Taylor D et al. Antidepressant withdrawal symptoms - telephone calls to a national medication helpline. J Affect Disord 2006: 95:l29-133.

 

10. Rosenhaum JF et al. Selective serotonin reuptalte inhibitor discontinuation syndrome: a randomized clinical trial. Biol Psychiatry 1998; 44:77-87.

 

11. Michelson D et al. Interruption of selective serotonin reuptalte inhibitor treatment. Double-blind, placebo-controlled trial. Br J Psychiatry 2000; l76:363-368.

 

12. Goodwin GM et al. Agornelatine prevents relapse in patients with rnaior depressive disorder without evidence of a discontinuation syndrome: a 24-week randomized, double-blind, placebo-controlled trial. J Clin Psychiatry 2009; 70:1128-ll37.

 

13. Berigan TR. Mirtazapine-associated withdrawal symptoms: a case report. Prim Care Companion J Clin Psychiatry 2001; 3:143.

 

14. Benazzi F. Mirtazapine withdrawal symptoms. Can J Psychiatry 1998;43:525.

 

15. Berigan TR et al. Bupropion-associated withdrawal symptoms: a case report. Prim Care Companion J Clin Psychiatry 1999; 1:50~5l.

 

16. Lejoyeux M et al. Antidepressant withdrawal syndrome: recognition, prevention and management. CNS Drugs 1996:5:278-292.

 

17. Haddad PM. Antidepressant discontinuation syndromes. Drug Saf 2001; 24:l83-l97.

 

18. Anon. Antidepressant discontinuation syndrome: update on serotonin reuptalre inhibitors. J Clin Psychiatry 1997; 58(Suppl 7):3-40.

 

19. Sir A et al. Randomized trial of sertraline versus venlafaxine XR in major depression: efficacy and discontinuation symptoms. J Clin Psychiatry 2005;66:1312-1320.

 

20. Baldwin DS et al. A double-blind. randomized. parallel-group. flexible-dose study to evaluate the tolerability. efficacy and effects of treatment discontinuation with escitalopram and paroxetine in patients with major depressive disorder. Int Clin Psychopharrnacol 2006;21:l59-l69.

 

21. Fava GA et al. Effects of gradual discontinuation of selective serotonin reuptake inhibitors in panic disorder with agoraphobia. Int J Neuropsychopharmacol 2007:10:835-838.

[Altostrata]

From: [Altostrata]

Subject: The Maudsley Prescribing Guidelines in Psychiatry

Date: November 10, 2012 2:16:51 PM PST

To: David.Taylor at slam.nhs.uk, carol.paton at oxleas.nhs.uk, shitij.kapur at kcl.ac.uk

 

Dear Doctors Taylor, Paton, and Kapur:

 

I am writing regarding the advice in the 2012 edition of The Maudsley Prescribing Guidelines in Psychiatry regarding discontinuation of antidepressants.

 

Specifically, I am interested in the following statement:

 

Many people suffer symptoms despite slow withdrawal and even if they have received adequate education regarding discontinuation symptoms.(8,21) For these patients, the option of abrupt withdrawal should be discussed. Box 4.9 lists the key points about which patients should be aware. Some may prefer to face a week or two of intense symptoms rather than months of less severe discontinuation syndrome.

 

My question is: What is your evidence that abrupt discontinuation in the above situation leads to only a week or two of intense withdrawal symptoms? I cannot find this information in any of your references.

 

To your knowledge, has this been put into clinical practice? What have the outcomes been?

 

If it is indeed effective, it may resolve the entire issue of tapering. Why not discontinue everyone abruptly, if only a week or two of intense symptoms follow?

 

Sincerely,

 

Altostrata

[dalsaan]

Well done Alto, I'll be interested to see if you get a response. I have never seen any data/references supporting this approach and it defies logic from my perspective

[Barbarannamated]

Gia, any thoughts on Ann Blake-Tracy's book or CD on withdrawal? Someone mentioned in another thread that it is very, very heavy scientific info. I want to read it, but have been too overwhelmed to tackle it yet. The little I have read in her articles is inline with advice on this board: very slow tapers, less than 10% in many cases.

[GiaK]

no...I've not read it...

 

In the past (it's been years since I looked at any of it) her work struck me as sensationalized and I stopped looking at it.

 

As I said, it's been years so that's not something I stand by at this point. I don't really remember particulars about why I reached that impression.

[Altostrata]

I agree with Gia.

[dalsaan]

Hi Alto

 

Did you get any response to your email?

[Altostrata]

From: Altostrata

Subject: Re: The Maudsley Prescribing Guidelines in Psychiatry

Date: November 15, 2012 10:25:44 AM PST

To: David Taylor <David.Taylor at slam.nhs.uk>

Cc: carol.paton at oxleas.nhs.uk, Shitij Kapur <shitij.kapur at kcl.ac.uk>

 

How can you determine who will have only a week or two of symptoms and who will have more severe and long-lasting symptoms, i.e. who is a candidate for cold turkey?

 

On Nov 11, 2012, at 6:37 AM, Taylor, David wrote:

 

This advice is based on clinical and personal experience. I know of no studies which support abrupt withdrawal but we have observed that symptoms persist only for a week or two after sudden stopping.

 

The reason it is not recommended to all is that the symptoms can be disabling and necessitate absence form work, etc. Symptoms are better tolerated in slow withdrawal.

 

D

 

Professor David Taylor

Director of Pharmacy and Pathology