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Spiller, 2007 Antidepressant withdrawal syndrome and DUI evaluation


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Antidepressant withdrawal syndrome and DUI evaluation.

By: Spiller, Henry; Sawyer, Tama S.

Publication: The Forensic Examiner

Date: Saturday, September 22 2007


[this paper has a excellent selection of references, see below]


Full text at http://acfei-forensics.blogspot.com/2008/03/antidepressant-withdrawal-syndrome-and.html

and http://findarticles.com/p/articles/mi_go1613/is_3_16/ai_n29371114/


Abstract at http://www.ncjrs.gov/App/publications/Abstract.aspx?id=247046




Millions of Americans annually receive selective serotonin reuptake inhibitor antidepressants and dual-action antidepressants for their symptoms of depression. These patients are at risk for a well-documented withdrawal syndrome if they abruptly stop their medication. This withdrawal syndrome may produce significant effects that may impair a person's ability to drive, putting at risk both the driver and others on the road. In a situation of the antidepressant withdrawal syndrome, the impairment is due to the absence of drugs in the patient, producing the paradox of a potentially impaired driver because of an absence of the influence of a drug. This article reviews the antidepressant withdrawal syndrome and describes the effects on cognition, memory, vision, and motor performance and reviews how these clinical effects might be misinterpreted using standardized field sobriety tests suggesting the patient is intoxicated in the absence of other drugs or alcohol.


Key Words: withdrawal syndrome, DUI, selective serotonin reuptake inhibitor




Worldwide use of antidepressants has increased dramatically in the past decade (Berndt, Bhattacharjya, Mishol, Arcelus, & Lasky, 2002; Ciuna et al., 2004; Helgason, Tomasson, & Zoega, 2004; Hemels, Koren, & Einarson, 2002). Use of antidepressants may range from 26 to 72 defined daily doses per 1000 people, depending on the country (Ciuna et al.; Helgason et al.; Hemels et al.). The estimated range of Americans using antidepressants is from 7 to 18 million patients annually. Of the various classes of antidepressants available, the Selective Serotonin Reuptake Inhibitors (SSRI) and Dual Action Antidepressants (DAB.), involving serotonin and norepinephrine reuptake inhibition, make up more than 75% of the prescriptions filled for antidepressants (Berndt et al.; Hemels et al.). Additionally, use of SSRIs and DAAs has increased more than 600% in the last 10 years (Ciuna et al.). While the drugs in these two classes have proven to be generally safe and effective, studies have documented a problem with the effects of withdrawal (Stahl et al., 1997).


Though symptoms from withdrawal are diverse, all include effects on cognition (impaired concentration and/or confusion) and motor performance (impaired coordination, loss of balance). (See Table 2 for a complete list of the clinical effects reported with withdrawal syndrome associated with the SSRI and DAA drugs.) These withdrawal effects may put patients at risk of impaired driving in the absence of other drugs or alcohol. While this is a potentially serious problem for both the patient/driver and others on the road, it has not been previously explored in the literature. This article describes the withdrawal syndrome associated with the SSRI and DAA drugs including clinical effects, with a focus on the potential effects these drugs may have on driving. Additionally, this article includes a discussion on the impact antidepressant withdrawal syndrome might have on field evaluation of a driver with tests such as the standard field sobriety test.


Antidepressant Withdrawal syndrome


Several groups of antidepressants, including the tricyclic antidepressants, the tetracyclic antidepressants, the SSRIs, the DAAs, and newer antidepressants such as mirtazapine (Remeron), may produce a withdrawal syndrome (Benazzi, 1998a; Coupland, Bell, & Potokar, 1996; Dilsaver, Kronfol, Sackellares, & Greden, 1983; Hindmarch, Kimber, & Cockle, 2000; Rosenbaum, Fava, Hoog, Ascroft, & Krebs, 1998). However, the withdrawal syndrome produced by the SSRIs and the DAAs is clinically different from that produced by the classic tricyclic antidepressants (Lejoyeux, Ades, Mourad, Solomon, & Dilsaver, 1996; Stahl et al., 1997). The withdrawal syndrome from the tricyclic and tetracyclic antidepressants is primarily a cholinergic syndrome with symptoms such as nausea, vomiting, anorexia, diarrhea, rhinorrhea (runny nose), diaphoresis (excessive sweating), myalgias (muscle pain), increased anxiety, agitation, and sleep disturbances (Dilsaver, 1994; Dilsaver et al.). In contrast, the withdrawal syndrome from the SSRIs and DAAs is primarily a serotonergic syndrome, with symptoms such as dizziness, lethargy, impaired concentration, electric-like shock sensations, impaired coordination, blurred vision, and sleep disturbances (see Table 2). This article discusses the impact of the serotonin-related antidepressants. The SSRI and DAA drugs that may produce a withdrawal syndrome are listed in Table 1. The syndrome may be seen in a substantial minority of patients taking these drugs--up to 25% (Coupland et al.; Michelson et al., 2000; Rosenbaum et al., 1998).


A brief understanding of the mechanism(s) of action of these drugs will improve the understanding of the withdrawal syndrome.



The sudden withdrawal of these drugs produces a sudden decrease in serotonin transmission due to reduced persistence of the neurotransmitter in the synaptic cleft (Zajecka, Tracey, & Mitchell, 1997). In effect, it produces a reduction of activity in some areas of the brain controlled by serotonin in the case of SSRIs and by serotonin and norepinephrine in the case of the DAAs.


It is this sudden decrease in activity that is responsible for the effects seen in these patients. If the decrease is of sufficient magnitude, an antidepressant withdrawal syndrome will occur. The dosage range of these drugs varies, with as much as a five-fold difference in some of the drugs between the lower and upper range of the therapeutic dose. (See table 1.) Any decrease that significantly effects serotonin transmission may produce a withdrawal syndrome. The withdrawal syndrome is transitory but may persist for days to weeks as the brain adjusts to new levels of activity on these neuronal pathways. Additionally, the syndrome may be reversed by restarting the antidepressant therapy. The true incidence of the withdrawal syndrome is unclear, with reports suggesting that 3%--30% of patients experience some form of the syndrome (Coupland et al., 1996; Oehrberg et al., 1995; Stahl et al., 1997).



There are a number of symptoms of the withdrawal syndrome that could potentially cause a patient to operate a motor vehicle in a manner that might be interpreted as operating under the influence of alcohol or drugs. These symptoms include visual disturbances, dizziness/vertigo, impaired coordination, tremors, confusion, impaired concentration, and jerking eye movements that cause difficulty with tracking and memory impairment. These clinical effects might produce an altered driving pattern, including weaving, erratic speed and erratic lane changes, which might be interpreted as driving while intoxicated. Additionally, if the vehicle were stopped for possible impaired driving and the patient evaluated, there are a number of symptoms that might be interpreted as the patient being under the influence of drugs or alcohol. These symptoms include confusion, agitated behavior, distracted affect if the patient is experiencing repeated sensations of electric shocks, an unsteady gait, and inattention to questions because of inability to hear on account of tinnitus.



Table l: SSRI and DAA Medications


Generic Drug Name|Brand Name|Drug Class|Elimination Half-life|Starting Dose|Dosing Range



Escitalopram Lexapro SSRI 22-32 hours l0mg 10-20mg

Citalopram Celexa SSRI 33-37 hours 20mg 20-60mg

Fluoxetine Prozac SSRI 70 hours 20mg 20-60mg

Fluvoxamine Luvox SSRI 17-23 hours 50mg 50-300mg

Paroxetine Paxil SSRI 15-22 hours l0mg 10-50mg

Sertraline Zoloft SSRI 24-27 hours 50mg 50-200mg

Duloxetine Cymbalta DAA 11-16 hours 20mg 20-60mg

Venalfaxine Effexor DAA 5 hours 75mg 75-375mg



Table 2: Clinical Effects Reported with Antidepressant Withdrawal



Cognitive Impairment Effects


* Agitation


* Anxiety


* Confusion


* Depersonalization/detachment


* Electric shock-like sensations


* Impaired concentration


* Irritability


* Short-term memory impairment


Motor Impairment Effects


* Blurred vision


* Dizziness/lightheaded/vertigo


* Gait instability


* Incoordination or impaired coordination


* Jerking eye movements


* Loss of balance


* Tremor


* Visual disturbances


Other Effects


* Diarrhea


* Chills


* Headache


* Insomnia


* Myalgia


* Nausea/vomiting


* Parathesias


* Sleep disturbances


* Suicide thoughts or behavior


* Sweating


* Tinnitus (ringing in the ears


* Vivid dreams or nightmares


(Table complied from references: Black, Shea, Durson, & Kutcher, 2000;

Compagne, 2005; Coupland, Bell, & Potokar, 1996; Leiter, Nierenberg,

Sanders, & Stern, 1995; Michelson et al., 2000; Rosenbaum, Fava, Hoog,

Ascroft, & Krebs, 1998; Stahl et al., 1997; Young & Haddad, 2000;

Zaiecka, Tracey, & Mitchell, 1997)




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Benazzi, F. (1998b). Sertraline discontinuation syndrome presenting with severe depression and compulsions. Biological Psychiatry, 43(12), 929–930.


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Helgason, T., Tomasson, H., & Zoega, T. (2004). Antidepressants and public health in Iceland. Time series analysis of national data. British Journal of Psychiatry, 184(2), 157–162.


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Lejoyeux, M., Ades, J., Mourad, I., Solomon, J., & Dilsaver, S. (1996). Antidepressant withdrawal syndrome. Recognition, prevention and management. CNS Drugs, 5(4), 278–292.


Michelson, D., Fava, M., Amsterdam, J., Apter, J., Londborg, P., Tamura, R., et al. (2000). Interruption of selective serotonin reuptake inhibitor treatment: Double-blind placebo-controlled trial. British Journal of Psychiatry, 176(4), 363–368.


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Rosenbaum, J. F., Fava, M., Hoog, S. L., Ascroft, R. C., & Krebs, W. B. (1998). Selective serotonin reuptake inhibitor discontinuation syndrome: A randomized clinical trial. Biological Psychiatry, 44(2), 77–87.


Schmidt, M. J., Fuller, R. W., & Wond, D. T. (1988). Fluoxetine, a highly selective serotonin reuptake inhibitor: A review of preclinical studies. British Journal of Psychiatry, 153(3), 40–46.


Stahl, M. M. S., Lindquist, M., Pettersson, M., Edwards, I. R., Sanderson, J. H., Taylor, N. F. A., et al. (1997). Withdrawal reactions with selective serotonin re-uptake inhibitors as reported to the WHO system. European Journal of Clinical Pharmacology, 53(3–4), 163–169.


Tharp, V., Burns, M., & Moskowitz, H. (1981). Development and field test of psychophysical tests for DWI arrest. (DOT HS 805–864). Washington, DC: U.S. Department of Transportation, NHTSA.


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Zajecka, J., Tracey, K. A., & Mitchell, S. (1997). Discontinuation symptoms after treatment with serotonin reuptake inhibitors: a literature review. Journal of Clinical Psychiatry, 58(7), 291–297.

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

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