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J Psychiatry Neurosci. 2000 May;25(3):255-61.

Selective serotonin reuptake inhibitor discontinuation syndrome: proposed diagnostic criteria.

Black K, Shea C, Dursun S, Kutcher S.

Abstract at http://www.ncbi.nlm.nih.gov/pubmed/10863885

Free full text at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1407715/?tool=pubmed

and http://www.mediafire.com/?1kgew9ccf6vuxqg

 

http://survivingantidepressants.org/topic/17537-black-2000-selective-serotonin-reuptake-inhibitor-discontinuation-syndrome-proposed-diagnostic-criteria/

 

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Free full text at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3024727/

 

and http://www.mediafire.com/?dava88qwmumhdxs

 

Abstract at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3024727/?report=abstract&tool=pmcentrez

 

J Can Acad Child Adolesc Psychiatry. 2011 February; 20(1): 60–67.

 

SSRIs and SNRIs: A review of the Discontinuation Syndrome in Children and Adolescents

 

Sheik Hosenbocus, MD, FRCP©1 and Raj Chahal, MSW2

 

1 Department of Psychiatry, Royal Inland Hospital, Kamloops, British Columbia

2 Department of Social Work, Royal Inland Hospital, Kamloops, British Columbia

Corresponding email: dr.sheik.hosenbocus@interiorhealth.ca

 

ABSTRACT

 

Objective

To review the occurrence, clinical relevance and characteristics of the discontinuation syndrome in children and adolescents who have been on a selective serotonin reuptake inhibitor (SSRI) or a serotonin/norepinephrine re-uptake inhibitor (SNRI) for various conditions as an update for physicians prescribing these medications in this population.

 

Method

An on-line literature search was done using MEDLINE, PubMed, CINAHL, PsychARTICLES, and PsychINFO with the following key words: selective serotonin reuptake inhibitors or SSRIs, serotonin/norepinephrine re-uptake inhibitors or SNRIs, discontinuation syndrome, pediatric or children or adolescents, occurrences and characteristics.

 

Results

Not a single randomized placebo-controlled trial was found that addresses this condition solely in the child and adolescent population. A couple of papers written by the same authors indicate that children and adolescents taking an SSRI definitely experience discontinuation reactions that can be mild, moderate or severe when the medication is stopped suddenly or high doses are reduced substantially. Among the SSRIs paroxetine seems to be the worst offender and fluoxetine the least while sertraline and fluvoxamine tend to be intermediate. However, the most serious discontinuation reactions came from the SNRI venlafaxine. There was no study or reports found on citalopram, another SSRI that is commonly prescribed in children and youth. While the adult literature abounds with papers describing the different aspects of this condition including clinical features, diagnostic criteria, management and prevention, the limited information available to-date in children and adolescents indicate that the essential features of the discontinuation syndrome may not be significantly different than in adults. There were no specific characteristics identified relating to the child population.

 

Conclusion

In considering the use of an SSRI in children, physicians must seriously weigh the not so clear benefits against the risks of adverse reactions including the discontinuation syndrome. The frequency and severity of this reaction seem dependent on the SSRI half-life and although children metabolize drugs much faster than adults the reactions to-date have been reported as similar. The use of fluoxetine with its long half-life appears safer in this respect with paroxetine and venlafaxine causing the most concerns. Patients and their families should be well informed of the risks of stopping the medication abruptly and instructed not to do so without consulting their physician. Physicians in Canada who are using these medications off-label in children need to be knowledgeable and vigilant about such adverse reactions. These could be avoided through adequate follow ups which will also ensure better adherence. They may benefit from this review even though the information comes mostly form the adult literature. More prospective studies are needed to clarify this issue and identify any specific features relating to the pediatric population.

 

-----------------

Adapted from the paper

 

Symptomatology Table 2

(Compiled from different sources)

 

Nervous system

Dizziness

Light-headedness

Vertigo (feeling faint)

Tremor

Ataxia (gait instability)

Visual disturbances

 

Somatic

Lethargy

Fatigue

Headache

sweating

Myalgia

Flu-like symptoms

 

Gastrointestinal

Nausea

Vomiting

Diarrhea

Abdominal discomfort

Abdominal cramps

Abdominal distention

 

Sensory

Numbness

Tingling

Electric/shock-like sensations

Blurred vision

Paresthesia

 

Sleep-Disturbance

Insomnia

Vivid dreams

Nightmares

 

Psychological/affective

Irritability

Dysphoria

Low mood

Anxiety

Nervousness, agitation

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Altostrata

Abstract at http://www.ncbi.nlm.nih.gov/pubmed/11945110

 

CNS Drugs. 2002;16(4):273-83.

 

Discontinuation syndrome in dysthymic patients treated with selective serotonin reuptake inhibitors: a clinical investigation.

 

Bogetto F, Bellino S, Revello RB, Patria L.

 

Source

 

Unit of Psychiatry, Department of Neuroscience, University of Turin, Turin, Italy.

Abstract

 

OBJECTIVE:

 

Many authors have reported discontinuation symptoms associated with selective serotonin reuptake inhibitors (SSRIs). The aim of this study was to investigate the incidence and characteristics of the discontinuation syndrome in patients who stopped treatment with the SSRIs paroxetine and fluoxetine under the usual conditions of clinical practice, and to identify clinical predictors of the syndrome.

 

METHODS:

 

Ninety-seven outpatients who received an initial diagnosis of dysthymic disorder, who responded to >or=8 weeks treatment with paroxetine (n = 52) or fluoxetine (n = 45), and who discontinued the SSRI according to their psychiatrist's instructions were included. They were assessed at the time of discontinuation using a semi-structured interview for clinical and treatment characteristics, the Hamilton Depression Rating Scale (HAM-D) and the Montgomery-Asberg Depression Rating Scale (MADRS). Patients were then assessed 4 weeks later using a checklist for discontinuation symptoms, a semi-structured interview for discontinuation symptom characteristics, and the HAM-D and the MADRS.

 

RESULTS:

 

A discontinuation syndrome was found in 26 patients (26.8% of our sample); of this group, 22 patients (84.6%) had received paroxetine, and 4 patients (15.4%) had received fluoxetine. The mean time at onset of symptoms was 2 days after drug discontinuation and the mean duration was 5 days. The statistical comparison between the groups with and without a discontinuation syndrome found two significant differences - a discontinuation syndrome was more common in patients treated with paroxetine and in patients with an earlier onset of dysthymic disorder. Multiple regression analysis confirmed that these two factors were related to the duration of discontinuation symptoms, while the number of symptoms was associated with three factors, including use of paroxetine, age at onset of dysthmia and female gender.

 

CONCLUSIONS:

 

A discontinuation syndrome is common after treatment with SSRIs is stopped in patients with dysthymia, and it appears to be more common in patients receiving paroxetine than in those receiving fluoxetine. The syndrome is related both to drug and clinical characteristics. The features of the syndrome in patients with different Axis I diagnoses should be compared in further investigations.

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Altostrata

Abstract at http://www.ncbi.nlm.nih.gov/pubmed/12177584

 

Int Clin Psychopharmacol. 2002 Sep;17(5):217-25.

 

Discontinuation symptoms: comparison of brief interruption in fluoxetine and paroxetine treatment.

 

Judge R, Parry MG, Quail D, Jacobson JG.

 

Source Lilly Research Laboratories, Eli Lilly and Company, Lilly Corporate Centre, Indianapolis, Indiana 46285, USA.

 

Abstract

 

Abrupt interruption or cessation of selective serotonin reuptake inhibitor (SSRI) treatment may result in discontinuation or treatment interruption symptoms. Recent reports suggested these symptoms occur more frequently with shorter half-life SSRIs. Previous studies indicated a 5-8-day treatment interruption resulted in fewer discontinuation-emergent adverse events in fluoxetine-treated patients than in paroxetine-treated patients. This study examines the effects of shorter treatment interruption (3-5 days), as would occur if patients miss just a few doses of medication. Patients successfully treated for depression with fluoxetine or paroxetine underwent treatment interruption in a double-blind fashion. Treatment interruption-emergent symptoms were assessed using the Discontinuation-Emergent Signs and Symptoms checklist. Other assessments included the Montgomery-Asberg Depression Rating Scale, Clinical Global Impressions-Severity scale and a social functioning questionnaire. Of 150 patients enrolled, 141 completed the study. Following treatment interruption, fluoxetine-treated patients experienced fewer treatment interruption-emergent events than did paroxetine-treated patients. The paroxetine treatment group also experienced significant increases in depressive symptoms, clinical global severity scores and difficulty in social functioning; the fluoxetine treatment group did not. These results are consistent with reports suggesting abrupt interruption of treatment with paroxetine is more often associated with somatic and psychological symptoms than is abrupt interruption of fluoxetine. Patients treated with fluoxetine appeared to be protected by its longer half-life.

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Altostrata

Abstract at http://www.ncbi.nlm.nih.gov/pubmed/9646889

 

Biol Psychiatry. 1998 Jul 15;44(2):77-87.

Selective serotonin reuptake inhibitor discontinuation syndrome: a randomized clinical trial.

 

Rosenbaum JF, Fava M, Hoog SL, Ascroft RC, Krebs WB.

 

Source Clinical Psychopharmacology Unit, Massachusetts General Hospital, Boston 02114, USA.

 

Abstract

 

BACKGROUND:

 

Recent reports describe discontinuation-emergent adverse events upon cessation of selective serotonin reuptake inhibitors including dizziness, insomnia, nervousness, nausea, and agitation. We hypothesized that interruption of fluoxetine treatment would be associated with fewer discontinuation-emergent adverse events than interruption of sertraline or paroxetine treatment, based on fluoxetine's longer half-life.

 

METHODS:

 

In this 4-week study, 242 patients with remitted depression receiving maintenance therapy with open-label fluoxetine, sertraline, or paroxetine for 4-24 months had their maintenance therapy interrupted with double-blind placebo substitution for 5-8 days. The Symptom Questionnaire (SQ), the Discontinuation-Emergent Signs and Symptoms checklist, the 28-item Hamilton Depression Rating Scale, and the Montgomery-Asberg Depression Rating Scale were used to assess somatic distress and stability of antidepressant response.

 

RESULTS:

 

Two hundred twenty patients (91%) completed the study. Following interruption of therapy, fluoxetine-treated patients experienced fewer discontinuation-emergent events than either sertraline-treated or paroxetine-treated patients (p < .001). The mean SQ somatic symptom scale score in fluoxetine-treated patients was significantly lower than that in sertraline-treated and paroxetine-treated patients (p < .001). Fluoxetine-treated patients also experienced less reemergence of depressive symptoms than sertraline-treated or paroxetine-treated patients (p < .001).

 

CONCLUSIONS:

 

Abrupt interruption of antidepressant therapy for 5-8 days was associated with the emergence of new somatic and psychological symptoms in patients treated with paroxetine and to a lesser degree sertraline, with few symptoms seen with fluoxetine.

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Altostrata

See below for full text.

 

Abstract at http://www.ncbi.nlm.nih.gov/pubmed/12926179

 

Postgrad Med. 2003 Aug;114(2):79-84.

 

SSRI discontinuation syndrome. Awareness as an approach to prevention.

 

Ditto KE.

 

Source Massachusetts Mental Health Center, 74 Fenwood Rd, Boston, MA 02115, USA. kditto@earthlink.net

 

Abstract

 

Although SSRIs are widely used and generally considered safe, an abrupt cessation of SSRI use may result in a discontinuation syndrome that can mimic serious illness and can be distressing and uncomfortable. Several pharmacokinetic and pharmacodynamic factors influence the frequency and onset of these symptoms. Rapid identification of SSRI discontinuation syndrome and reinstitution of the medication can provide rapid symptom relief. Ongoing education and discussion about the illness and its treatment can promote medication compliance and thus minimize the potential for sudden cessation of the SSRI, the uncomfortable experience of discontinuation symptoms, and unnecessary medical expenditures.

 

----------

Full text from http://psychrights.org/articles/SSRIDiscontinuationSyndrome.htm

 

SSRI discontinuation syndrome

Awareness as an approach to prevention

 

Kara E. Ditto, MD, MPH

 

VOL 114 / NO 2 / AUGUST 2003 / POSTGRADUATE MEDICINE

 

CME learning objectives

 

* To be able to recognize the symptoms that can occur with abrupt discontinuation of selective serotonin reuptake inhibitor (SSRI) therapy

* To appreciate the pharmacokinetic factors that can influence the onset and duration of SSRI discontinuation symptoms

* To learn effective preventive strategies and treatments for SSRI discontinuation syndrome

 

The author discloses no financial interests in this article and no unlabeled uses of any product mentioned.

 

Preview: In recent months, as the United States has struggled with the effects of terrorism, economic stress, and job layoffs, prescriptions of antidepressants have been on the rise. Even before this increase, compliance in the use of antidepressants, including the selective serotonin reuptake inhibitors (SSRIs), was compromised. Discontinuation syndrome, a cluster of symptoms caused by sudden cessation of SSRI use, is experienced by up to 25% of patients who abruptly quit taking these agents. Here, Dr Ditto discusses the incidence, onset, duration, and severity of these symptoms and offers ways to prevent unnecessary medical workups yet facilitate early recognition of discontinuation syndrome. Ditto KE. SSRI discontinuation syndrome: awareness as an approach to prevention. Postgrad Med 2003;114(2):79-84

 


A 57-year-old man from Boston travels to Barcelona with his wife. He has a history of depression, hypertension, and type 2 diabetes and takes paroxetine hydrochloride, metoprolol, and metformin hydrochloride. With a 2-week supply of his medications on hand, he arrives in Barcelona and enjoys his usual state of health during the trip. His return flight to Boston is delayed 14 hours, and he and his wife stay in a hotel overnight. During the flight the next morning, he experiences headaches, anxiety, restlessness, and numbness and tingling in his hands and face. The symptoms persist when he arrives at an emergency department in Boston, where his evaluation results are unremarkable.

 

Symptoms of SSRI discontinuation syndrome are generally mild and short-lived. However, as this hypothetical case illustrates, the phenomenon may be mistaken for physical illness (eg, myocardial infarction, pulmonary emboli, transient ischemic attack) or relapse into depression and may prompt some patients to seek costly emergency department visits and unnecessary medical workups. Once the syndrome has been identified, healthcare providers can reassure most patients that their symptoms will abate when the antidepressant is restarted.

Use of SSRIs

 

SSRIs are considered the medications of choice for a wide range of psychiatric disorders, including depression, anxiety, posttraumatic stress disorder, bulimia, premenstrual dysphoric disorder, obsessive-compulsive disorder, dysthymia, and other problems such as irritable bowel syndrome. These agents include fluoxetine hydrochloride (Prozac, Sarafem), paroxetine hydrochloride (Paxil), fluvoxamine maleate (Luvox), sertraline hydro-chloride (Zoloft), and citalopram hydrobromide (Celexa).

 

A major reason for such widespread use of SSRIs is their safety and tolerability relative to the agents previously used, such as tricyclic antidepressants (TCAs), which are known for their anticholinergic side effects and lethal-ity in overdose (as a result of hypotension, cardiac arrhythmia, or seizure). However, one often overlooked problem with SSRIs is discontinuation syndrome, a constellation of symptoms that can occur as a result of intermittent noncompliance, abrupt cessation of treatment and, less often, tapering of the SSRI dose.

 

Definition

 

Malcolm Lader (1) suggested that a discontinuation syndrome should be "a well-defined syndrome with predictable onset, duration, and offset of action containing psychological and bodily symptoms not previously complained of by the patients. It can be suppressed by the reinstitution of discontinued medication." Several researchers have proposed criteria for an SSRI discontinuation syndrome (2,3). Despite the lack of a definition based on consensus criteria for the syndrome, patients who have disequilibrium, flulike symptoms, and sleep or sensory disturbances within 24 to 72 hours after discontinuing SSRI use are likely to be experiencing a discontinuation reaction. This is especially true if the symptoms cannot be ascribed to other causes and are alleviated by reintroduction of the medication.

 

Although the symptoms of discontinuation syndrome are not dangerous, they can be uncomfortable and distressing to patients. They include psychiatric, gastrointestinal, neurologic, motor, and somatic manifestations (table 1) (2-5). Dizziness is the most commonly reported symptom and may also be described as lightheadedness, faintness, vertigo, ataxia, or a "spaced out" sensation that markedly worsens with movement (3,6).


Table 1. Symptoms of SSRI discontinuation syndrome

Psychiatric

Anxiety

Crying spells

Insomnia

Irritability

Mood lability

Vivid dreams

 

Gastrointestinal

Nausea

Vomiting

 

Neurologic

Dizziness

Headache

Paresthesia

 

Motor

Dystonia

Tremor

 

Somatic

Chills

Fatigue

Lethargy

Myalgias

Rhinorrhea

 

SSRI, selective serotonin reuptake inhibitor.

 

Information from Schatzberg et al (2), Black et al (3), Haddad (4), and Richelson (5).


Discontinuation symptoms usually begin within 1 to 3 days after abrupt cessation of SSRI use and can be relieved within 24 hours by restarting anti-depressant therapy. Untreated, however, these symptoms can last from 1 to 3 weeks (2). Although most discontinuation reactions are mild and short-lived, the symptoms can be mistaken for physical illness or relapse into the treated illness, thereby promoting unnecessary long-term treatment (7). Symptoms caused by an abrupt discontinuation of SSRI therapy during hospitalization may confound the ongoing assessment of mental status changes or physical findings of a comorbid acute illness (eg, meningitis, stroke, myocardial infarction) (8) and may result in unneeded and costly diagnostic evaluations.

 

Incidence and frequency

 

Given the diverse manifestations of SSRI discontinuation syndrome and the confounding comorbidities of many patients who receive these agents, the establishment of incidence, risk, and predisposing factors has been a challenge. The incidence reported can vary widely. There are no significant associations with age, sex, or diagnostic grouping (6). Since most discontinuation reactions are self-limiting and usually go unrecognized and unreported by both patient and physician, the reported reactions are likely to be marked underestimations of the true incidence.

 

The likelihood of discontinuation syndrome is associated with the duration of SSRI treatment; reactions rarely occur in patients who receive treatment for less than 6 to 8 weeks (3,4,6). Although discontinuation symptoms can develop during a slow taper of an antidepressant medication, they occur more often when a patient abruptly stops or misses several doses of the medication (2,6).

 

The variation in frequency of discontinuation reactions among the SSRIs can be partly explained by various pharmacokinetic factors, such as the half-life of the parent drug, the presence of active metabolites, and autoinhibition (4,5,9,10), which results in a nonlinear elimination curve (especially with paroxetine and fluoxetine). Among the SSRIs, the potency of inhibition of serotonin reuptake and the affinity for muscarinic blockade (both greatest for paroxetine) are pharmacodynamic factors that may influence the variation and severity of discontinuation reactions (table 2) (4,5).

 

Discontinuation symptoms are more likely to occur in patients who take an SSRI with a shorter half-life than in patients taking an SSRI with a longer half-life and long-acting metabolites. The SSRIs implicated most often are paroxetine and fluvoxamine, which have a short half-life and no active metabolites. The rates of symptom occurrence reported for paroxetine are comparable with those reported for TCAs and monoamine oxidase inhibitors (MAOIs) (4).

 

Discontinuation symptoms have been reported less often for sertraline (6), which has a long half-life (2 to 4 days) and a minimally active metabolite, desmethylsertraline (11). The symptoms may occur less often with fluoxetine because of its long half-life (2 to 3 days) and the long elimination half-life (7 to 9 days) of its active metabolite, norfluoxetine (11). Discontinuation of fluoxetine is also associated with a late and more gradual onset of symptoms of milder severity, sometimes occurring more than 1 week after use of the drug has been stopped (9).

 

Several anecdotal reports of symptoms that followed citalopram discontinuation have also been recorded (4,12). The elimination half-life of citalopram is 30 to 35 hours; citalopram's metabolites are present in much smaller concentrations, are much less potent, and do not enter the brain as readily as the metabolites of other SSRIs, and they do not appear to play a significant role in its clinical action (12).

Other antidepressants

 

Discontinuation syndromes have also been reported among related classes of antidepressants. These agents include the cyclic antidepressants trazodone hydrochloride (Desyrel) and nefazodone hydrochloride (Serzone) as well as the serotonin-norepinephrine reuptake inhibitors venlafaxine hydrochloride (Effexor) and mirtazapine (Remeron) (2). Earlier onset of discontinuation symptoms--sometimes within 24 hours of a missed dose--may be associated more with venlafaxine than with paroxetine or fluoxetine. Anecdotal reports of discontinuation symptoms exist for nefazodone (its metabolites have a half-life of 2 to 18 hours) and for mirtazapine. Discontinuation of therapy with TCAs and MAOIs also can precipitate a similar profile of symptoms.

 

Differential diagnosis

 

At a time when US hospitals are cutting staff, overworked residents in outpatient clinics and in emergency departments may miss this very treatable syndrome. As a result, costly tests may be ordered that medical facilities can ill afford. When the diagnosis is missed in inpatient units, hospital stays become longer and more expensive.

 

Diagnosis of SSRI discontinuation syndrome is complicated by the fact that symptoms can mimic upper respiratory infection, benign paroxysmal positional vertigo, radiculopathy, or the effects of certain medications. Presentation of discontinuation phenomena also may be confounded or exacerbated by the presence of substance abuse, dehydration, or concurrent physical illness.

 

Careful history taking can help physicians discriminate between discontinuation symptoms and other medical concerns, a relapse of depressive symptoms, the emergence of psychosis, and rebound phenomena. A detailed description of symptoms and a review of organ systems can elucidate possible medical causes. Because patients are not always forthcoming about medication noncompliance, the evaluator should ask specifically about any changes in the medications that a patient has been taking. The patient should be asked whether refills have been appropriately obtained, doses have been missed, pills have been split to make them last longer, and side effects (eg, sexual dysfunction) have affected the patient's compliance with antidepressant use. Potential drug interactions should also be noted.

 

A report of the patient's use of alcohol and illicit substances should be elicited. These substances may influence the presentation of discontinuation phenomena, and certain potentially dangerous substance withdrawal syndromes require different management. For example, alcohol abuse, distinguished by its dysautonomia (ie, tachycardia, diaphoresis, and elevated blood pressure), requires detoxification.

 

Distinguishing discontinuation reactions from a return of psychiatric symptoms is essential. Discontinuation symptoms have a typical onset of 1 to 3 days after use of the antidepressant is stopped. By comparison, rebound phenomenon (a return of some of the symptoms of depression) or a full depressive relapse usually takes 2 to 3 weeks to become evident and does not remit within 24 hours of restarting the antidepressant.

 

Because discontinuation phenomena arise acutely and can mimic certain emergent medical events (eg, myocardial infarction, stroke, pulmonary embolism), further evaluation, such as an electrocardiogram and basic serum chemistry testing, may occasionally be necessary to rule out medical illness. With a high index of suspicion for antidepressant discontinuation symptoms and a presentation consistent with these phenomena, the evaluation and appropriate reinitiation of an antidepressant can be undertaken with minimal need for further medical workup or extended hospitalization.

 

Management

 

A patient who has SSRI discontinuation syndrome can be reassured that the symptoms are likely to be mild and short-lived. If symptoms are acute, relief is usually achieved within 24 hours by restarting the SSRI at the same dose the patient was taking when the medication was discontinued. A slow taper can then be instituted over several weeks. If the patient continues to have difficulty, even with a slow taper, cross-tapering with an agent that has an extended half-life may prevent discontinuation symptoms during the taper (8).

 

Prevention

 

Because adherence to the medication regimen is necessary to minimize the occurrence of discontinuation phenomena, education about the natural course of the illness for which the SSRI has been prescribed and about medication compliance is crucial. This education begins with establishment of rapport and negotiation of physician-patient differences in beliefs and expectations about the illness and its treatment.

 

Treatment options that may supplement medication and enhance compliance (eg, psychotherapy, support groups) should be discussed with the patient, thus minimizing the likelihood of frustration and premature discontinuation. Prior antidepressant trials, the cost and side effects of medication, the complexity of preexisting medical regimens, and the chronicity of the illness are integral to a discussion about the patient's expectations and willingness to continue treatment as prescribed.

 

In particular, physicians should explain that a full response to medication might take up to 6 weeks. Patients should be advised to continue taking their medication--even after they begin to feel better--to maximize their ability to achieve a full response, avoid reemergence of symptoms or a full relapse, and avoid discontinuation symptoms that can occur when doses are missed or the antidepressant is stopped abruptly.

 

Patients also should be informed that before they stop taking an antidepressant, they should contact their physician, who can guide a slow taper of the antidepressant dose. On follow-up visits, an evaluation of symptom relief, side effects, missed doses, and substance use should be done, as well as an assessment of changes in job performance and in family and social relationships.

 

Patients often wonder how long they will need to take an antidepressant. Physicians should explain that antidepressant therapy needs to continue for 6 to 12 months to minimize the chance of relapse. They also should explain that maintenance treatment for 1 year to several years may be appropriate for a patient who has had multiple episodes of depression, a severe recurrent course of depression, or an early onset of depression (ie, before age 20 years), or has a first-degree relative with recurrent major depression or bipolar disorder (4).

 

Ongoing education and discussion about a patient's experiences of the illness and its treatment help to reinforce both the treatment alliance and medication compliance. In addition, the patient will be less likely to suddenly stop taking the medication and experience discontinuation symptoms.

 

Summary

 

Although SSRIs are widely used and generally considered safe, an abrupt cessation of SSRI use may result in a discontinuation syndrome that can mimic serious illness and can be distressing and uncomfortable. Several pharmacokinetic and pharmacodynamic factors influence the frequency and onset of these symptoms. Rapid identification of SSRI discontinuation syndrome and reinstitution of the medication can provide rapid symptom relief. Ongoing education and discussion about the illness and its treatment can promote medication compliance and thus minimize the potential for sudden cessation of the SSRI, the uncomfortable experience of discontinuation symptoms, and unnecessary medical expenditures.

 

References

 

Lader M. Benzodiazepine withdrawal states. In: Trimble MR, ed. Benzodiazepines divided. New York: John Wiley & Sons, 1983:17-31

Schatzberg AF, Haddad P, Kaplan EM, et al. Serotonin reuptake inhibitor discontinuation syndrome: a hypothetical definition. Discontinuation Consensus Panel. J Clin Psychiatry 1997;58(Suppl 7):5-10

Black K, Shea C, Dursun S, et al. Selective serotonin reuptake inhibitor discontinuation syndrome: proposed diagnostic criteria. J Psychiatry Neurosci 2000;25(3):255-61

Haddad P. Newer antidepressants and the discontinuation syndrome. J Clin Psychiatry 1997;58(Suppl 7):17-22

Richelson E. Pharmacology of antidepressants. Mayo Clin Proc 2001;76(5):511-27

Coupland NJ, Bell CJ, Potokar JP. Serotonin reuptake inhibitor withdrawal. J Clin Psychopharmacol 1996;16(5):356-62

Kaplan EM. Antidepressant noncompliance as a factor in the discontinuation syndrome. J Clin Psychiatry 1997;58(Suppl 7):31-6

Rosenbaum JF, Zajecka J. Clinical management of antidepressant discontinuation. J Clin Psychiatry 1997;58(Suppl 7):37-40

Lejoyeux M, Ades J. Antidepressant discontinuation: a review of the literature. J Clin Psychiatry 1997;58(Suppl 7):11-6

Schatzberg AF, Haddad P, Kaplan EM, et al. Possible biological mechanisms of the serotonin reuptake inhibitor discontinuation syndrome. Discontinuation Consensus Panel. J Clin Psychiatry 1997;58(Suppl 7):23-7

Lazowick AL, Levin GM. Potential withdrawal syndrome associated with SSRI discontinuation. Ann Pharmacother 1995;29(12):1284-5

Bezchlibnyk-Butler K, Aleksic I, Kennedy SH. Citalopram--a review of pharmacological and clinical effects. J Psychiatry Neurosci 2000;25(3):241-54

 

The author acknowledges Michael Hirsch, MD, one of her psychopharmacology mentors, for editorial assistance.

 

Dr Ditto is a resident in psychiatry, Massachusetts Mental Health Center, Boston. Correspondence: Kara E. Ditto, MD, MPH, Massachusetts Mental Health Center, 74 Fenwood Rd, Boston, MA 02115. E-mail: kditto@earthlink.net.

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Claudius

A patient who has SSRI discontinuation syndrome can be reassured that the symptoms are likely to be mild and short-lived. If symptoms are acute, relief is usually achieved within 24 hours by restarting the SSRI at the same dose the patient was taking when the medication was discontinued. A slow taper can then be instituted over several weeks

 

This looks too close to the infamous GSK mantra that the "discontiuation syndrome" is mild and over within 3 weeks. I wonder whether this is really the biggest lie in the world or it is true for a majority of the long-term users.

Also the incubation time of WD is a mystery to me. After all my attempts, I was compeltely symptom free for 6 weeks and then hit by the hammer of debiliating WD symptoms. It was , among others, this very long incubation time that baffled me completely and made the docs firmly deny that it could be withdrawal. And it still baffles me in fact.

The only explantion I could think of that the half-life was for me much longer than avarage. But this assumption is viol;ated by the fact that I tries a alternating taper of 5-10-5 mg one time and got just as sick as after a CT. And even earlier than after 6 weeks.

This completely illogical pattern has brought me on the verge of suicide due to the 2 years of failed WD attempts and subsequent protracted WD which is not over yet after more than 3.5 years... so in total now it ruled almost 6 years of my life in a scaring and horrific way...:(

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Altostrata

....This looks too close to the infamous GSK mantra that the "discontiuation syndrome" is mild and over within 3 weeks. I wonder whether this is really the biggest lie in the world or it is true for a majority of the long-term users.

 

Also the incubation time of WD is a mystery to me. After all my attempts, I was compeltely symptom free for 6 weeks and then hit by the hammer of debiliating WD symptoms....

 

These papers represent mainstream thinking in the psychiatry industry. It may be true for a majority, but we believe it ignores a substantial minority. Prolonged withdrawal affecting even 1 in 100 would be considered medically significant.

 

One of the things we're trying to do with this site is to document prolonged withdrawal and bring it to the attention of medicine so the frequency can more properly be determined and use of the drugs restricted for public safety.

 

I initially had a 6-week period of feeling "great." I know now this was hypomania, a recognized symptom of withdrawal. After 6 weeks, I got very severe withdrawal symptoms. Claudius, it is possible you were experiencing very low-level hypomania at first, that wore off and the fun began.

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Irene33

Hi you all,

 

I have been chatting with psychiatrists from the American Psychiatric Organization and they all say the same: the symptoms should decrease an dissolve around 3 weeks or otherwise it is relapse.

 

I am just curious, do you experience neurological symptoms beside psychiatric symptomps up to this day?

 

 

Warm regards,

 

Irene

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Barbarannamated

Irene,

I was put on a succession of SS/NRIs for "anergic depression" (not mood) that was undiagnosed autoimmune endocrine failure. The serotonin, in particular, exacerbated the endocrine failure as it progressed. My energy, pain and mood worsened over the years as psychiatry stopped looking for physiological problems. Im now in palliative care (as I guess we all are, in truth) with neuroendocrine damage, liver disease ++. I'm 1 year post Pristiq.

 

There have been no studies on patients on ADs longer than several months or discontinued longer than a few weeks, so psychiatry has no idea. Also, any studies done have been with patients on 1 drug only, not a cocktail or progression of polydrugging over many years.

 

The damage is far more than neurological. SS/NRI use is associated with WORSENED DEPRESSION and increased risk of Parkinsons, diabetes, osteoporosis, stroke, etc. There are many scientific journal articles here on the forum. Many of these risks are coming out in the literature in recent years.

 

I worked closely with many psychiatrists from the APA in my career. They really don't know the long term effects of these drugs as they are thought to be needed "for life". No long term studies with adequate controls have been done.

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Altostrata

Irene, psychiatrists believe withdrawal symptoms disappear within a few weeks but there is ample evidence this is not always true.

 

Even their papers say "usually" disappear within a few weeks, allowing for some cases to last longer. Such research is based on anecdotes and opinion, not systematic study.

 

The belief that withdrawal symptoms always disappear within a few weeks is untrue and unfounded in any research.

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Hope1

how can there be all this information & yet Dr's deny withdrawl is a real problem?? too much print for me to cope with all of it.

 

i remember when it happened to me over 10yrs ago. i was told i had Tardive Dystonia & it'd stop, when it didn't i was told it was "in my head". i had some really horrible experiences in hospital with staff because of this. it was only much later i was told i was a 1 in so many million cases & that it was very rare.

 

yet here i am trying to withdraw from a anti depressant drug prescribed for neuropathic pain which was cause by the first lot of anti depressant drugs & Stemitil.

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Altostrata

Doctors are poorly informed and don't want to know the real risks of psychiatric drugs. Prescribing psychiatric drugs solves problems for them, it gets the patient out of the office, and it's easier for them to prescribe the drugs if they don't know the risks.

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Hope1

true but in my case my Dr DID know. she ought to have been a lot better informed than most given the many,many things in my notes.

 

when i was 1st in hospital i was having very bad spasms,i heard a dr telling 3 of his students what they were going to see was very rare,that they might only ever see it in a text book. he brought them round the curtain to look at me. i used to ( & still do) make jokes about my body/spasms to the medical staff to cover the distress of it all. i was so embarrassed & so sad to be in such a terrible state.

 

i feel v let down.

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Marmite

I agree with you Hope. I think doctors do know. They just choose to cover it up so that they cannot be held responsible.

They also hold a blind - almost unfathomably ignorant - belief in the reliability of clinical trial data, which in most cases consists of results from the pharmaceutical companies own testing of the drugs.

 

I believe your case Hope, and I also believe that your doctors treated you appallingly and should have known better than to place you on amitryptilene.

It's criminal.

Hang in there.

x

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Lilu

Just found this legal document by Dr. Glenmullen. It really made me sit up and go "Whoa!"

 

I'm going to give it to my psychiatrist and my therapist.  Even though they are going along with my whole antidepressant withdrawal claim, I don't feel that they really take it seriously or really believe me.  Also my therapist is totally not equipped to handle what it is that I'm experiencing. Will attempt to educate them. Again. Sighhhh.....

 

http://www.baumhedlundlaw.com/pdf/DrGlenmullenDeclarationSupportofCymbaltaClassCert.pdf

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Wondering

Wow, I know it's an old post, but have to thank you for posting it! Wondering

 

 

]Just found this legal document by Dr. Glenmullen. It really made me sit up and go "Whoa!"

 

I'm going to give it to my psychiatrist and my therapist.  Even though they are going along with my whole antidepressant withdrawal claim, I don't feel that they really take it seriously or really believe me.  Also my therapist is totally not equipped to handle what it is that I'm experiencing. Will attempt to educate them. Again. Sighhhh.....

 

http://www.baumhedlundlaw.com/pdf/DrGlenmullenDeclarationSupportofCymbaltaClassCert.pdf

 

Just found this legal document by Dr. Glenmullen. It really made me sit up and go "Whoa!"

 

I'm going to give it to my psychiatrist and my therapist.  Even though they are going along with my whole antidepressant withdrawal claim, I don't feel that they really take it seriously or really believe me.  Also my therapist is totally not equipped to handle what it is that I'm experiencing. Will attempt to educate them. Again. Sighhhh.....

 

http://www.baumhedlundlaw.com/pdf/DrGlenmullenDeclarationSupportofCymbaltaClassCert.pdf

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Lilu

New Classification of Selective Serotonin Reuptake Inhibitor Withdrawal

 

http://www.karger.com/Article/Pdf/371865

 

Chouinard G.a, b · Chouinard V.-A.c

aClinical Pharmacology and Toxicology Program, Departments of Psychiatry and Medicine, McGill University, and bUniversity Mental Health Institute of Montreal, Research Center Fernand Seguin, University of Montreal, Montreal, Que., Canada; cPsychotic Disorders Division, McLean Hospital, Harvard Medical School, Belmont, Mass., USA

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westcoast

What did you think of it, Lilu? I think they should come to sites like this, though I appreciate their effort. It reminds me of an old book where the author had heard of an elephant but hadn't seen one. Still, he was the authority, so however he drew it, that was a elephant.

 

 

 

Moreover, we will focus on SSRI withdrawal, noting that SNRIs produce similar types of withdrawal

:lol: What?

 

 

 

 

"intensification of suicidal ideation"

:rolleyes:  The "pre-exisiting" dodge. Nice try! 

pojavuik7ahpxz6lvr15.jpg

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