Gradually discontinuation of taking antidepressants is sometimes necessary, for example, when paradoxical effects occur. Doctors need to understand the right time and how to stop it to avoid unnecessary drug administration and drug withdrawal syndrome.

For some patients, long-term use of antidepressants is necessary. However, for some others, antidepressants are only given within a specific time, especially if there are conditions when it needs to be considered to be discontinued.

Doctors must understand how to stop antidepressants properly to prevent the occurrence of drug withdrawal syndrome. This way applies not only to psychiatrists but also to general practitioners.

When and How to Stop Antidepressants

When to Stop Antidepressants

Antidepressants for some patients only need to be given within a specified period. Considerations for stopping these antidepressants are medical considerations, pregnancy, and breastfeeding, paradoxical effects, low or reduced effectiveness of antidepressants, improvement of clinical conditions, or patient requests.

Improvement of clinical condition or clinical condition is not improved.
Improvement of clinical conditions is a major consideration for stopping antidepressants. Studies show that depressed patients who show clinical improvement can be given psychotherapy and reduce the dose of antidepressant slowly until it stops. In mood disorders or overall anxiety disorders, antidepressants can also be stopped gradually and replaced with behavioral therapy.

Otherwise, certain types of antidepressants may not be effective from the start or lose their effectiveness after a certain period. Thus, clinical conditions that do not improve can also be an indication of antidepressant discontinuation. 

Side Effects of Antidepressants
Long-term treatment of the latest generation of antidepressants can cause some significant side effects (gastrointestinal disorders, weight gain, cardiovascular problems, bleeding). So that antidepressants can be stopped, and close monitoring of side effects must occur. The following types of antidepressants and side effects are common:

a. Selective serotonin reuptake inhibitors / SSRIs (e.g., fluoxetine and sertraline) and serotonin-norepinephrine reuptake inhibitors / SNRIs (e.g., duloxetine and venlafaxine): gastrointestinal symptoms, bleeding risk and hypertension (specifical venlafaxine)
b. Monoamine oxidase inhibitors / MAOI (e.g., phenelzine and tranylcypromine): orthostatic hypotension, agitation
c. Tetracyclic antidepressants 
(mirtazapine and maprotiline): closed-angle glaucoma
(amitriptyline, amoxapine, and imipramine): cardiovascular problems (prolongation of QT intervals on ECG), hypotension.

Pregnancy and Breastfeeding
Many studies state the terrible effects of antidepressants on pregnant and lactating women. In pregnant women, consuming antidepressants is associated with the risk of impaired fetal development or premature birth, as well as neonatal abstinence syndrome. In nursing mothers, antidepressants are excreted through breast milk, which can cause the baby to experience irritable symptoms or sedation.

Nevertheless, the decision to stop antidepressants must consider the benefits and risks, especially the risk of postpartum depression. As a substitute for pharmacotherapy, increasing the frequency of psychotherapy and involve social support from the patient's family members is recommended. However, if it is very necessary (the idea of ​​suicide, a decrease in willpower which dramatically disrupts the quality of life), antidepressants of the SSRI group can be considered the safest.

Paradoxical effect
When the mood changes drastically to hypomania or mania, apathy, or the appearance of suicidal thoughts, antidepressants can be considered discontinued. In a case study, Fux et al. observed the appearance of depressive symptoms in 7 of 80 patients (9%) during the treatment of panic disorder with fluvoxamine. These patients had no history of mood disorders and showed no symptoms of depression before treatment with fluvoxamine. Depressive symptoms subside when fluvoxamine is stopped and replaced with tricyclic antidepressants or clonazepam. However, Depressive symptoms reappear when fluoxetine is given again.

Patient Request
It is very important, especially in the deliberative doctor-patient relationship model, that is, if the action given is a joint decision. If a patient wants to discontinue consuming antidepressants and the reason makes sense, it would be better if the doctor is monitoring and regulating the process, rather than letting the patient do it himself.

The Drug Withdrawal Symptoms.

About 20% of patients experience symptoms of dropping out of antidepressant medication after sudden discontinuation of antidepressants that are taken continuously for one month. Symptoms are usually mild and can occur in all types of antidepressants.

Doctors perform psychoeducation on patients about the effects that can occur when antidepressants are stopped suddenly or without a doctor's supervision to prevent the risk of withdrawal symptoms or relapse from depression.

Drug withdrawal symptoms occur within two to four days after drug withdrawal and usually the last one to two weeks (sometimes it can last up to one year). If the same or a similar type of drug is restarted, the symptoms will disappear within one to three days. Sociodemographic and clinical factors associated with increased susceptibility have not been identified.

Among SSRI types, paroxetine is associated with the highest incidence of withdrawal symptoms, whereas fluoxetine has the lowest incidence. For venlafaxine, the risk of drug withdrawal symptoms is higher, and symptoms can be more severe because it has a short half-life.

FINISH symptoms

Failure to recognize withdrawal symptoms from antidepressant drugs can cause medical or psychiatric misdiagnosis. The following symptoms of dropout syndrome antidepressant abbreviated as FINISH:

  • Flu-like symptoms: lethargy, fatigue, headache, aches, sweating
  • Insomnia: accompanied by a lucid dream or nightmare
  • Nausea: sometimes until vomiting
  • Imbalance: dizziness, vertigo, head feeling like floating
  • Sensory Disturbances: a feeling like burning, tingling, a sensation like being electrocuted
  • Hyperarousal: anxiety, irritability, aggressiveness, mania.

How to Stop Antidepressants

In general, decreasing the dose of antidepressant drugs that have a short half-life requires a longer time compared to drugs that have a longer half-life. The recommendation is to reduce the dosage by 25% every month or 12.5% every two weeks in four months.

  • Phenelzine or tranylcypromine: Gradually reduce the dosage for at least 4 weeks; reduce 15 mg for phenelzine or 10 mg for tranylcypromine every 2 weeks, or reduce 10% every week.
  • Duloxetine: Gradually reduce the dosage for at least 1-2 weeks; It is recommended to be reduced by 50% in the first week and then 50% in the second week.
  • Venlafaxine: Gradually reduce the dosage for at least 4 weeks; by reducing 75 mg every 4 days and reducing 25 mg every 5 to 7 days until the final dose 25-50 mg; for extended-release products, the recommended setting is 37.5-75 mg per week until the final dose is 37.5 mg before stopping
  • Citalopram: Gradually reduce the dosage for at least 4 weeks
  • Escitalopram: Gradually reduce the dosage for at least 1-2 weeks
  • Fluoxetine: Due to the long half-life, dosage adjustments are usually not necessary; Gradually reduce the dosage for at least 2 weeks if the dose is mg 40 mg/day
  • Fluvoxamine: Gradually reduce the dosage for at least 1-2 weeks; 50 mg every 5-7 days until the final dose of 25-50 mg
  • Paroxetine: Gradually reduce the dosage for at least 4 weeks; 5-10 mg/week until the final dose is 5-20 mg
  • Sertraline: Gradually reduce the dosage for at least 4 weeks; 50 mg every 5-7 days until the final dose of 25-50 mg
  • Tricyclic antidepressant classes: Gradually reduce the dosage for at least 4 weeks
  • Bupropion: Gradually reduce the dosage for 1 week, although withdrawal symptoms are rare
  • Mirtazapine: Gradually reduce the dosage for at least 4 weeks, although withdrawal symptoms are rare

Source: Alomedika
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Writer: Dr. Damba Bestari

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