Withdrawal symptoms are more common than we thought, here’s how to deprescribe…

Around one in seven Australians take antidepressants. The decision to start is often made in a time of crisis, with the thought they might help for a period and then be stopped. Most people don’t start antidepressants thinking they will take them for life.

Clinical guidelines recommend only six to 12 months antidepressant therapy for a single episode of moderate to severe depression.

However, about half of people taking antidepressants have been using them for longer than 12 months. People can experience unpleasant withdrawal symptoms when they attempt to stop antidepressants. Withdrawal symptoms are frequently misconstrued, by both doctors and patients, as relapse. Many of the symptoms of withdrawal are the same as symptoms of anxiety or depression. The misdiagnosis, or misinterpretation, of withdrawal contributes to ongoing and long-term use of antidepressants.

A recent Lancet systematic review found around one in six to seven people experienced withdrawal symptoms when stopping antidepressants. This is likely to be an underestimate, as most people included in the studies had been taking antidepressants for only a few months.

What did the systematic review find?

The Lancet review, which included 79 studies and 21,000 people, found 15% of antidepressant users experienced withdrawal symptoms after they stopped taking the drug. Common symptoms included dizziness, headache, nausea, insomnia and irritability.

Withdrawal symptoms are more common in people who have been taking antidepressants for a long time. But the Lancet study mainly included people taking antidepressants for only a short time – mostly for around three to six months but sometimes for as little as one week.

So the finding that one in six people who stop taking antidepressants experience withdrawal symptoms is likely an underestimate; this figure applies only to a small subset of people who have taken antidepressants short term.

The Lancet review also found around 3% of people experienced severe withdrawal symptoms, including thoughts of suicide. Again this is likely to be an underestimate, as it didn’t include longer-term users who are more likely to experience withdrawal symptoms and experience more severe withdrawal symptoms.

Recognising withdrawal symptoms

Some people continue taking antidepressants long-term in the belief that they are treating or preventing anxiety or depressive symptoms, but they may only be treating or preventing withdrawal symptoms.

Yet long-term use (longer than 12 months) of antidepressants is not harmless. Taking antidepressants for longer than 12 months can cause:

• emotional numbing
• sexual dysfunction, which may be long-lasting, including low libido and difficulty achieving orgasm in both men and women
• weight gain
• lethargy or fatigue
• increased risk of falls among older people.

Low awareness and recognition of withdrawal symptoms has resulted in both doctors and patients misinterpreting withdrawal symptoms as a “relapse” of anxiety or depression and ongoing need for medication.

The confusion is easy to understand as some symptoms of withdrawal, such as nervousness, irritability, insomnia, fatigue and agitation, can also be symptoms of anxiety and/or depression.

Distinguishing withdrawal from relapse

It is possible to distinguish withdrawal from relapse. In addition to feeling anxious and irritable, people experiencing antidepressant withdrawal may also experience symptoms such as:

• dizziness, vertigo or light-headedness
• electric shock sensations (‘brain zaps’)
• imbalance
• increased sensitivity to light or noise
• tinnitus
• nausea, diarrhoea or upset stomach
• muscle spasms or cramps
• vivid dreams or nightmares
• tremors
• confusion
• sweating

Further, withdrawal symptoms tend to start within hours, days or sometimes weeks of stopping or decreasing antidepressant dose and can last weeks or longer, whereas any relapse of anxiety or depression usually takes longer before recurring and may be associated with life events.

Minimising withdrawal symptoms to enable people to safely stop

Until recently, information on how to minimise withdrawal symptoms to enable people to safely stop antidepressants has been limited. Previous advice was often to halve the dose, halve again and then stop; or to take antidepressants on alternate days; or to switch to a different antidepressant. But while well-intended, these methods have likely resulted in withdrawal symptoms.

A better approach is a slow and hyperbolic decrease of antidepressant dose which can minimise withdrawal symptoms by generating steady decrease in brain receptor occupancy and giving the brain time to adjust to being without antidepressants.

Brain imaging techniques support a slow tapering of antidepressant drug dose to give a steady change in the brain to minimise withdrawal symptoms.

At lower, go slower: “Hyperbolic tapering” uses increasingly smaller decreases in drug doses. For example, a tapering schedule of 50mg, 25mg, 15mg, 10mg, 6mg, 4mg, 2mg, 1mg, then 0mg (stop).

Updated clinical guidelines now recommend this approach of slow hyperbolic tapering of antidepressant dose to safely stop antidepressants.

At the University of Queensland, we are conducting a randomised controlled trial in 28 general practices testing the effectiveness of antidepressant drug specific hyperbolic tapering schedules developed to support people to safely stop antidepressants.

The antidepressant mini-doses required for tapering are not readily available in Australia. But people can access antidepressant mini doses via a compounding chemist (or for some antidepressants, by crushing a tablet and mixing with water or diluting a liquid formulation.

Doctors can approach me to request printable copy of the antidepressant tapering protocols to use in their practice.
k.wallis@uq.edu.au

This article was adapted by the author for a general practitioner audience. Read the original Conversation article here: Many people get withdrawal symptoms when they try to stop antidepressants. So how can you safely stop?