How to Distinguish Antidepressant Withdrawal from Relapse

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In a new article in BJPsych Advances, researchers Mark Horowitz and David Taylor provide advice on how to tell the difference between antidepressant withdrawal and depression relapse. They suggest that withdrawal and relapse are often confused by patients and their clinicians. This leads to unnecessary antidepressant use, a failure to help patients discontinue the drugs, and misleading results from relapse prevention studies.

“We now recognize that withdrawal symptoms from antidepressants are common and can be severe and long-lasting in some people,” Horowitz and Taylor write. “Many withdrawal symptoms overlap with symptoms of anxiety or depression, making it difficult to distinguish withdrawal from relapse.”

So how can we tell the difference? Horowitz and Taylor suggest that there are a few ways. First, if the symptoms occur within a few days of stopping the drug or lowering the dose, they are likely to be withdrawal-related rather than relapse. Additionally, withdrawal symptoms often include physical sensations such as dizziness, nausea, and “brain zaps” (an electric shock sensation in the head). If these sensations occur alongside worsening anxiety and depression, it’s likely that those psychological experiences are also being driven by withdrawal.

Another way to tell: many people report that even the psychological symptoms of withdrawal are unique—a version of anxiety or depression that they never felt before or that feels worse than before they tried the drug. Finally, withdrawal symptoms often resolve quickly (often within a few days) when the drug is started again.

Withdrawal symptoms are common after antidepressant discontinuation, with one study reporting that 56% of people who stop using the drugs experience these symptoms. In addition, almost half of those with symptoms rated them as severe. These findings have begun to enter the official guidance for antidepressant use. For instance, in 2019, the UK’s NICE guidelines were updated to acknowledge that withdrawal symptoms can be severe and long-lasting.

According to the researchers, the best way to prevent withdrawal symptoms is to taper off antidepressants slowly. Particular care must be taken at the smallest doses, as tiny adjustments can make a big difference due to the hyperbolic curve of the drugs’ effects on the brain. Mad in America interviewed Mark Horowitz about this technique and the neurobiology involved in 2019. Tapering strips have been proposed as a way to ensure appropriate dosing during this process.

In the current article, Horowitz and Taylor also suggest that the confusion around withdrawal symptoms (versus relapse) has led to poorly designed studies of antidepressants for relapse prevention. These studies involve suddenly stopping antidepressants, which causes withdrawal symptoms, and then reinstating the antidepressants—resolving the withdrawal symptoms—and calling that evidence that the drugs prevent “relapse.”

Horowitz and Taylor write:

“In these discontinuation studies people have their antidepressants stopped abruptly or rapidly, making withdrawal symptoms very likely, and little effort is made to measure withdrawal symptoms or distinguish them from relapse. We conclude that there is currently no robust evidence for the relapse prevention properties of antidepressants, and current guidance might need to be re-evaluated.”

Horowitz and Taylor write that in the future, researchers attempting to study antidepressants for relapse prevention should ensure that they taper the drugs appropriately and carefully distinguish withdrawal from relapse.

 

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Horowitz, M. A. & Taylor, D. (2022). Distinguishing relapse from antidepressant withdrawal: clinical practice and antidepressant discontinuation studies. BJPsych Advances. DOI: 10.1192/bja.2021.62 (Link)

5 COMMENTS

  1. There ‘s no alternative to biomedical model of psyche, because psyche is not medical empiricism, to begin with. Jesus was Jesus, not a schizophrenic. Medical empiricism without the idea of the psyche is pure psychopathy. “We are empty materialists without soul – you are different than we are, we do not want to understand you and give a worth (marxism, capitalism psychopathy and so on) so we will “cure you”. There was a movie about it. “Invasion” with Nicole Kidman. Monists are antipsychological psychopats. People lost the idea of the psyche in The Enlightement era. It would be better for people to die out, than sell the soul to medical empiricism. It is a disaster. Psychiatry is a trash bin for greatness of rejected imagination. Barbarians are the rulers – they think they are smarter than mother – psyche. Ego won’t be smarter than psyche, just because it function well in empty materialism. Or maybe because of well functioning in the wrold of psychopathy.
    “26 What good will it be for someone to gain the whole world, yet forfeit their soul? Or what can anyone give in exchange for their soul?” Civilization and ego cult without soul is pointless. Clinical (cynical) empiricism is the history of death of our imagination and the scientific preludium to prolonged and propably also spectacular death of our stubborn species.
    Psychosis depression and so on are not problems to solve, these are necessities. The way of seeing. Do not try to slove this – you will lose both soul and the science. You will lose your heart and become a biological machine. And then the digital one.

  2. Honestly, I do not see how you can tell the difference between withdrawal and relapse. It would seem a very subjective thing. If someone is enlightened, they might consider that it is withdrawal. If one does not think outside most current psychiatric thinking, then it would be considered a relapse. After my experiences, taking these drugs, I would try to tell people, just like they tell people about starting the “illegal drugs.”–“Just don’t’ start them.” Perhaps, many of these diagnoses might be debated. And there is the ongoing debate as to “medicalizing the normal human condition.” In my mind, there is very little debate about using these drugs as any kind of “treatment.” In most cases, “treatment” should not harm the person more than the distress or illness that causes it. Sadness is a common human condition. Sadness can give us important information we need to know about our lives and the condition our lives at any particular time. However, these anti-depressants basically “short-circuit” any important information we need to know about ourselves. and as been pointed out in other articles on this site; the emotions are blunted. In essence, the emotions get so blunted, that one is basically “sleep-walking” through life. This is especially, so, when you add other psychiatric drugs; which usually happens; as these drugs can cause the very “psychiatric symptoms” they claim are the “disease.” Our bodies and our brain constantly give us signals we need to know. When we learn these signals; which are highly individual; we can, as they say, “live our best life” which is uniquely tailored to each person. But the drugs take all that away. So, really one should ask why consider even starting an anti-depressant. Then one does not have to worry whether it is “withdrawal” or “relapse.” However, I could almost “bet the farm” that the symptoms one experience when stopping an anti-depressant are very probably not “relapse” but most assuredly “withdrawal.” Thank you.

    • I agree with you that it is highly subjective and that there is no way to tell relapse from withdrawal. I’ll go a step further and comment that trying to separate them out by symptom observation mimics the way that the DSM describes syndromes. Also, describing whatever happens when the drugs are stopped as relapse implies that the drugs are somehow correcting/keeping away illness that returns when the drugs are stopped – really a restatement of the chemical imbalance marketing strategy. I agree that slower tapering keeps withdrawal symptoms minimal, but it doesn’t ‘prevent relapse.’ Absent a distinct pathophysiology for the so called ‘relapse’, everything that occurs after stopping the drugs is withdrawal.

  3. https://youtu.be/jDZPeUar0DU

    As a heretic I want to say that in the epoch of the Old Testament accounts many prophets were driven out of their villages for hearing the word of God because they did not possess the “right” qualifications. Their rambling bible soothsaying got them pinned as mad.

    These days they’d have been pummelled with psychiatric medication.

    To me a schizophrenic person is someone who experiences being ill from a shattered psyche, mind, brain, body, whatever the cause may turn out to be. But precisely this shattering creates an openness to influxes of impressions and discernments that may not be deranged babbling. Madness has always been at times spookily predictive. It has been shown that during creativity the person’s focus or awareness darts all over the brain to pick up disparate bits and fragments of idea and feelings in order to form something unique. That is the brain doing a different kind of rummage than a brain does when it is being orderly and calculated. There has been some new hints that one person’s brainwaves can have an effect on another person. All of this suggests to me that the dynamic creativity and messy looseness in madness grants a receptivity to being spoken to by other. I believe the mad know more about what may be about to happen than the plodding didactic and seemingly “sane” or “normal”. The village.

    But because madness is unwelcome, just as “feeling too much” is unwelcome. Nobody ever listens to the mad. And so the prophets almost have the job description of being ignored. Like rejection is a prerequisite.
    Luckily the mad are not in a hurry to prove their “visions” are “right” or “logical” and so they dry their tears and stagger off crestfallen into the desert.

    For over a decade I have been told by my angels about a huge flood that is going to engulf some parts of the globe. So for ten years, more maybe, I have been sitting on a desert boulder telling passersby about the colossal flood that is going to r
    affect some coastal regions globally. I never knew when it will come nor what places. I just know it will.

    But everyone here knows how listeners can make you believe you are fool for entertaining mad little thoughts or invisible angels. So I became more hushed in case it is all just from the schizophrenic part of my brain.

    And even though I predicted the pandemic years before it went “all real” on my televison, and the same for the war that is occurring just now on our planet, that has come “real and true” also, I hid my “flood notes”. I hid them because I only want to be healing. And so that means saying nice stuff. But then if a toddler is going to get run over you don’t just stifle your yell of care just because it might give them a jolt. Sometimes a jolt is the healing thing to say. Even as a preparation.

    It has been over a decade. Several months ago I found this fellow creative “receiver’s” video on youtube. She hears aliens but angels/aliens/heralds/deities might all be from the same cosmos birthing Source.

    Some way into this video my astonishment at what she was saying made me weep with joy that someone else whom I have never encountered before received the same vision and got the same kind of memo.

    When a global flood rumbles into town I am prepared with a plan for getting people on to higher land. I have ropes to fling to the flailing. I do not obesses about it but I just try to be wise.

    I feel something may occur to the Hoover Dam but that is not the Ocean Flood on the globe I mention. More it is just that the Hoover Dam is a sign.

    But I am happy for people to call me nutty and chase me from the desert boulder. That way I do not have to feel guilty at jolting them. My nuttiness protects them from bothering to listen to me.

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