Gradual Tapering Recommended for Antidepressant Discontinuation

A new literature review reinforces the need to “down-titrate” or taper antidepressants, especially drugs like Celexa and Paxil.

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Antidepressant discontinuation syndrome (ADS) is best avoided by gradually tapering antidepressant medication. The gradual tapering approach, as opposed to more abrupt discontinuation, is supported by new scholarship out of Europe.

The study, published in the journal of European Neuropsychopharmacology, sought to appraise the most recent literature on ADS and withdrawal from antidepressants. They found that “down-titrating” or tapering is almost always warranted in the clinical setting, especially for antidepressants like citalopram.

“Many patients abruptly discontinue their antidepressant medications early without the knowledge of the prescribing clinician for several reasons,” the authors explain. “Antidepressant discontinuation may lead to systemic and neuropsychological symptoms of varying severity and duration, accounting for the so-called ‘antidepressant discontinuation syndrome.’”

Abruptly stopping SSRIs (Selective Serotonin Reuptake Inhibitors) like Zoloft, Citalopram, and Escitalopram can be disruptive and harmful to your day-to-day life—sometimes causing flu-like symptoms, insomnia, nausea, and or anxiety. However, quitting your antidepressant cold turkey may also cause confusion between you and your healthcare provider, as it may be difficult to distinguish between a reoccurrence of symptoms of depression and symptoms of withdrawal and ADS.

The literature review first highlights that the newest version of the Diagnostic Statistical Manual for Mental Disorders, the DSM-TR, does note that ADS “may occur following treatment with all types of antidepressants” and that “the incidence depends on the dosage and the half-life of the medication being taken and the rate at which the medication is tapered.” In particular, the authors found that the most likely culprit of ADS is drugs with high SERT occupancies and drugs with short-half lives.

Citalopram, known best by its brand name Celexa, has a “high SERT occupancy.” Selective serotonin reuptake inhibitors (SSRIs) are thought to stop serotonin from being removed from neuronal synapses. By binding to the serotonin transporter or “SERT,” SSRIs block serotonin transport and thus increase the presence of serotonin in the brain. Researchers and physicians can measure SERT occupancy (that is, how “occupied” or “bound” the serotonin transporters are) of an SSRI through medical imaging like PET scans. The authors explain:

“Specifically, the SERT occupancy of the SSRIs would vary across different doses. For example, the SSRI citalopram steadily administered at 60 mg/day would result in 87.8% SERT occupancy, 40mg/day would result in 85.9%, 20 mg/day in 80.5%, 9.1 mg/day in 70%, 5.4 mg/day in 60%, 2.3 mg/day in 40%, 1.5 mg/day in 30%, 0.8 mg/day in 20%, and 0.37 mg/day in 10%…This means that tapering off should be particularly gradual, especially upon reaching low doses of the SSRI.” 

Similarly, paroxetine, commonly known by its brand name Paxil, has a short half-life. Short half-lives increase the likelihood of withdrawal and discontinuation symptoms across all drug types, whereas long half-lives decrease withdrawal symptoms significantly. A drug’s half-life is the amount of time it takes to reduce to half of its original value or potency in your body. The quicker the drug loses potency in your body, the worse withdrawal you may experience. Or, in the case of antidepressants, the shorter the half-life, the higher the likelihood of ADS.

Moreover, individuals who are “already vulnerable” to antidepressant discontinuation symptoms, such as people who experience frequent panic attacks, are more likely to experience ADS if antidepressants are not tapered correctly.

As with all studies, there are limitations to this literature review. Of note, the literature review was conducted using a single database. And, whether it is because the studies reviewed did not contain demographic data or the authors themselves did not note demographic data, there is no mention of race, ethnicity, gender, or socioeconomic status in the review.

As the public grows more informed about depression, the questionable efficacy of antidepressants, and non-pharmaceutical treatment options, individuals deciding to discontinue their antidepressants may find it difficult to do so. Discussing discontinuation with your doctor is recommended to avoid ADS and withdrawal symptoms.

 

 

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Fornaro, M., Cattaneo, C. I., De Berardis, D., Ressico, F. V., Martinotti, G., & Vieta, E. (2023). Antidepressant discontinuation syndrome: A state-of-the-art clinical review. European Neuropsychopharmacology, 66, 1-10. (Link)

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Samantha Lilly
Samantha Lilly is a "global mental health" researcher and critical suicidologist. Previously a Thomas J. Watson Fellow, Sam is now pursuing a Fulbright research grant, conducting qualitative research on rights-based approaches to mental healthcare in Buenos Aires, Argentina.

6 COMMENTS

  1. Ms. Lilly says, “Discussing discontinuation with your doctor is recommended to avoid ADS and withdrawal symptoms.”

    That’s a terrible recommendation. Because most “doctors” are likely to:

    1. Dismiss “the patient’s” concerns

    2. Dissuade “the patient” from lowering the “dosage(s)” AT ALL

    3. INCREASES the “dosage(s)”

    4. Switch “the patient” to another yet equally damaging “medication”

    5. Add another “medication” to “treat” the “side effects” of the current “medication(s)”

    5. And if “the patient” refuses to “cooperate” (bow down) to “the doctor”, “the doctor” will usually resort to doing what “the doctor” did in the beginning, which was establish control over “the patient” by “diagnosing” (i.e. name calling) “the patient”. It’s “the doctor’s” unconscious but foolproof way of establishing power over “the patient” and “the doctor’s” unconscious but foolproof way of inducing feelings of hopelessness, degradation and stigmatization in “the patient”. It’s the sickest power play going.

    A better recommendation is this: make sure you have a good internet connection and know of some good peer-run ADS websites. It’s all anyone really needs. Plus a hell of a lot of luck, patience and courage —

    • Correction:
      6. And if “the patient” refuses to “cooperate” (bow down) to “ the doctor”, “the doctor” will usually resort to ARBITRARILY ASSIGNING YET ANOTHER “DIAGNOSIS” to “the patient”. It’s “the doctor’s” unconscious but foolproof way of establishing POWER over “the patient”, and “the doctor’s” unconscious but foolproof way of inducing feelings of hopelessness, degradation, and stigmatization in “the patient”. It’s the sickest power play out there.

      Define “arbitrarily”: on the basis of random choice or personal whim, without restraint in the use of authority; autocratically; irrational, inconsistent, irresponsible, subjective, unreasonable, willful, offhand, capricious, and the list goes on….and plenty of examples are available in the DSM!

  2. Sam: Just as one is tapering slowly while being concerned with that dynamic, where or what practices are being discovered in being better aware for the creativity of being present as an informed citizen? By any chance, have you explored Richard Feynamen’s, “Surely You Must Be Joking” and Stafford Beers, “Too Many Grapes in the Wine”. Seemingly the behaviors of being placed on the meds and the minds working to insure compliance can be a challenge to taper off, let go while moving on into economies by which the ethics can be explored in the individual and collective sense.

  3. Thank you for educating the medical profession about ADS, Samantha, since none of my former doctors (including the psychiatrists) claimed to know anything at all about ADS.

    “Many patients abruptly discontinue their antidepressant medications early without the knowledge of the prescribing clinician …” And many doctors claim to be so insanely ignorant about ADS that they abruptly take people off the antidepressants. Not to mention, they prescribe antidepressants to people under the false claim they are “safe … meds,” as opposed to honestly admitting they’re prescribing mind altering “antidepressants.”

    Just an FYI, “brain zaps” should be added to your list of common symptoms of ADS. Especially since that is initially a rather frightening effect of ADS. And none of the doctors had even heard of “brain zaps” until 2005, which is proof of how “ignorant” the doctors are, in regards to antidepressant discontinuation syndrome.

    https://www.researchgate.net/publication/247806326_'Brain_shivers'_From_chat_room_to_clinic

    Gotta love the hubris of those who assume their clients are all too stupid to do research on the internet, don’t you? (sarcasm)

    And here is the medical evidence of the iatrogenic etiology of “the sacred symbol of psychiatry.” The “positive symptoms” are created via anticholinergic toxidrome, and the “negative symptoms” are created via neuroleptic induced deficit syndrome.

    https://en.wikipedia.org/wiki/Toxidrome
    https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome

  4. I’m afraid from my own experience Ms Lilly, discussing discontinuation syndrome with your doctor is not to be recommended.

    A few years ago my psychiatrist at the time told me I could stop one of the drugs I was on Cymbalta (30mg) immediately as it was a low dose. It had been causative of high liver enzymes. She was a nice woman but I have been treated coercively by psychiatrists in the past and I am very careful around them so I tapered it quietly myself.

    I had severe withdrawal and that resulted in my re-attending with another psychiatrist when she retired and receiving a raft of further drugs and psychiatric labels. Nowhere was protracted withdrawal mentioned in any of this.

    I only found out about protracted withdrawal in 2021 when I joined the Surviving Anti Depressants forum. I had been using supplements from ‘The Road Back’ an outpatient programme which now appears to be defunct which did not mention protracted withdrawal. I thought I would be ok if I just took the supplements and reduced every two week – that was not the case. I tapered too fast.

    Since then I have very slowly dragged myself away from the psychiatric net by being very nice to everyone I met in psychiatric service and have basically lied about the dose of the remaining drug I am tapering so I could be allowed leave the day service. I simply said that I am staying on this drug to keep myself stable and don’t want to add in additional drugs as they could destabilise me.

    On one occasion when I told one young doctor I had stopped the Seroquel after a bowel impaction and he mentioned ‘compliance’ I could hear again the whisper of coercion that had taken a large part of my early life so I went very quiet and reasonable. There is always danger in challenging a psychiatrist in any way on drugs because that’s their only real currency. I could sense the frustration in some of the young doctors I meet when I said I was maintaining on my last drug at every psychiatric appointment because they wanted to ‘do something’ and add in a new drug.

    I am currently tapering this last drug very slowly and I will take me at least two years if I make it.

    Because I won’t agree to take further drugs and seem stable the last doctor I met simply asked if they could refer me back to my GP as there wasn’t really anything else they could do for me i.e. I am not going to take any new drugs. If you present as relatively stable they can’t really push any more stuff on you.

    I have not even told my GP because if I did so given that I still suffer from distress at times I know that i would be told to resume or take a different drug.

    Discussing drugs openly with your doctor is of questionable value and could be very dangerous for a patient who is trying to get off drugs and is in a vulnerable state.

    The power imbalance between patient and doctor in matters of mental health is enormous. If I manage to get off this drug successfully at that stage, I will inform my GP of what I have done and of the difficulties that drugs caused me in withdrawal. However because I have suffered from ‘severe mental health issues’ throughout my life, I don’t think my telling the GP will carry much weight and that goes for most people with ‘mental illness’. Before and if I have successfully tapered however, I do not feel it would not be safe for me or for others diagnosed with ‘psychiatric’ illnesses to do so.