New research investigating current antidepressant tapering trends finds that strategies for reducing doses over time can lead to varying results in different individuals. The review, published in the Journal of the American Board of Family Medicine, advocates for a “one-size-fits-all” taper approach to ensure that withdrawal prevention is taken into consideration while simultaneously allowing for a process that is straightforward and not unnecessarily complex for most patients.
Withdrawal symptoms from antidepressants are common and can include dizziness, nausea, anxiety, depression, and “brain zaps,” which are sensations of electric shocks inside the head, among other symptoms. Given the overlap in symptoms between depression and antidepressant withdrawal, depressive relapse and withdrawal can be difficult to distinguish, which leads to confusion among patients and their providers.
Additionally, determining who will experience severe withdrawal symptoms from those who will not is difficult to predict, although research has shown that duration of use, previous experiences of withdrawal, and type of antidepressant used provide insight into who may experience withdrawal symptoms upon discontinuation.
Researchers, led by James Phelps, MD, of Samaritan Mental Health in Corvallis, OR, write:
“The severity of antidepressant withdrawal can be mitigated by carefully tapering the dose before stopping. Research is ongoing regarding which patients need a taper and the best way to discontinue their antidepressants. Most strategies emphasize the use of very small decrements in the last steps to zero.”
In the current study, Phelps and colleagues analyzed data from the past 7 years of Samaritan Mental Health patients who had discontinued their antidepressants. Data was included for patients who had been prescribed the same antidepressant for at least 6 months before stopping their medication. As tricyclics and trazodone are often also used for pain and sleep, patients taking these medications were excluded. Also, patients who had not been seen in one of Samaritan Mental Health’s clinics in over a 13-month period were also excluded to rule out any patients who may have gone elsewhere for medication management. The final sample included 7,583 patients, who were mostly White (95.9%), female (67%), on Medicare (45.2%), and more than 40 years old (39.6%).
Across the 7-year time frame, 676 or 8.9% of patients were tapered to the lowest available dose of their antidepressant before stopping the medication entirely. Researchers noted an increase in taper rates from 4.9% in 2014 to 9.5% in 2021, highlighting that taper rates have remained steady at around 10% over the past 4 years. Further, Phelps and colleagues found that the antidepressant venlafaxine tended to be tapered significantly more than fluoxetine and paroxetine.
The researchers describe the implications of their findings:
“Note that although they may have had significant symptoms of withdrawal, it seems that most patients were able to stop taking antidepressants without tapering through low doses. On the other hand, thousands of patients report severe antidepressant withdrawal symptoms even with very small dose reductions. This suggests that some patients clearly require slow, small-decrement antidepressant tapers, whereas others can manage without using a lower dose or with no tapering at all.”
With this in mind, Phelps and colleagues suggest that a standardized approach to tapering be adopted as a way to address the needs of patients who may be at risk for severe withdrawal alongside the need for a straightforward, routine method of tapering. They emphasize the need for the first dose decrease to go smoothly, without any withdrawal symptoms or adverse effects on mood, so that patients will be motivated to continue to taper and ultimately stop taking their medication. Therefore, they recommend that the first taper consists of the smallest reduction possible.
Phelps and colleagues describe how the first successful reduction helps patients to feel confident that their discontinuation is possible and manageable and discuss how some patients may desire more significant or more rapid reductions following a successful initial decrease in dose. They suggest that a period of at least 2 weeks occurs between dose reductions and that tapering occurs at a pace that feels manageable to patients, with reductions likely becoming smaller and slower again as patients approach zero.
The researchers caution that even with a slow-paced careful approach, some patients may still experience severe withdrawal symptoms and may need to follow tapering methods typically used for those who experience severe withdrawal, which include decreasing doses by as little as 10% of the previous month’s dose.
A major limitation of the study is its predominantly White female sample size, as its findings may not be generalizable to individuals of other backgrounds. In addition, the chart review approach used by researchers did not allow for them to analyze data from patients who may have subdivided their existing doses or who reduced their dose but not to the lowest dose of their particular antidepressant.
Overall, the study contributes to a growing body of research and calls for safe guidelines for antidepressant tapering. In 2019, the National Institute for Health and Clinical Excellence (NICE) updated its guidelines regarding antidepressant withdrawal. It recommended that providers have discussions with their patients about potential long-term, severe antidepressant withdrawal symptoms. Others have advocated for a slow tapering process to mitigate the risk of severe withdrawal.
Phelps, J., Nguyen, J., & Pipitone Coskey, O. (2023). Antidepressant tapering is not routine but could be. Journal of the American Board of Family Medicine Ahead of Print. doi: 10.3122/jabfm.2022.220239R1 (Link)