Cause and Effects

A scenario:

You've been on an SSRI antidepressant for five weeks or more. The doctor feels that the dosage needs to be decreased or the medication needs to be discontinued. He prescribes changes and tapering in the usual 10mg increments.

Within a couple of days of starting this, you begin to exhibit severe flulike symptoms - headache, diarrhea, nausea, vomiting, chills, dizziness and fatigue. There may be insomnia. Agitation, impaired concentration, vivid dreams, depersonalization, irritability and suicidal thoughts are sometimes occurring. These symptoms last anywhere from one to seven weeks and vary in intensity. You wonder what the heck is going on.

It's called SSRI discontinuation syndrome, and it can really be the pits. Here is what causes it:

Some SSRI medications have a very short half-life. This means they produce no metabolites that help the medication stay in the body for an extended period. They go in, last a few hours, and come out again.

SSRI's are split into two categories: long acting and short acting. For example, Prozac is a longer-acting SSRI. Paxil, Effexor, Zoloft and Luvox are short-acting. The shorter acting SSRIs, when discontinued or when the dosage is lowered, produce an "anticholinergic rebound," which is an interruption in production of the key neurotransmitter acetylcholine. (Acetylcholine is the neurotransmitter used more when a person is under greater stress.) These symptoms will last anywhere from one to seven weeks, and then disappear.

Neurologic symptoms include:

• Dizziness
• Vertigo
• Lightheadedness
• Difficulty walking

Somatic (bodily) complaints include:

• Nausea/vomiting
• Fatigue
• Headaches
• Insomnia

Less common difficulties:

• Shock-like sensations
• Parasthesia (skin crawling, burning or prickling)
• Visual disturbances
• Diarrhea
• Muscle pain
• Chills

Non-specific mental symptoms:

• Shock-like sensations
• Agitation
• Impaired concentration
• Vivid dreams
• Depersonalization - sense of unreality and loss of self
• Irritability
• Suicidal thoughts

Double-blind controlled studies now indicate that 35-78% of patients who, after five weeks or more of treatment with the medication, abruptly stop certain antidepressants or titrate down in 10mg increments or more, will develop one or more of the antidepressant discontinuation symptoms. When allowed to run its course, the syndrome duration is variable (one to several weeks) and ranges from mild-moderate intensity in most patients, to extremely distressing in a small number.

Practical Tips for Tapering Off Your Antidepressant

So ... you are using a short-acting SSRI medication. You have to discontinue it or titrate it down, you tend to be very sensitive to the effects of medication withdrawal, and you want to know what to do to head off discontinuation syndrome?

First, ask your doctor if a special dose is available for the specific purpose of weaning down. Some pharmaceutical companies are now manufacturing and offering them in sample form to doctors. Ask.

If such a dose is not available, the main thing to remember is that you want to try and wean down very slowly - usually in half the increments that your doctor would normally suggest for the weaning process in most people.

If you have tablets, and the insert doesn't indicate that splitting or crushing is taboo, you can split them (a pill splitter helps, a couple of bucks at the pharmacy).

ALWAYS check the insert or a drug monograph first to make sure you can split them. This makes it pretty easy to halve the original titration recommendation and take each step down for a week.

I had great success using this method when titrating down from Paxil, one of the most notorious drugs for causing DS. My doctor refused to acknowledge the discontinuation problem and couldn't seem to give me any helpful suggestions for reducing the discomfort. So I did it this way, and the effects were much more tolerable.

The main thing is that the brain's production of acetylcholine is not interrupted. One of the simplest things you can do to prevent this in addition to ultra-slow titration is to add supplements: in particular, choline, lecithin, and B complex. The B vitamins will help sustain your brain's current levels of the neurotransmitter acetylcholine (the depletion of which is the cause of DS). You should also use choline supplements or lecithin supplements (which are 13 percent choline) to help increase the level of available choline that the brain uses to make acetylcholine while the titration or discontinuation is happening.

Dietary changes (temporary if you wish until after the med is weaned) can also be made. Lecithin and choline can be found in a wide variety of foods, but many of the richest sources are foods also high in cholesterol and fat. Egg yolks are one of the best dietary sources of lecithin/choline. Other excellent sources of dietary choline are beef steak, liver, organ meat, spinach, soybeans, cauliflower, wheat germ, peanuts, and brewer's yeast.

Discontinuation symptoms are not restricted to the SSRIs, as many of you here can attest. Many drugs that act on the central nervous system can cause DS symptoms: monoamine oxidase inhibitors, tricyclic antidepressants, antiparkinsonian agents, traditional antipsychotics, and clozapine. Some people have a condition known as rebound, that occurs with the consumption of short acting medications (an agitated state of emotion that occurs at the end of the dosage cycle, and lasts for fifteen or twenty minutes, then disappears). The dietary modifications are helpful for this problem.

It's good to know that the psychiatric professional community recognizes this phenomenon as valid. Although the symptoms are varied, and are both physical and psychological, a characteristic SSRI discontinuation syndrome is now recognized.

next: More on Antidepressant Discontinuation Syndromes and
next: How to Safely Stop Taking Your Antidepressant

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Reviewed: 01/2006