Antidepressant withdrawal - Ketamine therapy does not often lead to withdrawal symptoms

Antidepressant withdrawal: what is it, how do I deal with it?

Antidepressants can be a godsend for people experiencing mild to major depression, anxiety, and other emotional suffering. About one in 10 Americans aged 12 and above takes antidepressant medication, according to the Centers for Disease Control and Prevention (CDC), and about 14% of them have been taking the medications for more than 10 years. As people begin to feel better, they want to be able to comfortably move on from the medication, triggering antidepressant withdrawal. 

What is Antidepressant Withdrawal?

Antidepressant withdrawal may occur from abruptly stopping to take an antidepressant medication, particularly if you have been taking it for more than four weeks. If you feel better while taking antidepressants, chances are your doctor will renew the prescription until they are comfortable that your symptoms will not relapse. It is quite common for patients to take antidepressants for more than a decade. Antidepressant withdrawal has a wide range of symptoms, which are sometimes referred to as antidepressant discontinuation syndrome. These symptoms usually last for a few weeks. They include:

  • Nausea
  • Anxiety
  • Headaches
  • Tiredness
  • Irritability
  • Insomnia or vivid dreams
  • Electric shock sensations
  • Flu-like symptoms, including achy chills and muscles
  • Dizziness 
  • Return of depression symptoms  

Common Antidepressants

The following are some commonly-prescribed antidepressants:

  • Remeron (mirtazapine)
  • Zoloft (sertraline)
  • Lexapro (escitalopram)
  • Effexor (venlafaxine)
  • Wellbutrin (bupropion)
  • Celexa (citalopram)
  • Lexapro (escitalopram)
  • Prozac (fluoxetine)
  • Savella (milnacipran)
  • Cymbalta (duloxetine)
  • Vestra (reboxetine)
  • Luvox (fluvoxamine)
  • Paxil (paroxetine) 

Categories of Antidepressants

Antidepressants can be categorized into 5 groups, based on how they impact the brain. The way they bind to the brain system will largely determine the chance that they also cause withdrawals, and how severe the withdrawal symptoms would be if you discontinue them abruptly:

Selective Serotonin Reuptake Inhibitors (SSRIs)

Antidepressants in this category impact the brain by inhibiting the re-uptake of serotonin, to improve people’s mood. The most commonly prescribed SSRIs include Paxil, Prozac, Zoloft, Celexa, and Lexapro.

Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)

These antidepressants ease depression by impacting the neurotransmitters used to communicate between the brain cells. Effexor, Fetzima, Cymbalta, and Pristiq are some of the common antidepressants in this category.

Tricyclic Antidepressants (TCAs)

TCAs aren’t as common as SSRIs and SNRIs as they are more powerful and can cause more side effects. They work by raising the levels of serotonin and norepinephrine neurotransmitters. TCA antidepressants include Pamelor, Elavil, and Tofranil

Monoamine Oxidase Inhibitors (MAOIs)

MAOIs are the least common antidepressants and are rarely prescribed unless all other antidepressants have failed to work. They have more side effects and can interact with just about all other medications. Examples of MOAI medications are Nardil, Marplan, and Parnate.

Other Antidepressants

Other types of antidepressants include Oleptro and Remeron, which are known as sedating antidepressants, and the popular Wellbutrin, which is a norepinephrine and dopamine re-uptake inhibitor (NDRI).

How Do Antidepressants Cause Withdrawal?

All antidepressants work by altering the levels of chemical messengers in the brain (neurotransmitters) that attach to receptors of nerve cells (neurons). As you continue taking antidepressants, your neurons will eventually adapt to the current levels of the neurotransmitter. And if you stop suddenly, the levels change too fast, leading to antidepressant withdrawal symptoms.

Generally, antidepressant discontinuation syndrome is not medically dangerous and doesn’t last long. But it is uncomfortable, and most importantly its effects can lead to a relapse in your care. Antidepressant withdrawal symptoms often emerge within days or weeks of lowering the dose or stopping the medication entirely, and often include depression and anxiety. 

Medications and Their Discontinuation Syndrome Risk Factors

According to Harvard Health, the antidepressants most likely to cause withdrawal symptoms are those that have “short half-lives” – the types that break down and leave the body quickly. Examples include Zoloft, Effexor, Paxil, and Celexa. Extended-release versions of these antidepressants enter the body more slowly but leave just as quickly. Medications with a longer half-life, e.g. fluoxetine, have fewer risks of discontinuation syndrome.

In a study by Harvard Medical School, nearly 400 patients were followed for more than 12 months after they stopped taking prescribed antidepressants for mood and anxiety disorders. Researchers found that those who discontinued rapidly (over one to seven days) had a higher chance of relapsing within a few months compared to those who reduced the dose gradually over two or more weeks. The findings show that discontinuation typically begins when 90% or more of the medication has left the system.

The ’Half-Lives’ of Commonly Available Anti-Depressants?

Drug                                        50% out of body in:                             99% out of body in:

Effexor:                                   6 hours                                                1 day

Cybalta                                    12 hours                                              2.5 days

Pristiq                                      12 hours                                              2.5 days

Zoloft:                                      24 hours                                              4.4 days

Wellbutrin                                21 hours                                              4.4 days

Paxil:                                       29 hours                                              5.4 days

Lexapro:                                  30 hours                                              6.1 days

Clexa:                                      36 hours                                              7.3 days

Prozac:                                    5 days                                                 25 days.

Does Antidepressant Withdrawal Mean I’m Addicted to the Medication?

No, having symptoms of discontinuation syndrome doesn’t mean you are addicted to an antidepressant. Addiction is not always related to withdrawal, and is considered an entirely distinct (and dangerous) condition characterized by long-term chemical changes in the brain. Intense cravings and an inability to control the use of a substance are some of the signs of addiction. While antidepressant withdrawal is not dangerous, medically speaking, you still need to work towards preventing it if you are planning to stop using an antidepressant.  

How to Prevent or Manage Antidepressant Withdrawal

You can prevent or reduce the chances of experiencing antidepressant withdrawal by following some procedures before you stop taking the medication. Of course, the symptoms and possibility of relapse are not anything a patient wants to have to think about. While it’s somewhat daunting, take the following as some helpful tips:

Consider Tapering Down the Dose

You can minimize the risk of antidepressant withdrawal if you gradually lower or taper the dose over weeks or months. There isn’t an exact method for tapering an antidepressant dose. Some start reducing it by half, and later by half again. Some taper down the dose within a month, while some take several months. You can also consider substituting longer-acting antidepressants for shorter-acting ones (as they clear your system in the same amount of time regardless).

Consider Psychotherapy

Mindfulness-based therapies and cognitive behavioral therapy may also help. According to Harvard Health, people who undergo psychedelic-assisted psychotherapy while stopping an antidepressant are less likely to experience a relapse.

Ensure a Healthy Lifestyle

Healthy living is another great way of preventing discontinuation syndrome. Good nutrition, regular sleep, and taking on less stress all play a role in your recovery. Studies have also shown that people who exercise at least three times a week are less likely to experience a relapse after discontinuing an antidepressant.

Talk to Your Doctor

Your doctor can provide the support you need to prevent antidepressant withdrawal. Be open and honest in describing the emotional and physical symptoms related to your discontinuation syndrome. Depending on the severity of the symptoms, your doctor may be able to prescribe other drugs to help alleviate the symptoms, including a schedule for your tapering down. 

References

https://jaoa.org/article.aspx?articleid=2761944

https://www.mayoclinic.org/diseases-conditions/depression/expert-answers/antidepressant-withdrawal/faq-20058133

https://www.health.harvard.edu/diseases-and-conditions/going-off-antidepressants

https://www.cdc.gov/nchs/products/databriefs/db76.htm

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