by Giovanni A. Fava, Alessia Gatti, Carlotta Belaise, Jenny Guidi, and Emanuela OffidaniPsychotherapy and Psychosomatics. 2015 84:72-81.
Background: Selective serotonin reuptake inhibitors [SSRI] are widely used in medical practice. They have been associated with a broad range of symptoms, whose clinical meaning has not been fully appreciated.Methods: The PRISMA guidelines were followed to conduct a systematic review of the literature. Titles, abstracts, and topics were searched using the following terms: ‘withdrawal symptoms’ OR ‘withdrawal syndrome’ OR ‘discontinuation syndrome’ OR ‘discontinuation symptoms’, AND ‘SSRI’ OR ‘serotonin’ OR ‘anti- depressant’ OR ‘paroxetine’ OR ‘fluoxetine’ OR ‘sertraline’ OR ‘fluvoxamine’ OR ‘citalopram’ OR ‘escitalopram’. The electronic research literature databases included CINAHL, the Cochrane Library, PubMed and Web-of-Science from inception of each database to July 2014.Results: There were 15 randomized controlled studies, 4 open trials, 4 retrospective investigations, and 38 case reports. The prevalence of the syndrome was variable, and its estimation was hindered by a lack of case identification in many studies. Symptoms typically occur within a few days from drug discontinuation and last a few weeks, also with gradual tapering. However, many variations are possible, including late onset and/or longer persistence of disturbances. Symptoms may be easily misidentified as signs of impending relapse.Conclusions: Clinicians need to add SSRI to the list of drugs potentially inducing withdrawal symptoms upon discontinuation, together with benzodiazepines, barbiturates, and other psychotropic drugs. The term ‘discontinuation syndrome’ that is currently used minimizes the potential vulnerabilities induced by SSRI and should be replaced by ‘withdrawal syndrome’.
In the past decade, few studies assessed the presence of discontinuation symptoms, and the topic has attracted limited attention also as to literature reviews. To the best of our knowledge, in the English language there has been no systematic review on the clinical aspects of SSRI discontinuation according to established criteria. Yet, such knowledge is important because of the wide-spread use of SSRI in medical practice.
As a psychiatry resident [1974-1978], my references for psychiatric drugs were textbooks, under an inch thick. They’re still around with the kind of underlining that you look back on and wonder what you thought you were doing. Almost everything ended up underlined or high lighted – like you could vacuum up the information with a yellow felt pen. But my point is that I don’t recall the drugs changing at some rate that required constant updating. There were the MAOIs and the TCAs [Monamine Oxidase Inhibitors and the Tricyclic Antidepressants]. They were laid out in neat tables with various columns of characteristics, describing how they differed. They were primarily inpatient drugs, used primarily on patients with the various melancholic depressions, but not so much for outpatients. We all knew the side effects because the patients told us about them all the time. While I never saw a fatality, we all worried about overdoses because a month’s supply prescription could be a fatal dose. I remember a rule of sorts – if a patient responded to an antidepressant, they should continue for at least six months because patients who stopped sooner had an increased incidence of relapse. But my point is that these weren’t long term drugs because depression wasn’t considered a long term problem and the everyday side effects – things like dry mouth and constipation were gladly left behind.
When the DSM-III and the SSRIs came along, things were different. Depression became a Disorder, Major Depressive Disorder, and the treatment became the antidepressant drugs that flowed from the pipeline. They were better tolerated and the old short-term rules just sort of evaporated. People stayed on them for long periods and thought of them as treating some kind of disease they had. Many seemed to think of them as keeping the disease at bay, and were afraid that if they stopped, it would come back. If they got depressed again, they said "my antidepressant has stopped working." I missed most of that, and a lot of what I learned about those drugs was from patients talking about their experiences. And there was a pattern. First there would be a "occasionally" symptom like decreased libido with Prozac®. Then it was "sometimes", then "often." I learned about withdrawal from a friend’s wife who had a hell of a time getting off of Paxil®. At first, I thought it was a Paxil® thing, but then I heard about it with other drugs. And so it went, learning from patients before it came from the traditional sources like journals. I actually learned most of what I know about SSRI withdrawal here from the comments of Altostrata and her Surviving ADs site – things like the withdrawal symptoms being interpreted as the "depression is coming back" or always tapering with discontinuation rather than stopping abruptly. That information is available now, but not "back in the day."
An Editorialby Guy Chouinard and Virginie-Anne ChouinardPsychotherapy and Psychosomatics. 2015 84:63–71.
Conclusion: SSRIs have provided major therapy advancement in the treatment of depression and other mental disorders. Withdrawal symptoms may occur with SSRIs, similarly to other CNS drugs, and they must be identified and differentiated from relapse and recurrence of the original illness. The proposed diagnostic criteria will permit the identification of three types of withdrawal associated with SSRIs. Differentiating withdrawal from relapse and recurrence of the original illness will allow clinicians to more effectively reduce and withdraw SSRIs, and find a minimal therapeutic dose. It is most important to recognize persistent post·withdrawal disorders to prevent unnecessarily high doses and prolonged treatment.
This paper set me to thinking about something. It’s a report of something I need to know about, but it’s 25+ years after I needed to know about it. The first article on withdrawal listed in Fava et al’s supplementary material is in 1988, around the time Prozac® was introduced, and there are number in the 1990s. But I didn’t learn about it through medical channels. As an old man, I have the time to root around about things, but I sure didn’t in 1988. And yet, in my first career [Medicine] and early in the second [Psychiatry] I just knew about things. I didn’t think about "keeping up." I just read my journals, went to meetings and conferences, and lived in a world populated by colleagues and patients. There was always a library around for looking up things I had questions about. I never much liked CME [Continuing Medical Education], so I picked things "of interest" rather than review courses. My point is that I didn’t think about "keeping up." Medical life just "kept me up." That seems to have changed in the 1980s. I wish I’d been perceptive enough to notice it happening. I’d always read review articles, but I no longer found them very interesting. Too upbeat. Too pie in the sky. Too future oriented. I don’t recall ever thinking about why, but I just gradually stopped that kind of general journal reading and read books of interest.
My roommate in college struggled with depression. Her family HMO had put her on Prozac, but she wasn’t taking it. She wound up in a crisis and went to the University Health Services. I think she was even seen by the head of the psychiatry department. He put her on Effexor, not Effexor XR, but regular old Effexor which she was supposed to take multiple times a day. She wasn’t great about it, and she’d have horrible withdrawal symptoms in the middle of class.
I think that lasted a week or two, before she went back to the integrated HMO (a Kaiser-like entity) and got a Prozac prescription. I don’t know how regularly she took that, but I think the long half-life helped her get over SNRI withdrawal. I mean, I know that this is a recognized syndrome now.
She was really jonesing when she missed a dose of that Effexor, and she wasn’t on it for long at all.
I have had people on a high dose of Effexor decrease their daily dose by 37.5 mg one day per week for two weeks. Then the next two weeks they take the lower dose 2 days per week. So in 3 months their daily dose is down by 37.5 mg. It may take a couple of years but eventually they get down to where their dose is low enough for me to transition them to fluoxetine. That is easier to taper because of the long half-life.
As you suggest, there is a huge swathe of anecdotal information about the experience of SSRI withdrawal symptoms on the internet, suggesting that peer reviewed literature is far behind the curve on this topic.
So happy to see that research is finally starting to catch up. One day it may even lead to patients being properly informed about the risks and benefits involved in starting on SSRIs.
In the second paper, the authors state:
Differentiating withdrawal from relapse and recurrence of the original illness will allow clinicians to more effectively reduce and withdraw SSRIs, and find a minimal therapeutic dose.
I can’t second this strongly enough as an ultimate aim for best practice. It is something that holds equally true for anti-psychotics and bipolar medication as well, perhaps even more so, given the even greater levels of withdrawal.
However you feel about Robert Whittaker, I think the legacy if his polemic will be greatest in this particular domain.
In the Fava, Gatti et al. paper, there is a reference to a study that included patients using venlafaxine (Effexor):
“In order to examine
two different tapering strategies, Tint et al. [46] randomized
28 patients treated with different SSRI or venlafaxine
to a short (3 days) or long (14 days) taper. Results showed
that 46% of subjects reported discontinuation symptoms
and that the incidence was similar in both conditions (47
vs. 46% in the short vs. long taper groups).”
Haven’t time to look at the Tint et. al paper though, unfortunately.
Just to advise colleagues out there, in my 20 plus years of travels with withdrawal issues from non controlled substance medications, often (NOT ALWAYS MIND YOU) there is a characterological element to the severity and persistence of complaints to prolonged withdrawal from a reasonable and responsible taper schedule with SSRIs and other psychotropics known to have withdrawal risks. Even Lithium has withdrawal risks, forget exacerbation of manic symptoms as a withdrawal phenomenon for a minute, please.
So, I think it is both important and prudent to weigh the characterological factors to the patient when changing or withdrawing meds, especially when someone is telling you he/she has failed a dozen or more med trials in the past and also claims to have been diagnosed with many Axis 1 illnesses in less than a 5 year time period.
What is true withdrawal, and what is exaggerated reactivity simply because the patient has to unconsciously or subconsciously weigh yet another failed treatment trial? Again, this theory is not applicable to everyone, but, I think it applies to more than a small minority percentage of patients.
Also, I don’t read here about people titrating medications in the beginning of treatment, is that just an oversight of commenters, or, is that a figurative if not literal Freudian slip, after all, I would bet Freud would just slap patients on full dosages on Day 1 of treatment. As his theorems seemed to apply to everyone anyway.
Not an application for everyone, but, if on a drug for more than 6 months, for every 3 months on a med, expect to taper off in a 2-3 week time period for that 3 months period. Patients can handle a 20-25% drop in dose every 7-10 days at least the first 3-4 dosage decreases until you get to 25% of the original Maximum dose prescribed. Once at 25% of original max dosage, you then drop by 15-20% every 4-6 days until completed if the length of use was more than a year’s time. The max out is about 2, maybe 3 or 4 months tops though to taper, as one has to address the psychological issues to stopping meds if there is not a medication substituting for the medication being discontinued.
After all, it’s a bit deal to be asking to stop a medication having been on it for years at a time, so that is not just a biological discussion, true?
But, let’s be candid here for a minute, most psychopharmacologists don’t seem to have the skills these days to actually talk to patients outside the scripted discussions they practice in their pill mill offices. Asking a patient how they feel and getting a response more than 3 sentences challenges the 10 minute med check parameters these days, eh? Also, what do you expect to read in a colleague’s chart to rationalize and defend these supra-therapeutic dosages of meds, lets start with Lexapro 40mg or Prozac 100 as a start?!
And how do people put up with seeing a psychiatrist in less than 10 minutes time per visit if there is an interest to have a dialogue, not a doctor monologue?? Sorry, getting off point for this thread here…
Just my imperfect opinion…
Mickey, thank you for posting this. The more doctors that see the information the better.
From what we see on http://SurvivingAntidepressants.org, attempting to taper by inconsistent dosing or skipping doses (which many doctors, unaccountably, recommend) can cause severe withdrawal symptoms. Because of the short half-lives of these drugs, inconsistent dosing causes small fluctuations in blood level. Some people are sensitive to this, even with fluoxetine.
Rather, we advise using liquids, pill cutting, compounded liquids or capsules, etc. to lower dosage in a consistent manner. Taking into account the most sensitive individuals, we advise a decrease of 10% per month.
The long interval is based on our observations that withdrawal symptoms do not always appear immediately upon a reduction. Sometimes it takes weeks.
If the person has made other reductions in the meantime, the severity of withdrawal symptoms is exacerbated. So we suggest 1-month intervals to make sure there are no repercussions from a dosage cut.
If withdrawal symptoms do occur, we recommend intervals longer than a month and decreases of less than 10%.
We are extra-cautious because the people on my site are doing this themselves, without a safety net. If they could find physicians to guide them, they certainly would consult them — and we would be happy to refer them. (If any physicians reading this are willing to assist a systematic taper, please contact me at survivingADs (at) comcast dotnet.)
Certainly doctors may have seen people doing well with a faster taper, but there is clearly a proportion who need a rate of taper tailored to individual tolerance.
Is this slow tapering inconvenient? Heck, yes. I have people who have had to taper for years and are still not off Paxil, Effexor, Cymbalta, Lexapro, Prozac, etc.
I have not seen a personality correlation. These people are not complainers. If they’re following the 10% (or less) taper, they are responsible, organized people who are determined to get off the drugs.
The difficulty in discontinuation is a flaw of the drugs, not a flaw in the patients.
Dr. Hasselman, I feel hopeful and encouraged by your general concern for close patient monitoring and very conservative dosing with SSRIs, and your emphasis on informed consent. In general, I think you know how much I appreciate your comments on this forum.
As for the issue of whether extended (or, I might add, atypical or otherwise difficult) SSRI withdrawal might sometimes be confused with characterological factors or reactivity, in my much more limited experience, I have only observed this in one or two borderline clients. Even in those situations, I felt like the client’s attachment to their incomplete treatment response, their symptoms, or their medication was a separate phenomenon from symptoms that were a direct result of medication changes. I can’t tell you exactly why– I don’t have the chops yet– it just seemed like a more useful way to think about it.
I remember one client who told me that when they were late with their venlafaxine dosage by even a single hour, the electrical shock sensations would start. This was a very high-functioning individual I was seeing for a relational problem, someone who was very interested in discontinuing SSRIs but absolutely could not, even by slow titration. (I think they did take ER version and maybe that was part of the problem– can’t remember, not what I was seeing them for.) This was the kind of client who might tend vaguely towards panic attacks or obsessional thinking, but no more so than any number of people who would have been diagnosed with exactly nothing in 1978, except maybe GAD. I think I gave this individual a V-code and GAD, I have no clue why anyone would have put them on an SSRI. This client also knew nothing about psychopharmacology, and claimed to have never done any independent research on withdrawal symptoms before experiencing them. Their story is not typical, but I’ve heard several similar ones.
And they make me very nervous. It’s always problematic to compare yourself to your clients, but I’ve been taking Lorazepam in a low dose for 20 years. I’ve missed doses when there was confusion at the pharmacy, or when my psychiatrist was out of town, and never had anything like that happen even if I was 30 hours late. I was pretty damn edgy, but the last time that happened, I worked a full shift at one clinic and a half shift at another with no significant problems.
Then there’s the question of what we classify as a withdrawal symptom. I know that I had PSSD for four years after taking paroxetine in a very low dose for about ten days, and then discontinuing abruptly. I have a friend who had a different kind of sexual disorder after using a low dose of Prozac for only a few weeks and stopping abruptly, and that took years to clear up– very reliable narrator, that one, least hysterical person I know. Was it the drugs or stopping the drugs? For me, the symptoms got really bad about six weeks after I stopped, and of course there’s no way of knowing what would have happened if I had continued.
For what it’s worth, my own psychiatrist and most psychiatrists I’ve worked with are a little dubious about SSRI withdrawal. Having taken them myself definitely biases my own opinion. They were just a completely different animal from any other drug I tried, and in the bad old days, I experimented with everything from heroin to mandrake root. It just feels like they… shift something in a way that’s very hard to shift back– something more subtle than whatever LSD or mescaline does, and something not so much in the PFC. Felt more like MDMA, a drug I really despised. Perhaps it’s not withdrawal, but it can be pretty damned unpleasant and last a very long time.
It could very well be that Joel gets the cranky patients!
I’ve never been the primary prescriber for either Paxil® or Effexor®, but I’ve been around for the withdrawal time a lot. What’s intriguing to me is that some can stop these drugs without a whiff of a problem. Others have a very hard time. I understand why Fava et al want to call it “withdrawal” rather than a “discontinuation syndrome,” but It’s different from the “withdrawal” we’re all familiar with [opiates, hyponotics, sedatives]. For one thing, I’m not used to this kind of variability among people in those cases. So I think of it differently – some kind if change of state [see Catalytz above]. My only real source until recently has been what patients’ say, and it seems to be “drug specfic” in that a person who gets it may not get it with a different drug, or at least that’s the impression I get from patient’s stories [anecdotes].
For every legitimate case that requires this alleged year detox off an SSRI/SSNI med like Paxil/Effexor, the next 49 do not. Thus, why some advocate for EVERYONE to have to endure some prolonged and unnecessary withdrawal protocol is just ludicrous to have to read.
Again, I think readers can decide if my point about the role of characterological features playing into this need to be decrease by 1-2% of the dose by weeks at a time, well, not even Methadone needs that kind of detox.
Pharmacokinetics are such that a change of diet or exercise or water intake can effect blood levels more that 1-2% so it is reasonable to infer that anyone taking any drug will have greater than this variation on a daily basis. If you’re taking Effexor at the same dose on a steady basis, it’s absurd to think that everyday your serum levels aren’t already going up and down 10% or so anyway. Not to mention peak/troughs based on half-life and time of day administration.
Humans are not Ehrlenmeyer flasks.
Dr. Hassman, do you have a link to a study that proves your contention that most people do not need a slow taper or is that based on your experience as a psychiatrist.
Regarding personality issues being a factor in withdrawal, just wanted to state an experience I had with a regular doctor regarding a med side effect. When I called to complain about it, I was told to stop taking it until further evaluation. No questioning my competence or personality.
Regarding the slow taper, as slow as I tapered off of 4 psych meds, I actually think I would have done better going even more slowly. For various reasons, I feel going too fast would have been a disaster and no, it had nothing to do with my personality. I am quite sensitive to meds and feel I take after a family member who also had difficulty with them.
Treatment is on an individual basis, note I am NOT saying NO ONE has a need for a slow taper off an SSRI or other psychotropic that could legitimately have a physiological withdrawal risk, but, some people at threads debating the need for tapers that are slow infer that anyone on these meds should be tapered at a pace that just agitates the process until proven otherwise. Come on folks, there are psychological withdrawal factors, and somaticizing via meds is not so far fetched a concept.
And I am sticking to my guns, those I have met who claim a need to taper for more than 3-4 months and only on the medication for less than a year have comorbid issues beyond an Axis 1 diagnosis, if a legitimate Axis 1 diagnosis in the first place. Hey, just my imperfect opinion.
I agree the above comment. My point was that if a 2% or even 5% variation in dosage caused discontinuation syndrome, then people taking the drug steadily as prescribed would have discontinuation syndrome every other day.
Mickey, there does indeed seem to be wide variation in tolerance for psychiatric drug reduction.
It could be that some people do fine switching or going off psychiatric drugs a few times, but eventually develop a vulnerability to withdrawal syndrome.
There’s another twist — on Surviving ADs, we see people who seemed to have done fine with a conventional taper of a few weeks or even cold turkey who, some months later, develop odd symptoms. These symptoms can resemble withdrawal symptoms in that they come in intense waves that do not have any other cause. (Fortunes have been spent on MRIs, etc. for this.)
In other cases, the symptoms are more psychological, tending towards emotional anesthesia or depersonalization.
El-Mallakh, et al, 2011 termed this “tardive dysphoria.” Andrews, et al, 2011 suggested this phenomenon is related to Giovanni Fava’s theory of oppositional tolerance, first proposed in 2003, in which correction of drug-induced receptor downregulation may be impaired in some individuals, or leave them with fragility in that regulatory system.
Andrews, et al, 2011 speculates on the evolutionary mechanisms behind the phenomenon of more frequent “relapse” after antidepressant use (some of the “relapse” being prolonged withdrawal syndrome).
The new quasi-targeted psychiatric drugs may have a more intensive downregulation effect than the older drugs of addiction. Very little research has been done on to what extent serotonin receptors re-regulate after chronic medication, and how long this might take.
(I was once in a very long e-mail discussion with Dr. Fava, Dr. Andrews, and Robert Whitaker about whether serotonin receptors recover in this situation. Opinions were mixed.)
Brian H. Harvey published a paper in 2003, “Neurobiology of antidepressant withdrawal” and has since written a number of papers on the topic that support Fava’s metaphor of a compressed spring that springs back with compromised elasticity.
Stuart Shipko, a clinical psychiatrist with a background in neurology who has somewhat of a subspecialty in withdrawal from benzos and antidepressants, believes that “tardive dysphoria” is fairly common after long-term antidepressant use, and takes pains to inform patients who come to him that going off an antidepressant carries this risk.
Another clinical psychiatrist of my acquaintance, with a specialty in “treatment-resistant depression,” is preparing a naturalistic study on the hypothesis that long-term antidepressant use might contribute to the condition.
Please see our 1,700+ case reports at http://survivingantidepressants.org/index.php?/forum/3-introductions-and-updates/ and form your own hypotheses about what rate of taper best protects your patients.
Actually, Altostrata and AA are on to something, the more potent an SSRI like Paxil and Lexapro seem to be, then the more sequelae not only for side effects while ON the medication, but getting off them as well.
And, what is this BS by colleagues writing for dosages above 60mg for Paxil and 30mg for Lexapro anyway?! You want to be a maverick and go beyond the FDA rec for ceiling dosage limits, then be prepared for consequences with your patients!
Again, as I have said repeatedly, if the comparison for Lexapro to Celexa is about a 10mg to 30 mg ratio respectively for them, then I just want to ask these docs writing for 30mg plus of lexapro, do you write for 80mg or more of Celexa?
Oh, my bad, you would then have to defend yourself to FDA limits of 40mg with Celexa these days, not that I agree with the FDA on that 40mg limit, but 60mg, yes, I do adhere to that limit.
People, if you have consequences with supra therapeutic dosage prescribing by your doctor with an SSRI, he/she needs to explain this ceiling violation, and if you are ok with it, then, good luck!
By the way, sorry, I know this next comment is being ignorant to some degree, but, that site of surviving antidepressants, it isn’t about surviving but just bitching until proven otherwise. People get off SSRIs and other antidepressants and move on, just like they do with Meth and opiates and benzos in general.
Some people just want to be on a stage…
By the way to AA earlier, no, I don’t have a link to a study, I have 20 years plus of prescribing experience what works to get people off meds if they want to go that route. I am on to your thinking, if there is no study, then there is no validation to my opinion based on experience.
Besides, then you go off when a “study” dissents from your agenda, so, studies and stats just to back up your agenda is not validation, just cohorts to the message trying to be sold.
SSRIs have a dark side, but, that infers there is a bright side too. If the moon was never full again, is that a good thing???
Joel, how often do you hear this complaining while your patients are tapering or after they’ve been off the drug for a while?
Would there be any downside to recommending they taper more gradually, other than extending your therapeutic relationship with them?
If a patient is having a legitimate difficult time tapering off a medication per my recommendation, of course I would advise a bit longer taper, but, where is the legitimate biological reaction to a taper off a medication a person has only been on for several months to a year at most? You have alluded in past comments at other threads and sites that even if on these meds for a few months there are those who need to be tapered for 6 or more months, and that is just preposterous to hear.
Yes, when someone has been on an SSRI for yearS and is going off and not substituting, I agree there should be a long taper, maybe for 3-4 months if not a bit longer, but, you don’t address my theory there could be a psychological withdrawal factor that could play out with somaticizing. It is not that outlandish, maybe not applicable to all who are claiming withdrawal issues still after tapering for more than 4 months, but, don’t dismiss there are those with coexisting Axis 2 factors to getting themselves on these meds in the first place.
People need to move on after failing multiple medication trials. I saw someone recently who admits to failing every single antidepressant on the market in the past 15 years, and is still looking to be on yet another trial. Why is it considered absurd there needs to be another perspective to seek out reduction of symptoms not involving medication, at least for a six month period?
I’ll tell you why, maybe not for this specific person as I don’t know the person well enough yet, but, some people really can’t handle the truth. Mood lability is not always just an Axis 1 mood disorder. And why medicating Axis 2 can be more debilitating than not medicating at all. But, how many psychiatrists not only can’t admit that, but even can’t understand that!?!?
Give the wide variability in human psychology as well as neurology. it could be that some “somaticize” when withdrawing. Still, if it’s anxiety that causes them to report withdrawal symptoms, why not slow the taper to a rate that is more comfortable for them? This might contribute to a relationship of trust. Why continue to punish them?
However, withdrawal syndrome is the horse, not the zebra — it is “somatization” that is the rare striped animal. Early studies of withdrawal syndrome (some authored by Mauricio Fava and Alan Schatzberg before they sold out to the drug companies) stated that anyone taking antidepressants for more than ONE MONTH is at risk for withdrawal syndrome. Rate of withdrawal syndrome ranged from 20% to 80%.
(From what we see at SurvivingAntidepressants.org, length of having taken the drug is no predictor of difficulty in withdrawal, which must be based on an combination of drug action and individual neurology.)
Warner, et al, 2006 (full text here) http://www.aafp.org/afp/2006/0801/p449.html carefully explains “A high index of suspicion should be maintained for the emergence of discontinuation symptoms” (a phrase borrowed by Mickey for a 2011 post http://1boringoldman.com/index.php/2011/10/22/high-index-of-suspicion/)
As for how long a taper should take, the final arbiter is the patient’s own nervous system. If a person feels withdrawal symptoms by reducing by 25% after taking 20mg Celexa for 5 months, that rate of taper is too precipitous for that person.
Given you cannot predict who can easily go off an antidepressant, it would seem prudent to start slow and low in terms of dosage decrements. On SurvivingAntidepressants.org, we have many, many people who developed severe withdrawal syndrome from 25% reductions.
If you preconceive your patients’ complaints as nothing but “bitching,” you risk misidentifying withdrawal symptoms as psychological problems — exactly what dozens of papers about withdrawal syndrome warn against.
If you insist that long-term post-discontinuation complaints are likewise “bitching,” you risk missing an important under-reported adverse consequence of too-fast withdrawal.
It sounds like you have heard both types of “bitching” in your practice. You might well consider a more gradual rate of taper overall if you don’t want to hear more of it.
What is this persistent “gradual rate of taper” you keep echoing? What part of my prior comments aren’t saying that to some degree?
You should work at a Methadone clinic, as your philosophy about tapers would encourage a snail to just laugh and dash by these patients. Here’s an opinion why Meth clinics are a joke now for two reasons at least: 1. they tell patients they have to have these 1-2mg tapers at 50mg so they “won’t be discomforted and risk relapse”, but, do the math for 2mg every week from 50mg; yeah, that is at least a half a year, and that gives time to trip them up with something to then make the dose be raised again “for next time’s attempt to wean”; then 2. be tolerant that other docs can put these addicts on benzos to minimize the anxiety side effects from tapers, like, xanax, that has an additive effect for a large portion of Meth users to feel elation and then NOT want to taper.
Here is the irony, per my perspective, from your theory of long tapers: the patients stay on these meds that you so despise in the first place longer than necessary, risk wanting to easily stop the taper and thus continue the meds, and then risk the psychological assumption they won’t be able to get off and thus become “addicted”. Seems to distract from the agenda at the end of the day, not be on the meds that are so near impossible to stop.
So, antidepressants get falsely lumped as opiates, are near impossible to stop without some level of discomfort, and most people now believe that there should be no withdrawal syndrome in any fashion, so why go off them in the end?
Or, suck it up to some degree, have the few weeks of some discomfort when at 10% of the original high dose, and then be free once that time passes and are off the meds, and then stay the hell away from them hereon.
Hey, just my imperfect opinion.
Joel, Alto…
I think you could just go on forever with this and I sure don’t want to jump into the middle, but there is one thing that I’ve thought about all of this. It seems like there is a difference between Opiate/Benzo withdrawal and the withdrawal from SSRIs and the like. With both kinds, there’s a fear/terror of the physical withdrawal symptoms. That’s the case with the lady I mentioned above [Effexor]. She is terrified, period. But with the opiates and Benzos, there’s something else – a loss. People lose the euphotia/anxiolytic effect of the drug too. I’m not aware that the SSRIs have that as part of the picture.
And while I’m at it, the other thing I’ve seen since I moved to Appalachia where home cooked meth is the thing is that the kind of prolonged craving/discomfort those people experience when they stop goes on and on and on. I’ve never seen anything like it. Well over a year, well over. And I think it’s physical because it’s such a constant complaint. Up here in the mountains, the courts and parole officers follow them like hawks because they relapse in that first year with such great regularity. And when you ask why, they often say, “I couldn’t not.” Whatever that means. When I first encountered the legal vigilance, I thought it was big brother-ish. But now I see it as the right thing to do. I’ve had patients say that too.
Interesting thoughts on loss, opiates and benzos. It’s tempting to feel that this sense of loss strikes some users as unpredictably as SSRI withdrawal, because one can think of heroin addicts who basically just moved on at some point, and others who have a lot more trouble with it. As one of my friends (currently recovered from vitamin H about 10 years) put it, “Those dogs never stop barking,” but it;s just not that way for other people I’ve known who are in recovery from terrible opiate habits.
Meth is just a baffling drug to me. It’s almost in a class by itself in terms of recreational drugs, because the half life is so damn long and it induces such a long-lasting psychotic state. Stop smoking for two weeks and you could be on your way to recovery, and nicotine addiction is hardly trivial. Quit smoking meth for two weeks, and your odds of relapse barely budge.
The “change of state,” as Dr. Nardo aptly puts it, is something I would never risk putting myself through again, whether it was a side effect or a withdrawal artifact. I thought I had gone through andropause, except it had happened so fast that I knew that was impossible. And it lasted for years.
It was only one aspect of arousal that was affected, and it was like nothing I had ever experienced in my life. It was like losing a part of being human. (And when it returned it was equally abrupt, and perhaps even more disorienting, like going through some weird form of adolescence at 52.)
I’d rather lose my memory, my sanity, than deal with anything like that ever again. Cravings for alcohol or nicotine I experienced seem trivial in comparison, but I suppose I was pretty damn sick of them by the time I stopped. (I was also surrounded by psychotherapists, had been in therapy for nearly half a century, been meditating for 30 years– there are a lot of reasons it may have seemed easier to me. And of course, in a lot of ways it wasn’t and still isn’t, I’m just saying the paroxetine shook me up a lot more.)
Mickey, that craving is the distinction drawn between drugs of abuse and other psychoactive drugs.
Catalyzt, the sexual anesthesia has a name: Post-SSRI Sexual Dysfunction (PSSD). There is a small body of journal articles about it (see http://survivingantidepressants.org/index.php?/topic/786-papers-about-post-ssri-sexual-disorder-pssd/), several Web sites containing many anecdotal reports from patients, and a long-standing Yahoo discussion group, SSRIsex.
PSSD is not the most disabling component of long-term withdrawal syndrome, but those who suffer from it find it very distressing, particularly the males. As you say, the void is existential.
From anecdotal reports, PSSD seems to resolve very, very gradually and may last for many years. Some see no end in sight.
I experienced it as genital anesthesia for about 4 years (other symptoms continued). A change of state? I’d have to agree with that. Overall, my nervous system will never be the same.
Regarding psychiatric drugs, I do not have contempt for them. Drugs are inanimate objects that can be used for benefit or for injury.
A psychiatric drug never ran a TV ad misrepresenting its capabilities, made an incorrect diagnosis, prescribed itself and a bunch of ill-assorted fellows, or subsequently ignored complaints from patients of adverse effects.