\nWithdrawal Symptoms after Selective Serotonin Reuptake Inhibitor Discontinuation:
A Systematic Review<\/a><\/div>\nby Giovanni A. Fava, Alessia Gatti, Carlotta Belaise, Jenny Guidi, and Emanuela Offidani <\/div>\nPsychotherapy and Psychosomatics<\/font><\/strong>. 2015 84:72-81.<\/div>\n[full text on-line<\/a>]<\/div>\n[supplementary material<\/a>] <\/div>\n<\/p>\n
Background<\/font><\/strong><\/u>: 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.<\/div>\nMethods<\/font><\/strong><\/u>: 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. <\/div>\nResults<\/font><\/strong><\/u>: 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. <\/div>\nConclusions<\/font><\/strong><\/u>: 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’. <\/div>\n<\/blockquote>\nWhile Fava et al sure seem to have scoured the literature, considering the incidence, there wasn’t nearly as much data as I would’ve thought. They say themselves:<\/div>\n\nIn 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.<\/div>\n<\/blockquote>\nThe supplementary material<\/a> is all available on-line in tables in a Microsoft Word file. <\/div>\nAs 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.<\/p>\n
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.<\/em>" 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<\/em>" symptom like decreased libido with Prozac®. Then it was "sometimes<\/em>", then "often<\/em>." 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<\/font> and her Surviving ADs site<\/a> – things like the withdrawal symptoms being interpreted as the "depression is coming back<\/em>" or always tapering with discontinuation rather than stopping abruptly. That information is available now, but not "back in the day." <\/p>\n
In this study by Fava et al, I kind of wish they had added OR ‘venlafaxine’ OR ‘duloxetine’ OR ‘desvenlafaxine’ OR ‘vilazodone’<\/font><\/strong> to their search string of ‘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’<\/font><\/strong>. The drug I’ve seen the most withdrawal problems with is Effexor® [venlafaxine<\/strong>]. I have recently seen a particular patient who is on 350 mg of EffexorXR®<\/font> daily [big dose], and is unwilling to even try to come down again, or try any maneuver like changing over to something else to then come down. Both she and her husband agree – she’s on it for life because she gets "so damn sick" with any attempt to lower the dose. That’s apparently not uncommon. I’ve sent her to Alto’s site, given her articles, but she’s not going to budge, at least not yet. The look on her face says volumes about the discomfort of withdrawal. I haven’t any idea what that dose of EffexorXR®<\/font> for life will do, and worry about that. But for the moment, she’s very clear about what she’s going to do – stay on it.<\/div>\n\n