Introduction to Antidepressant Withdrawal
In early 2023, Liana Shatova began taking low doses of an antidepressant to ease symptoms of a premenstrual disorder marked by mood swings, anxiety and depression. At first, the difference was remarkable for her.
“I felt full of energy and could juggle multiple things at once,” said Shatova, 40, a business development manager from the Greater Boston area.
Then, after around 18 months on the medication, she started to fear she was becoming emotionally numb.
“My best friend’s mom died unexpectedly, everyone was in shock and sobbing, and I couldn’t cry at all,” said Shatova. “I just felt nothing.”
When Shatova asked her doctor if she could stop taking the medication sertraline, an antidepressant better known by its brand name Zoloft, she said she was reassured that she was on the lowest prescribed dose and that coming off it wouldn’t be difficult.
Initial Withdrawal Symptoms
Initially all seemed well, but after a month, Shatova said she experienced her first bout of what would become chronic insomnia, followed by panic attacks. Other symptoms emerged, including night sweats, muscle and joint pain and mood swings that left her unable to work.
She said her doctor told her that the symptoms were a relapse of her premenstrual dysphoric disorder, and suggested a different antidepressant. Shatova declined the new drug.
Antidepressants, primarily SSRIs, or selective serotonin reuptake inhibitors, are some of the most widely prescribed medications in the United States, taken by tens of millions of adults. About twice as many women as men report using an antidepressant in the past 30 days, with antidepressant use highest among women aged 60 and older, according to government data.
Side effects are a key reason people choose to go off their medication, but stopping the drugs can also lead to withdrawal symptoms, research indicates. Along with the growing awareness, a deprescribing movement is building up in the field of psychiatry, aimed at helping patients reduce or stop their medications when no longer considered necessary.
Research on Antidepressant Withdrawal
In a recent large analysis published in The Lancet in November, researchers at King’s College London found that physical side effects, including quick weight gain, significantly increased heart rate or elevated blood pressure, may be more common than once thought, depending on the drug. The review analyzed results from 151 clinical trials and 17 reports from the Food and Drug Administration, involving about 30 different prescription drugs used to treat depression, anxiety, and bipolar and panic disorders.
The researchers examined the effects of antidepressants on weight, blood glucose, total cholesterol, blood pressure and heart rate. They didn’t look at emotional changes experienced by patients such as Shatova, although the lead study author said it should be examined further in future studies.
“Not all antidepressants are built the same when it comes to their physical health side effects,” said Dr. Toby Pillinger, an academic clinical lecturer at King’s College London, who led the study. “Up until recently, we’ve approached antidepressant prescribing with a one-size-fits-all policy, and I think we need to move away from that.”
Severity of Withdrawal Symptoms
Separately, in August, psychiatry researchers in the U.K. found that serious withdrawal effects may be more common than previously suspected, especially with longer-term use, although the study was small with just 18% of participants responding to the survey. The results showed that among people who had been taking antidepressants for more than two years, 63% reported moderate or severe withdrawal effects, with a third describing withdrawal issues that lasted more than three months.
Symptoms ranged from insomnia to confusion, electric sensations, muscle cramps, agitation, mood swings and derealisation or an alteration in the person’s perception of the world.
Dr. Mark Horowitz, a clinical research fellow at University College London who led the withdrawal study, said other research has found that roughly a quarter of patients experience severe symptoms when they abruptly stop taking their medications, from burning pain in the skin or limbs, balance problems, ongoing panic attacks, and sound and light sensitivity.
Abrupt cessation of antidepressants is not recommended, but research has found that withdrawal symptoms can occur even when people attempt to taper. A review of various existing studies published last year by a group of German psychiatrists concluded that as many as 1 in 3 antidepressant users will experience some kind of withdrawal symptoms, with severe symptoms occurring in 1 in 30 users.
Understanding Withdrawal Symptoms
Dr. Joseph Goldberg, clinical professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York, said that antidepressants have long been known to cause "discontinuation symptoms," mainly nausea and dizziness, particularly if stopped abruptly.
It’s unclear why some patients have severe symptoms after stopping their medications. Some researchers, concerned by reports of antidepressant withdrawal, suggest that the underlying mechanisms are similar to those faced by people suffering from alcohol and opiate withdrawal.
“Withdrawal symptoms tell you that your brain is trying to restore a balance that it was forced to change by the presence of a drug,” said David Cohen, professor of social welfare at the University of California Los Angeles. “I think it’s the best accepted explanation for why stopping any centrally active drug, whether its antidepressants, coffee or heroin, leads to some discomfort.”
Challenges in Psychiatry
The challenge for psychiatrists is that the drugs, which are often prescribed along with therapy, do help many people, particularly in the short term. Dr. Jonathan Alpert, a psychiatry professor at Albert Einstein College of Medicine, said that anecdotes of extreme withdrawal do not reflect his own professional experience.
In his practice, Alpert estimated that two-thirds of his patients have been on antidepressants for more than five years, and only a small handful had experienced protracted withdrawal symptoms lasting more than a few days.
“There’s been this very inflated idea that it’s really difficult to come off psychiatric medications,” said Alpert. “Even though I respect people’s narratives of their own experience, it feels very different from what we see in clinical practice and research studies.”
Goldberg also expressed skepticism as to whether antidepressants themselves are actually responsible for the symptoms being reported by patients.
“If somebody, after years of treatment, develops some frankly rather peculiar and unexpected neurological problems, I’m not sure how confident one can attribute that to medicine,” he said. “Anything is possible. But I think we have to consider the more likely possibility that the thing they’re encountering may be unrelated.”
Tapering Off Medication
More than a year after Shatova first attempted to taper off the medication, she said she’s still undergoing a painstaking process of tiny, gradual reductions to try to avoid exacerbating her symptoms.
“I am still tapering and now at 0.835 mg of Zoloft, doing it very slowly and carefully,” she said. “My sleep has gotten better, but I still have windows and waves triggered by life stresses and hormonal fluctuations.”
It’s essential not to dismiss people’s experiences, Goldberg said, and anyone going through symptoms should undergo further testing. A past president of American Society of Clinical Psychopharmacology, Goldberg said that the organization is now completing new guidelines on deprescribing. The goal is to help doctors explain what to expect when stopping psychiatric medications so patients don’t self-taper without medical supervision.
Future Research
Alpert suggested analyzing different types of data stored in electronic health records to get insight into the characteristics of patients who have prolonged withdrawal symptoms.
“Do they have abnormal MRIs or blood tests with inflammatory markers? Through looking at large datasets, it will be more possible to identify predictors of this subset of people who seem to have unusually prolonged symptoms.”
Cohen feels that the field of psychiatry needs to speed up research. However, in the wake of the 43% cut to the National Institutes of Health annual budget proposed to Congress by the current administration, a figure which is equivalent to $20 billion per year, it is likely that such studies would need to be carried out by either U.K. or European researchers.
“We need large, nonindustry funded trials to examine what happens when people stop antidepressants, using various tapering strategies and long enough follow-up,” Cohen said. “We need dozens of such trials now.”
Conclusion
The issue of antidepressant withdrawal is complex and multifaceted, with many factors at play. While some patients may experience severe symptoms when stopping their medications, others may not. It’s crucial for doctors and patients to work together to find the best approach for each individual, taking into account their unique circumstances and medical history. By continuing to research and understand the mechanisms of antidepressant withdrawal, we can better support those who need to stop their medications and improve their overall quality of life.
FAQs
Q: What are the common symptoms of antidepressant withdrawal?
A: Common symptoms of antidepressant withdrawal include insomnia, panic attacks, night sweats, muscle and joint pain, and mood swings.
Q: Can antidepressant withdrawal be severe?
A: Yes, some patients may experience severe symptoms when stopping their medications, including burning pain in the skin or limbs, balance problems, ongoing panic attacks, and sound and light sensitivity.
Q: How can doctors help patients who are experiencing antidepressant withdrawal?
A: Doctors can help patients by explaining what to expect when stopping psychiatric medications, providing guidance on tapering off the medication, and offering support and monitoring throughout the process.
Q: What is the deprescribing movement?
A: The deprescribing movement is a growing trend in the field of psychiatry aimed at helping patients reduce or stop their medications when no longer
