thursday (article II)

SSRI WITHDRAWAL PROCEDURE

Getting Off Antidepressants May Be Made Easier

 

The use of antidepressants has been steadily increasing since they were first developed 50 years ago, with no end in sight (see graph, below). These drugs are not only used for what might be considered a neurologically depressed mental state: about half the prescriptions are for eating disorders, post-traumatic stress syndrome, anxiety disorders, obsessive-compulsive syndromes, chronic pain, and a variety of other conditions.

 

The first major class of drugs put into clinical use for these applications were the tricyclic antidepressants (TCAs); the main drugs are amitriptyline (Elavil), imipramine (Tofranil), and nortriptyline (Pamelor). These were followed by monoamine oxidase inhibitors (MAOIs), of which phenelzine (Nardil) and tranylcypromine (Parnate) are still used for treatment resistant depression. One of the recent additions to the antidepressants is the class of selective serotonin reuptake inhibitors (SSRIs).

 

 

The commercial names of some SSRIs are well-known, such as: Prozac (fluoxetine), Paxil (paroxetine), Lexapro (escitalopram), and Zoloft (sertraline). The first SSRI, Prozac, was introduced in 1985, so there is now 20 years experience with this group of drugs. A newer class of antidepressants are serotonin-norepinephrine reuptake inhibitors (SNRIs), represented by Effexor (venlafaxine), introduced in 1993.

 

Withdrawing from use of SSRIs (and from SNRIs) is a frequently mentioned concern. Despite their effectiveness and relative low level of side effects, many people are uncomfortable with the idea of using drugs at all and seek to get off their daily antidepressant regimen as soon as possible. Some people get side effects, particularly sexual dysfunction and fatigue, and hope to be able to eventually be freed of those adverse effects by withdrawing from use of the drug after a period of successful treatment.

  

 

 

 

  

 

Depressed feelings often arise from stressful situations (brain defects might make it easier to become depressed), and people who find themselves in improved circumstances may be able to stop using drug therapy to control depression. Imbalanced brain function can be exacerbated or induced by poor health habits, and some people may change their lifestyle (e.g., increase exercise) and improve their nutritional status, hoping to reduce the need for use of drugs. In such circumstances, the SSRI or SNRI may be withdrawn. Yet, there are other cases, some with genetic basis, where continued medication is required, despite a desire to cease its use.

 

The problem of side effects from using the drugs is substantial. A study-interview (1) involving 672 patients who had discontinued or switched SSRIs was carried out to elicit reasons for the change, documenting the status at 3 and 6 months after starting treatment. It was noted that 43% of patients discontinued or switched their SSRI because of an adverse effect within the first 3 months of starting, while another 27% did so for this reason in the second 3 months.

 

The adverse effect most frequently reported as the reason for early discontinuation or switching was drowsiness/fatigue (10.2%), followed by anxiety, headache, and nausea (each at just over 5%). In a review of clinical studies involving SSRIs, it was found that 27% of patients withdrew from the studies due to either adverse events or lack of efficacy (2).

 

  

 

 

 

 

Changes in serotonin transport function and in neuroreceptor loading that occur over the course of antidepressant use create a dependence on the drug that takes some time to be eliminated even when the drug is no longer needed to stabilize depression. Adverse effects that can arise from reducing the drug dose have been given a name: SSRI Withdrawal Syndrome or SSRI Discontinuation Syndrome. To avoid this syndrome, very gradual withdrawal-as little as 5% dosage decline per week-has been recommended; rarely are the drugs withdrawn at a rate of more than 20% per week.

 

 

Unfortunately, many patients are hesitant to spend this much time withdrawing from the drug, and many physicians do not recommend such gradual dosage decline, believing that the majority of the patients will do well with relatively rapid withdrawal, so SSRI Withdrawal Syndrome can readily occur; some patients may experience the symptoms even with very gradual tapering of dosage. A sample tapering schedule has been recommended for commonly used drugs (3); other tapering schedules may be prescribed to patients:

 

 

Drugs	Suggested Withdrawal Schedule
Fluoxetine (Prozac)	Reduce by 5 mg every two weeks until dose is 5 mg/day, then by 2.5 mg every two weeks
Paroxetine (Paxil)	Reduce by 10 mg every two weeks until dose is 10 mg/day, then 5 mg/day every two weeks.
Sertraline (Zoloft) Venlafaxine (Effexor)* Fluvoxamine (Fluvox)**	Reduce by 25 mg every two weeks until dose is 25 mg/day, then 12.5 mg every two weeks. *For Effexor XR, decrease by 37.5 mg every two weeks. **Fluvoxamine is used in Europe and Canada for depression; it is currently only approved for OCD in the U.S.

 

 

The duration of withdrawal depends on the starting dose and the characteristics of the drug (such as its half life in the body). In the schedule presented here, reductions in dosage are made at two week intervals, usually involving 2-4 months of withdrawal duration.

 

  

 

 

In the following section, this article provides some suggestions regarding Chinese herbal assistance in alleviating or avoiding withdrawal symptoms, especially if one of the more rapid withdrawal schedules is attempted. It is important to note, however, that all patients taking SSRIs or SNRIs should consult with the prescribing physician, or with a psychiatrist, prior to considering any withdrawal from the drug. And, practitioners who offer Chinese therapies (such as acupuncture and herbs) must remain aware that those who suffer severe depression, which has been controlled by drugs, may suffer from their original neurological symptoms during and after withdrawal.

 

 

Concern should be expressed and appropriate observation taken to consider potential complications of suicidal ideation, which can be intense and unforeseen during SSRI withdrawal. Eating disorders or behavioral problems associated with reduction or elimination of the drug could lead to harm as well. In most cases, antidepressant drugs are intended for a limited duration of use (e.g., one year) to be supplemented by psychological counseling to help alleviate the ideation and behavioral problems; nonetheless, long-term therapy can be vital to the neurological health of some patients.

 

A listing of symptoms that have been repeatedly observed in patients withdrawing from SSRIs is arranged in the left column of the following table by general type, and paired with a potential TCM interpretation of the symptoms in the right column (offered by the current author).

 

Symptoms	Potential TCM Interpretation
Psychiatric anxiety, crying spells, insomnia, irritability, agitation, mood lability, vivid or bizarre dreams, difficulty with concentration and memory	Deficiency of blood affecting the liver and heart, with instability of shen and hun (spirit associated with the liver; especially affects dreaming). These symptoms may additionally correspond to qi deficiency and stagnation (liver/spleen disharmony or simple spleen weakness), so the total syndrome would involve qi and blood deficiency and qi stagnation, destabilizing the mind.
Neurologic dizziness, lightheadedness, headache, paresthesia (electric shock-like tingling), vertigo	Damp accumulation may produce all of these symptoms; insufficient rise of clear yang qi may also produce these symptoms.
Motor dystonia (gait instability), tremor	These symptoms may correspond to generation of internal wind, a condition which results from deficiency of liver blood.
Gastrointestinal nausea, vomiting, diarrhea	Accumulation of dampness is a possible cause; adverse flow of qi may occur (upward or downward flow contrary to normal flow).
Somatic chills, fatigue, lethargy, myalgias, rhinorrhea, sweating	Qi deficiency, along with impaired circulation of qi may cause these symptoms; dampness can contribute to all these symptoms.

 

Summing up the notes about TCM interpretation, the withdrawal syndrome may revolve around the problems of qi and blood deficiency, which may be accompanied by qi stagnation and dampness accumulation (in rare cases, also by internal wind). These deficiency syndromes of Chinese medicine are attributed to the spleen (for qi) and liver (for blood); a Western interpretation of the same pattern might be a relative deficiency in serotonin availability or an imbalance of neurotransmitters that occurs when the drugs are removed.

 

  ~ by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine

<tangent> Prozac stays in the body for so long that is least likely of the SSRIs to cause withdrawal symptoms. Some physicians will switch a person who is having problems tapering off another SSRI to Prozac, because it washes out of the body slowly, over several weeks, giving the body a chance to adjust. Other physicians are not aware of or won’t acknowledge the level of discomfort some patients experience when going off antidepressants.

Tags: anti-depressant, prozac