Table 3 . Steps to deprescribing of the antidepressant therapy .
BEFORE : Make an informed decision ; discuss the options and alternatives ; be aware of possible withdrawal symptoms or return of depression ; consider starting psychotherapy ; if involved in psychotherapy , discuss well in advance of the final session ; make a plan ; choose a good time ; decide the speed of reduction ; establish a contact person in the event of problems ; seek support from friends and family ; make arrangement at work place as one may need time off ; avoid recreational substances , including alcohol .
DURING : Reduce slowly ; closely supervise and evaluate frequently to observe for symptom return or exacerbation ; be prepared to stop the reduction or increase dose again if needed ; keep a diary of symptoms and drug doses .
AFTER : Continue to monitor symptoms ; realize it may take some time before things fully stabilize ; keep active ; continue ( CBT )/ relaxation techniques if you have been taught these ; do not hesitate to see your doctor .
“ needs the pills .” Although more concerning in the elderly and ailing population , the selective serotonergic reuptake inhibitors ( SSRI ) use is associated with an increased risk of hyponatremia in the elderly , with studies showing an increased risk ranging from 0.5 to 32 %. 21 Also in the same population , antidepressant use is associated with an increased risk of falling and bone fractures in the elderly 22 and probably SSRIs associated lower bone mineral density . 23 The data from three prospective epidemiological studies have found that , even after controlling for depressive symptoms , antidepressant use is associated with an increased risk of death in the elderly . 24-26 The tricyclic antidepressants ( TCAs ) are usually associated with an increase in cardiac events , mainly due to anticholinergic properties and norepinephrine reuptake blockade . 27 However , studies on SSRIs effect on cardiovascular system have produced mixed results . In addition , in treatment of depression in children and adolescents , there is lack of clear evidence of SSRI ’ s being beneficial , with only two antidepressants , Fluoxetine and escitalopram approved by FDA for treatment of depression in children and adolescents . A meta-analysis by FDA found a higher rate of suicide related spontaneously reported adverse events with SSRI ’ s ( 4 % vs 2 %) and associated with few suicide attempts , no completion and occurring early in treatment and at the same time some evidence of prescribing outweighing the risks , it is important to use it judiciously and be aware of the side effects and prescribe for limited period of time . 28 This raises the question of how long to prescribe to avoid longterm side effects and whether or not to use nonpharmacological interventions for depression . As there are no clear guidelines on prescribing for how long and little is known about the effects , it would be wise to use it for a limited time period .
As such , the decision on how long to stay on antidepressant therapy does not have a straightforward answer and should involve a thoughtful discussion on the pros and cons of the therapy between the patient and the provider .
How to Taper and Discontinue Antidepressants
Once a decision is made to stop antidepressant therapy , steps should be taken to minimize or avoid the discontinuation symptoms that can occur if such medications are withdrawn too quickly . The term discontinuation symptoms is used to describe symptoms experienced on stopping prescribed drugs that are not drugs of dependence and is explained in the context of ‘ receptor rebound ’. 29 , 30 It has been hypothesized that antidepressants work by altering the levels of monoamine neurotransmitters in the forebrain . 31 As antidepressant therapy continues , neurons adapt to the changes in the level of neurotransmitters and rapid discontinuation of antidepressants leads to monoamine imbalances , causing symptoms that could range from mild to severely distressing . Usually an interruption of antidepressant therapy for five to eight days , or after missed doses of antidepressants with short half-lives , are associated with the emergence of new somatic and psychological symptoms . 32 , 33 These can be broadly divided into six categories : affective ( e . g . anxiety , irritability , depressed mood , or suicidal thoughts ); gastrointestinal ( e . g . nausea , stomach upset ); neuromotor ( e . g . ataxia , headaches ); vasomotor ( e . g . diaphoresis , dizziness ); neurosensory ( e . g . paraesthesia , electric shocks , or head zaps ); and other neurological ( e . g . vivid dreams , insomnia , or fatigue ). 30 Discontinuation symptoms are experienced by at least a third of patients 34-37 and are seen to some extent with all antidepressants . 38 Discontinuation syndrome is generally not medically dangerous but may be uncomfortable . Symptoms can vary in form and intensity and occur in any combination . They are usually mild and self-limiting , but can occasionally be severe and prolonged . The absence of forewarnings may negatively affect the perception of symptom severity . Table 1 describes proposed diagnostic criteria for the selective serotonin inhibitor discontinuation syndrome . 39 , 40 Symptoms vary according to the class of antidepressant ( see Table 2 ) and can be quantified using the discontinuation – emergent signs and symptoms ( DESS ) scale 35 .
Based on the nature of symptoms and time course of the emergence of the symptoms , one should be sure to differentiate antidepressant discontinuation syndrome from relapse of depression and other psychiatric and medical conditions , to avoid unnecessary investigations or reintroduction of the antidepressant . 41 Some studies have reported that half lives of sertraline , citalopram , paroxetine and bupropion are much shorter in adolescents than in adults . Therefore , one should be alert to the possibility of withdrawal side effects when these medications are being prescribed once daily . 42
When an antidepressant is being discontinued , it is best to taper the medication over the course of at least several weeks . Although anyone can experience discontinuation symptoms , the risk is increased in those prescribed short half-life drugs ( e . g . paroxetine , venlafaxine ) and higher speed of taper or abrupt cessation . 32 , 35 The risk is also increased in those who have been taking antidepressants for eight weeks or longer , 24 those who have developed anxiety symptoms at the start of antidepressant therapy ( particularly with SSRIs ), children and adolescents , those receiving other centrally acting medication ( e . g . antihypertensives , antihistamines , antipsychotics ), and those who have experienced discontinuation symptoms before . At-risk patients may need a slower taper or a temporary change to a longer half-life antidepressant . For patients receiving psychotherapy , it is recommended to discuss the issue of treatment discontinuation well in advance of the final session . Table 2 provides taper recommendations to decrease the risk of discontinuation syndrome . The end of the taper may need to be slower , as symptoms may not appear until the reduction in the total daily dosage of the antidepressant is substantial . Patients receiving MAOIs may need to be tapered over a longer period . The treatment of the discontinuation syndrome is pragmatic . For mild symptoms , reassure the patient that they will pass in a few days . For severe symptoms , reintroduce the original antidepressant ( or another with a longer half-life from the same class ) and taper gradually while monitoring for symptoms . Some evidence supports the use of anticholinergic agents in tricyclic withdrawal and fluoxetine for symptoms associated with stopping SSRI , clomipramine or venlafaxine . 43
As the antidepressant therapy generally continues for months to years , so should the taper be given adequate time to take effect . Several months may be required depending on the clinical and patient related factors , dose and pharmacologic profile of the drug , duration of treatment , and response of the patient during the taper period . It is currently inconclusive whether the development of discontinuation symptoms has a genetic component . However , a recent clinical study indicated a possible
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