Does Withdrawal Occur from Antidepressants?
When the term antidepressant medications is used, it refers to a specific type of medication that has the primary function to treat depression in people. A number of different medications may be used for people who are diagnosed with depression, but this class of medications consists of several subclasses. Many of these medications also have other medicinal uses, such as to treat anxiety, chronic pain, fibromyalgia, eating disorders, personality disorders, obsessive-compulsive disorder, and a number of other disorders/conditions.
Antidepressant medications are some of the most prescribed medications in the world. There are several major classes of antidepressants, which are organized based on their major method of action. Before going any further in discussing potential withdrawal symptoms, it is important to specify the general sub-classes of antidepressants:
- Selective serotonin reuptake inhibitors (SSRIs): This remains the most popularly prescribed class of antidepressants. These medications are believed to function by primarily increasing the levels of serotonin in the central nervous system by blocking the reuptake of serotonin once it is released in the neurons. They do not produce more serotonin; they simply are believed to block the reabsorption once the neurotransmitter is released. These include well-known drugs, such as Prozac, Paxil, Zoloft, and so forth.
- Tricyclic antidepressants: This was the major class of antidepressants before SSRIs were developed. These medications, such as Elavil and Anafranil, have a much broader mechanism of action than SSRIs. While their effectiveness in treating depression is similar to SSRIs, they have a much harsher side effect profile. They are as not commonly prescribed in the treatment of depression, but still have uses in other areas.
- MAO inhibitors: This class of drugs is rarely prescribed these days due to potential severe side effects. Their mechanism of action is to inhibit monoamine oxidase, a substance that breaks down certain neurotransmitters in the brain. Nardil and Parnate are examples of these drugs.
- Atypical antidepressants: This group consists of a number of different medications that have a different mode of action from the other three groups. The medicinal drugs here are Effexor, Wellbutrin, Cymbalta, and Remeron.
Can Quitting Antidepressant Medications Result in Withdrawal?
At one time, this was a controversial topic; however, it is generally considered that there is a potential to develop tolerance to and withdrawal from antidepressant medications under certain circumstances. Before going any further, it is important to differentiate the notions of physical dependence(tolerance and withdrawal) from addiction or a substance use disorder.
The development of physical dependence occurs in regard to many different types of drugs/medications. This occurs when individuals take a drug over time, their systems become habituated to the drug, and they need more of the drug to achieve the effects that were achieved at lower doses (tolerance).
Typically, following the development of tolerance, some individuals will develop withdrawal symptoms if they stop taking the medication because their systems have also learned to adjust and function normally only within the presence of the drug. Once they stop taking the drug, their systems are thrown out of balance, and this leads to the withdrawal syndrome.
Tolerance and withdrawal symptoms (physical dependence) are potential signs of an addiction, but just having tolerance and withdrawal symptoms do not indicate that a person has an addiction. For instance, individuals can take antidepressants for years under the supervision of a physician and use them as directed. Some of these individuals will develop physical dependence on the antidepressants but they will not have an addiction. An addiction is a disorder of behavior that occurs as a result of the nonmedical use of specific drugs or medications that leads to a number of dysfunctional outcomes (the term addiction is now referred to as substance use disorder in professional and clinical contexts).
Thus, one can experience tolerance to and withdrawal from antidepressant medications and not be abusing or addicted to them.
While there is some documentation that antidepressant medications are occasionally abused, they are most often abused in the context of polydrug abuse where an individual abuses several different drugs, such as alcohol, benzodiazepines, antidepressants, etc. It is rare for an individual to abuse antidepressants alone or take them for nonmedical reasons. However, there is a defined withdrawal process for individuals who have taken antidepressants for a significant length of time. This syndrome is known as an antidepressant discontinuation syndrome (ADS). Anyone who goes through ADS is not necessarily suffering from a substance abuse disorder or an addiction, but that does not make the distress associated with the withdrawal syndrome any less severe.
Although it is generally recognized that ADS can occur in anyone taking any antidepressant medications, it is generally recognized that medications that have actions on the neurotransmitter serotonin are significantly more likely to lead to the development of ADS. ADS can occur if:
- The person has regularly taken the antidepressant medication for a period longer than 6-8 weeks. It is extremely rare for ADS to occur in individuals who have taken antidepressants for less than a 6-week time period.
- The person must abruptly stop taking the antidepressant after this time in order for potential ADS symptoms to occur.
- Not everyone who takes antidepressant medications for the above specified time period and abruptly stops using them will develop ADS. Approximately 20 percent of individuals who abruptly stop using antidepressant medications after taking them for longer than 6 weeks will display some symptoms of ADS.
Timeline of the Development of ADS
The actual timeline that will develop in individual cases may vary depending on the type of antidepressant medication used, the amount of the medication taken, the length of time using the medication, and individual differences in physiology. However, research on ADS suggests that unlike other types of withdrawal syndromes, the timeline is relatively linear and not defined by specific stages or specific symptom clusters as in withdrawal from alcohol or narcotic medications.
The general timeline for ADS is reported as following this pattern:
- People who develop ADS begin feeling symptoms within 1-3 days after stopping the antidepressant.
- The duration of the symptoms lasts 1-3 weeks.
- The symptoms peak within a week and then steadily decrease in severity.
- The symptoms are typically reported as being relatively mild and not lasting very long. They are often mistaken for having the flu or some other illness. They are also often misinterpreted as indicating the person’s depression is returning.
- ADS symptoms can be relieved within 24 hours by taking the antidepressant medication that the person quit using.
As mentioned above, there are no clusters of symptoms that appear together and designate different phases of the withdrawal process. The symptom profile is variable, and different individuals may experience different combinations of symptoms. For reasons of simplicity, the symptom profile can be generally broken down into groups of potential symptoms; however, please be aware that these may not occur together but most likely will occur in different combinations.
- It is not uncommon for individuals experiencing ADS to have some gastrointestinal issues. Typically, these symptoms include stomach queasiness or mild nausea. Sometimes, the nausea can be severe and leads to vomiting, but this is rare.
- Cold or flulike symptoms that include headache, fatigue, mild fever, chills, blurred vision, runny nose, and general malaise.
- Some individuals may experience dizziness, tingling sensations, mild problems with balance, and/or mild issues with walking as a result of these symptoms. Some individuals may also experience some mild tremors or shakiness.
- Mood swings, anxiety, depression, irritability, crying spells, and trouble sleeping may occur. Some individuals may have vivid dreams that are distressing.
- There are reports of the development of manic behavior or hallucinations; however, these are typically only associated with individuals who have a history of a severe psychological disorder, such as a psychotic disorder or bipolar disorder.
Unlike withdrawal from alcohol or benzodiazepines, the withdrawal that occurs from using antidepressant medications is not generally considered to be potentially dangerous. However, individuals who experience significant mood swings or depression might be at risk for self-harm. Moreover, individuals who have extreme physical reactions may be at risk for accidents or potential mishaps due to impaired judgment as a result of their compromised physical and mental condition.
Medically Assisted Treatment and Medical Detox for ADS
Often, individuals who are experiencing ADS and begin having issues with depression and or anxiety as part of the ADS symptom profile mistakenly believe that their depression is returning and begin taking the antidepressant medication again. As the symptoms of ADS resolve rather quickly when one resumes their antidepressant medication, this is taken as further evidence that they need to continue to take the medication or they will become depressed again. There has been a bit of a controversy stirred by this particular practice and by several findings suggesting that antidepressant medications may not be as effective in the treatment of depression as originally conceptualized. Interested readers can read the books The Emperor’s New Drugs and Psychiatric Drug Withdrawal: A Guide for Researchers, Therapists, Patients and Their Familiesfor a bit of a different perspective on these medications and their effects on depression. Both of these books are written by doctorate-level mental health professionals.
Because the symptoms of ADS are generally mild, and there are no specific medications to address ADS, medically assisted treatment most often considers administering medications to treat certain symptoms, such as nausea, headache, etc.
The best overall approach to negotiating ADS in individuals who want to discontinue using their antidepressant medication is to adhere to a medically assisted tapering strategy.
Under the supervision of a psychiatrist or other physician, the dosage of the antidepressant medication is periodically tapered down to allow the person’s system to become used to functioning with decreasing levels of the drug present. Once the level of the medication reaches a minimum amount, the physician discontinues it altogether. This tapering medical detox strategy typically avoids any symptoms of ADS that are potentially distressing.