About 20% of patients develop antidepressant discontinuation syndrome following an abrupt stoppage of or marked reduction in the dose of an antidepressant taken continuously for one month.1 Symptoms are usually mild and may occur following treatment with any type of antidepressant. Symptoms occur within two to four days after drug cessation and usually last one to two weeks (occasionally may persist up to one year). If the same or a similar drug is started, the symptoms will resolve within one to three days. Sociodemographic and clinical factors associated with increased vulnerability have not been identified.2 Among the serotonin reuptake inhibitors, paroxetine is associated with the highest incidence of the syndrome and fluoxetine with the lowest. Because of venlafazine’s short half-life, the syndrome may occur more frequently following cessation and symptoms may be more severe.1 Failure to recognize antidepressant discontinuation syndrome may result in medical or psychiatric misdiagnosis. The mnemonic FINISH summarizes the symptoms of antidepressant discontinuation syndrome: Flu-like symptoms (lethargy, fatigue, headache, achiness, sweating), Insomnia (with vivid dreams or nightmares), Nausea (sometimes vomiting), Imbalance (dizziness, vertigo, light-headedness), Sensory disturbances (“burning,” “tingling,” “electric-like” or “shock-like” sensations) and Hyperarousal (anxiety, irritability, agitation, aggression, mania, jerkiness).3 Cessation of antidepressant therapy may increase the risk of relapse of depression or anxiety. Unlike the symptoms of antidepressant discontinuation syndrome, symptoms of relapse usually take more than a few days to appear and to disappear following reintroduction of the antidepressant.4 Physicians should be vigilant at times when patients may consider stopping an antidepressant (e.g., during pregnancy). Because not all formulations of the same drug are bioequivalent, there may be an unintended reduction in drug concentration if an antidepressant is switched to another formulation. To minimize risk of the syndrome, patients should be encouraged to consult their physician before stopping an antidepressant. Prescribing an antidepressant with a longer half-life or tapering the medication over six to eight weeks may reduce the risk.4 Management of antidepressant discontinuation syndrome needs to be done on an individual basis because of a lack of specific treatment data (Box 1).2,3,5 Prevention and management of antidepressant discontinuation syndrome2,3,5
Competing interests: Verinder Sharma has received grants from Assurex, Genome Canada, Neurocrine Biosciences, Stanley Medical Research Institute and Sunovion Pharmaceuticals. No other competing interests were declared. This article has been peer reviewed. 1. Diagnostic and statistical manual of mental disorders. 5th ed Arlington (VA): American Psychiatric Association; 2013:712–4. [Google Scholar] 2. Fava GA, Gatti A, Belaise C, et al. Withdrawal symptoms after selective serotonin reuptake inhibitor discontinuation: a systematic review. Psychother Psychosom 2015;84:72–81. [PubMed] [Google Scholar] 3. Berber MJ. FINISH: remembering the discontinuation syndrome. Flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal (anxiety/agitation). J Clin Psychiatry 1998;59:255. [PubMed] [Google Scholar] 4. Warner CH, Bobo W, Warner C, et al. Antidepressant discontinuation syndrome. Am Fam Physician 2006;74:449–56. [PubMed] [Google Scholar] 5. Ogle NR, Akkerman S. Guidance for the discontinuation or switching of antidepressant therapies in adults. J Pharm Pract 2013;26:389–96. [PubMed] [Google Scholar] Articles from CMAJ : Canadian Medical Association Journal are provided here courtesy of Canadian Medical Association
Medically reviewed by Rebecca Barnhart, PharmD, BCPP — Written by Jayne Leonard on May 4, 2021 Some people may experience symptoms when coming off antidepressants. These symptoms, known as withdrawal or discontinuation symptoms, can vary in their onset, severity, and duration. Withdrawal symptoms may occur if someone stops antidepressants because of rapid changes to the chemicals in the brain. These chemicals are called neurotransmitters, and they include serotonin, dopamine, and norepinephrine. Research indicates that discontinuation symptoms are common, affecting over half of people who stop taking antidepressants. But there are ways to help reduce and manage withdrawal symptoms. This article discusses discontinuation symptoms and explains how people can reduce any symptoms they may experience while coming off antidepressants.
Individuals may experience one or more of the following when coming off antidepressants:
People may also experience a return of depression and mood-related symptoms, including:
Timeline of discontinuation symptomsSymptoms may appear within 2 days of stopping antidepressant use and persist for several weeks. In a 2019 review of existing research, the authors noted that it is not uncommon for people to have antidepressant withdrawal symptoms for many weeks or even months. Some studies found that 40% of people had symptoms for 6 weeks, while 25% experienced symptoms for 12 weeks or more. Several factors may influence the duration of symptoms, including the drug’s half-life. This is a measurement of the time it takes for the drug’s active substance to reduce by half in the body. Drugs with a short half-life typically cause more withdrawal symptoms than those with a long half-life. Some popular antidepressants, and their approximate half-lives, are: Another influencing factor is the length of time someone has been taking antidepressants. The longer a person has been taking the medication, the more likely they are to have withdrawal symptoms. All antidepressants can cause withdrawal issues if someone has taken them for longer than 6 weeks, particularly if they stop or rapidly reduce their dose. Withdrawal symptoms vs. relapseIf someone has mood-related symptoms following antidepressant withdrawal, it does not always mean a relapse. To differentiate between withdrawal symptoms and relapse, a person should consider the following two things. First is the time of onset. Discontinuation symptoms appear shortly after coming off antidepressants, whereas relapse symptoms develop gradually, sometimes several weeks later. Second is how symptoms change over time. Discontinuation symptoms reduce as the body adjusts to the removal of antidepressant medication. Conversely, in a relapse, the depressive symptoms continue or get worse. Individuals who wish to come off antidepressants should discuss this with their doctor before making any medication changes. People should not stop taking antidepressants abruptly, as it could cause severe withdrawal symptoms. Strategies to minimize withdrawal symptoms include:
Individuals should only stop taking antidepressants when they have discussed it with a doctor. People should not make medication changes without professional advice. Carefully consider the benefits and disadvantages of stopping antidepressant treatment. It may be that another antidepressant would be a better option or that other therapies could help manage some of the adverse effects of antidepressant use. It is also worth considering if the antidepressants need more time to work — it can take 4–12 weeks to see a response to the treatment. In studies on adults with moderate or severe depression, 40–60% report improvements within 6–8 weeks. Those who wish to come off antidepressants because they feel better should ideally wait for at least 6–9 months after complete symptom remission before stopping their medication. But for people with chronic symptoms of depression or a history of multiple depressive episodes, doctors recommend that people continue to receive treatment. As a result, some people may need to take medication indefinitely. The following tips may help people who are coming off antidepressants:
Doctors may also help by making certain adjustments to a person’s medication. If someone is switching to another antidepressant, they could slowly decrease the dose of the current medication while increasing the dose of the new one. This method is called cross tapering. Another method to help manage withdrawal symptoms is to restart taking the medication at the dose the person was taking when the symptoms began. The doctor can then start a slower tapering of the doses. Individuals should speak with their doctor if they are experiencing unwanted side effects of antidepressant use. Their doctor may recommend switching to another drug or taking other medications to reduce adverse reactions. Those who wish to come off their antidepressants should ask their doctor how to do so safely with medical supervision. People who are experiencing discontinuation symptoms after coming off medication should make an appointment with their doctor. If these symptoms are severe, seek prompt treatment. Call 911 if someone is having thoughts of suicide or having urges to attempt suicide. If someone has thoughts of suicide, but there is no immediate danger to life, they should speak with their doctor or a mental health professional without delay. The National Suicide Prevention Lifeline provides 24/7 support at 1-800-273-8255. Coming off antidepressants can cause several adverse effects. But there are ways to safely stop taking these medications while minimizing any potential discontinuation symptoms. Individuals who wish to stop taking antidepressants should work with their doctor to develop a plan that meets their needs. Last medically reviewed on May 4, 2021
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