generally start abruptly with a few days of stopping the antidepressant - usually resolve within 24 hours if the drug is restarted (1)
terms 'antidepressant discontinuation symptom' and 'antidepressant withdrawal symptom' are used interchangeably in the literature
discontinuation is preferred by some authorities, as it does not imply that antidepressants are addictive or cause a dependence syndrome, whereas the term 'withdrawal' may imply this
SSRIs can, in some cases, be associated with a withdrawal/discontinuation reaction upon cessation of regular use
in addition to sensory and gastrointestinal-related symptoms, the somatic symptoms of the SSRI discontinuation syndrome include dizziness, lethargy, and sleep disturbances
psychological symptoms have also been documented, usually developing within 1-7 days following SSRI discontinuation
characteristics of the discontinuation syndrome have been linked to the half-life of a given SSRI, with a greater number of reports emerging from paroxetine compared to other SSRIs (1)
in the majority of patients
discontinuation symptoms are self-limiting, of short duration and mild
in a minority of cases they can be severe, last several weeks and cause significant morbidity
examples of featurs of SSRI discontinuation reactions include ataxia leading to falls, fatigue causing difficulty walking and electric-shock-like sensations impairing walking and driving
there is no accepted definition of an antidepressant discontinuation syndrome (1,2)
Incidence
a systematic review and meta-analysis states that incidence of antidepressant discontinuation symptoms is approximately 15%, affecting one in six to seven patients who discontinue their medication (3):
desvenlafaxine, venlafaxine, imipramine, and escitalopram were associated with higher frequencies of discontinuation symptoms, and imipramine, paroxetine, and either desvenlafaxine or venlafaxine were associated with a higher severity of symptoms
Time of Onset
symptoms usually appear within a few days of stopping an antidepressant or, less commonly, reducing the dose
onset of symptoms after more than 1 week is unusual
Duration
the majority of antidepressant discontinuation reactions are of short duration, resolving spontaneously between 1 day and 3 weeks after onset
Effect of Restarting medication
discontinuation symptoms usually resolve fully within 24 h if the original antidepressant is recommenced
Primary SSRI discontinuation syndrome
features of this have been suggested as (2):
Sensory symptoms
Paraesthesia
Numbness
Electric-shock-like sensations
Rushing noise 'in head'
Palinopsia (visual trails)
Disequilibrium
Light-headedness
Dizziness
Vertigo
General somatic symptoms
Lethargy
headache
Tremor
Sweating
Anorexia
Affective symptoms
Irritability
Anxiety/agitation
Low mood
Tearfulness
Gastrointestinal symptoms
Nausea
Vomiting
Diarrhoea
Sleep disturbance
Insomnia
Nightmares
Excessive dreaming
most common symptoms are dizziness, nausea, lethargy and headache (4)
some patients experience sensory symptoms (e.g. sensations resembling electric shocks) or symptoms of disequilibrium (e.g. dizziness) in brief bursts when they move their head or eyes
Primary TCA discontinuation syndrome
Has been suggested that characteristically features may include (2):
General somatic symptoms
Lethargy
headache
Tremor
Sweating
Anorexia
Affective symptoms
Irritability
Anxiety/agitation
Low mood
Tearfulness
Gastrointestinal symptoms
Nausea
Vomiting
Diarrhoea
Sleep disturbance
Insomnia
Nightmares
Excessive dreaming
MAOI discontinuation syndrome
reactions to MAOI discontinuation, particularly those reported with tranylcypromine, tend to be more severe than with other antidepressants (2)
features may include:
(i) a worsening of depressive symptoms, exceeding the severity of the state that originally led to treatment
(ii) an acute confusional state with disorientation, paranoid delusions and hallucinations
(iii) anxiety symptoms, including hyperacusis and depersonalisation
Reference:
Drug and Therapeutics Bulletin (1999), 37 (7), 49-52.
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