SSRI Discontinuation Syndrome - Prevention and Treatment

Prevention and Treatment

Patients should be advised of the elimination half-life times of their specific medication, and patients should be aware if changing from a long half-life medication such as fluoxetine (Prozac), to a shorter one, that taking their dose regularly becomes much more important. Patients taking fluoxetine can often miss several doses without noticing any discomfort, but the shorter halflife of other SSRIs such as venlafaxine, paroxetine, duloxetine, citalopram, escitalopram, and sertraline (ranging approximately 10 hours) means that a single missed dose may cause withdrawal symptoms. When discontinuing an SSRI with a short half-life, switching to a drug with a longer half-life (e.g. fluoxetine or citalopram) and then discontinuing from that can decrease the likelihood and severity of withdrawal syndrome.

If one wishes to stop taking an SSRI medication, one method is to switch to a long half-life medication such as fluoxetine for several days at a relatively low dose and then stop taking any SSRI altogether. The longer half-life of fluoxetine will avoid any withdrawal symptoms because this medication effectively tapers itself from the patient's system over a few days.

SSRI withdrawal symptoms may be alleviated by either recommencing the original or lesser dose of the SSRI (or a similar SSRI), or slowly reducing the dosage over several weeks or months. While slowly reducing the dosage does not guarantee that a patient will not experience the discontinuation syndrome, it is considered a safer method than abrupt discontinuation. Gradual discontinuation, or tapering, or titration, can be accomplished by breaking pills into parts or using a graduated oral syringe with the liquid form. Alternatively, a compounding pharmacy may take one's prescription and divide it into smaller graduated doses. For example, a 20 mg prescription of Cymbalta, which comes in gel capsules containing tiny sphere-shaped pellets, may be divided into 20, 15, 10, 5, and 2.5 mg doses.

Treatment is dependent on the severity of the discontinuation reaction and whether or not further antidepressant treatment is warranted. In cases where further antidepressant treatment is required then the only step required is restarting the antidepressant; this is usually the case following patient noncompliance with the drug. If antidepressants are no longer required, treatment depends on symptom severity. Mild reactions may only require reassurance. Moderate cases may require symptom management. Benzodiazepines may be used for insomnia, although it's very important to note that benzodiazepine withdrawal is known to be severe and long-lived. If symptoms of SSRI discontinuation are severe, or do not respond to symptom management, the antidepressant can be reinstated and then withdrawn more cautiously.

People experiencing severe withdrawal symptoms may taper dosage by 5% per week (or month, or even longer) in order to avoid a drastic drop in serotonergic activity; however, even gradual reductions can produce withdrawal symptoms in some cases. Switching to an SSRI with a longer half-life, then tapering off that, may eliminate withdrawal symptoms; see "Fluoxetine as intervention in SSRI Discontinuation Syndrome" below.