Discontinuation Syndrome

Sue Henderson

Definition

• Cluster of symptoms that may occur in response to the reduction or cessation of any antidepressant, but is more common in antidepressants with a short half life and when long term therapy is abruptly halted.

Cause

• Exact cause unknown

• Theory: CNS adapts to antidepressant treatment and is disrupted by cessation.

Discontinuation V withdrawal

• Antidepressants are not:

• Habit forming

• Craving and drug seeking behaviour does not occur upon discontinuation

Risk factors

• Incidence, severity variable - dependent - type of antidepressant, duration treatment & rate of cessation (Haddad, Anderson, & Rosenbaum, 2004).

• 20% of individuals taking antidepressants for at least 6 weeks and then stopping abruptly (rare under 6 – 8 weeks).

• More frequent in antidepressants with short half lives (Paroxetine, Sertraline)

• Occurs less frequently - dose reduction, missed doses, when swapping from one antidepressant to another.

• There is no association with age, sex or diagnosis (Warner, Bobo, Warner, Reid, & Rachal, 2006).

Reasons for stopping abruptly

• Feel better (believe no longer need meds)

• Women who discover they are pregnant (worry about effect on foetus)

• Troublesome side effects• Believe not gaining any benefit (Warner, Bobo,

Warner, Reid, & Rachal, 2006).

Onset/Course

• On cessation most people experience mild transient symptoms

• Mean onset: 2 days

• Mean duration: 5 days

• Complete resolution within 1 – 2 weeks

Discontinuation V re-emergence clinical condition

• If symptoms abate on restarting the antidepressant if is probably antidepressant discontinuation syndrome.

FINISH

• Flu-like symptoms (Fatigue, Lethargy, General malaise, Muscle aches/headaches, Diarrhoea)

• Insomnia• Nausea• Imbalance (Gait instability, Dizziness/light-

headedness, Vertigo• Sensory disturbances (Paraesthesia, “Electric

shock” sensations, Visual disturbances• Hyper-arousal (Anxiety, Agitation) (Berber, 1998)

Management

1. 3 major areas:

2. Prevention

3. Symptomatic treatment

4. Specific treatment

Prevention

• Before prescribed individual warned that abrupt cessation may precipitate discontinuation syndrome

• Reminded to talk to the prescriber before stopping an antidepressant.

Symptomatic treatment

• analgesics for headache, insomnia or agitation with a short term prescription of a hypnotic and or benzodiazepine (Bailey, 2002).

Specific treatment

• Restart antidepressant and taper more slowly

• If symptoms severe switch to fluoxetine (longer half life antidepressant) which can generally be stopped without major problems (Haddad, Anderson, & Rosenbaum, 2004)

Review Questions

Which symptoms may indicate SSRI discontinuation syndrome?

a. palpitations and hypertensive episodes

b. fever, tachycardia, and labile blood pressure

c. dizziness, irritability, and tingling of the face and hands

Review Question

Which one of the following antidepressants is least likely to produce flu-like withdrawal symptoms upon abrupt discontinuation?

a. Paroxetine (Paxil)

b. Imipramine (Tofranil)

c. Fluoxetine (Prozac)

d. Sertraline (Zoloft)

ReferencesBailey, K. P. (2002). Selective serotonin reuptake inhibitor

discontinuation syndrome. Journal of Psychosocial Nursing 40(12), 15-18.

Berber, M. J. (1998). FINISH: Remembering the discontinuation syndrome. Flue-like symptoms, Insomnia, Nausea, Imbalance, Sensory disturbance, and hyperarousal (anxiety/agitation). Journal of Clinical Psychiatry, 59, 255.

Haddad, P. M., Anderson, I., & Rosenbaum, J. (2004). Antidepressant discontinuation syndromes. In P. M. Haddad, S. Dursun & B. Deakin (Eds.), Adverse syndromes and psychiatric drugs: A clinical guide (pp. 183-205). Oxford: Oxford University Press.

Warner, C. H., Bobo, W., Warner, C., Reid, S., & Rachal, J. (2006). Antidepressant discontinuation syndrome. American Family Physician, 74(3), 449-456.