Understanding Discontinuation Syndrome

Depression is a serious mental health condition that’s estimated to affect around 5% of adults worldwide, according to the World Health Organization (WHO). While the treatment approach may vary depending on the individual and their unique circumstances, medication may be a recommended component for depressive and anxiety disorders. Some medications can lead to a significant improvement in symptoms. However, if an individual doesn’t take them according to their doctor or psychiatrist’s instructions, they may experience something called antidepressant discontinuation syndrome from psychotropic medications. From flu-like symptoms to insomnia, abruptly discontinuing medication can result in mental and physical disturbances. However, patient education on how to prevent and recognize antidepressant discontinuation syndrome if symptoms occur can help minimize its effects. 

According to the Canadian Medical Association Journal, around 20% of patients are affected by antidepressant discontinuation syndrome, but most experience mild symptoms.

Sudden interruption or drastic reduction of dosage of antidepressant drugs may cause symptoms of insomnia, nausea, imbalance, such as dizziness or vertigo, as well as other disturbances. Some of these symptoms are common across the different classes of antidepressant drugs. That’s why a health professional will typically advise you to stop taking an antidepressant gradually if they’re making changes to your treatment plan in order to avoid or minimize discontinuation syndrome.

In the past, discontinuation syndrome was referred to as “the withdrawal effect”. To some, this contributed to the idea that antidepressants were harmful drugs. More recently, the term “discontinuation syndrome” has come into use instead.

The main reason for the change is that what happens in a discontinuation situation is different from the withdrawal effect you might see with an addictive drug. Antidepressants aren't usually considered addictive; people who are on them don't tend to engage in typical seeking behaviors to get more of them.

Instead, with discontinuation syndrome, the brain suddenly no longer has the medication it's used to having—medication that was helping it perform its normal functions related to mood control. In a recent randomized clinical trial, those who were assigned to discontinue their medication had higher risk of depressive relapse than those who continued with the treatment. These findings underscore the importance of determining a suitable plan for discontinuation with your doctor and therapist. When the medication is no longer there, the natural, neural processes must take over the job completely. This can happen gradually and relatively painlessly when your doctor tapers down the dose over time. When it happens abruptly, however, you may experience symptoms of discontinuation syndrome.

Recognizing the symptoms of antidepressant discontinuation syndrome may make recovering from it easier. Different types of antidepressant treatment include monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRI), and tricyclic antidepressants, and they each affect the body differently. For example, tricyclic antidepressant discontinuation syndrome may include nausea, imbalance, sensory disturbances, and nightmares. MOAIs, on the other hand, may include psychotic symptoms, such as hallucinations and delusions. 

Among the SSRI antidepressants, the symptoms of serotonin reuptake inhibitor discontinuation are most often linked with paroxetine, whereas fluoxetine present the lowest incidence of discontinuation syndrome. However, treatment duration and dosage amount are also linked with the severity of symptoms and depressive relapse for those undergoing paroxetine treatment, as well as other types of treatment. Those who have been taking medication the longest and at higher doses are at higher risk of SSRI discontinuation syndrome when dosage is significantly reduced or stopped altogether.  Symptoms of discontinuation syndrome may include insomnia, nausea, imbalance, sensory alteration such as blurred vision, and flu-like symptoms. 

If you suspect you’re experiencing this phenomenon, you can check your medications to make sure you've taken them as prescribed. If not, you can call your doctor immediately to ask if you should resume taking them to avoid antidepressant discontinuation syndrome. Even if you feel you haven’t missed a dose, it may still be worth contacting a healthcare professional to address the symptoms you’re experiencing. 

There are six main symptoms of discontinuation syndrome. The mnemonic device FINISH can make them easier to remember. They are:

1. Flu-like symptoms such as headache, lethargy, diarrhea, and appetite disturbances
2. Insomnia or other sleep disturbances, such as trouble falling asleep or being awakened by nightmares
3. Nausea and sometimes other related gastrointestinal symptoms, such as abdominal cramping, abdominal pain, and vomiting
4. Imbalance and movement problems depending on the type of medication, which may include dizziness, lightheadedness, vertigo, akathisia (a feeling of agitation and restlessness), twitches, jerks, tremors, or Parkinsonian movements
5. Sensory disturbances like blurred vision, nerve feelings like you’re being shocked with electricity, numbness, and paresthesia (a pins-and-needles feeling that results from pressure on a nerve)
6. Hyperarousal, or extreme alertness that makes every sensation feel as if it were multiplied many times—which may also be coupled with unusual emotions such as agitation, irritability, anxiety, or sadness

In extreme cases, an individual could experience more severe symptoms such as psychosis, catatonia, delirium, delusions, or hallucinations. These are rare, but it’s important to seek professional help immediately if you notice them affecting you. It’s also important to note that symptoms of discontinuation syndrome may vary somewhat depending on the specific antidepressant you’ve been taking. For example, discontinuation syndrome symptoms after stopping selective serotonin reuptake inhibitors (SSRIs) in particular may include dizziness, gastrointestinal discomfort, lethargy, anxiety, low mood, sleep problems, and headaches.

The onset of discontinuation syndrome symptoms usually begins within three days after you stop your medication abruptly. In some cases, it can happen within hours of the first missed dose. The symptoms usually run their course in one to two weeks. In extreme cases, symptoms may last up to one month or longer. A few factors that may affect symptom onset and duration include:

Length Of Treatment Time

Whether you'll have discontinuation syndrome and whether it will be mild or severe may depend partly on how long you've been taking the antidepressant. It doesn't tend to happen unless you've been taking a medication for at least six weeks before you discontinue it. If you've been on it for many months or even years, your chances of having symptoms are increased.

The Medication’s Half-Life

Abruptly stopping a medication with a short half-life may be more likely to result in symptoms, or more severe symptoms. The half-life is the amount of time it takes for the amount of the drug in the body to be reduced by one half. For example, Zoloft discontinuation syndrome may be less severe or less likely to occur than Cymbalta discontinuation syndrome, because Zoloft has a half-life of 26 hours, while Cymbalta has a half-life of only 11–16 hours.

Dosage

If you've been taking a high dose of an antidepressant, you may be more likely to have discontinuation syndrome upon abruptly stopping it than if you've been taking a low dose.

Every individual’s situation is different, including how long they’ve been on antidepressants and what their other life circumstances are. That’s why the reasons for discontinuation syndrome occurring can vary widely. Here are a few situations in which it might happen.

At first, you might have no trouble remembering to take your medications as directed. However, suppose that one day, you forget to take your antidepressant. That one day can turn into several, during which the medication can completely leave your system, causing discontinuation symptoms. This may be especially likely to happen if you're on several medications and take them directly from their bottles each day instead of from a daily pill organizer. It could also happen if you travel and forget to bring your meds with you.

Lack Of Medication

Discontinuation syndrome may happen simply because you don't have the medication when you need it. This situation may be a result of experiencing financial problems that prohibit you from refilling your prescription, or abruptly running out of medication because you didn’t realize how few pills you had left. It could also occur if someone else usually picks up your antidepressants from the pharmacy for you and they’re suddenly unable to do so.

At some point, you might decide not to take your medication anymore. Maybe it has done its job wonderfully and you no longer feel depressed, so you don't feel the need to keep taking it. Alternatively, you might not like taking the medication because of some of the side effects. For example, sometimes antidepressants can cause a person to shift into mania if they have bipolar disorder. They may stop the medication in an attempt to regain control.

While taking action as a result of either of these situations is understandable, it’s highly recommended that you speak with your doctor or psychiatrist first before making changes to your medications so that you can avoid the potential undesirable effects, such as flu-like symptoms, insomnia, and nausea resulting of stopping abruptly.

How Dangerous Is Discontinuation Syndrome?

For most people, discontinuation syndrome doesn’t tend to present serious danger. It can be uncomfortable, and if you don't know what's going on, it can be alarming. However, it rarely causes any problems that can't be managed for the days or couple of weeks it takes for symptoms to fade away. 

That said, there are rare instances when severe physical effects can occur. There’s also the real risk of relapsing and experiencing depression again. If that happens, the original disorder may cause problems. Finally, it’s also important to note once more that rare symptoms of withdrawal or discontinuation syndrome like psychosis, catatonia, delirium, delusions, or hallucinations can be serious, and that you should seek professional help if you experience these.

What To Do If You Experience It

If you suspect you have antidepressant discontinuation syndrome, contacting your doctor or mental health care provider is usually the recommended course of action. Consulting with them can also be important if you aren't sure your symptoms are actually withdrawal or discontinuation syndrome, or if resuming taking your antidepressant doesn't help. It may turn out that you have a different condition with similar symptoms. 

Adjusting your medication without the advice or input of the professional who prescribed it to you is generally not advised. When you do, they may suggest one of a few different courses of action based on your particular situation. Unless you have shifted into the manic phase of bipolar disorder as a result of stopping your medication, you may be able to alleviate discontinuation symptoms by taking the medication again as directed. This may be the best course of action if you've only missed a few days. Or, your doctor or psychiatrist may decide to alter your dosage or the type of medication you’re on.

If you experienced withdrawal syndrome due to forgetting to take your medications, it may be helpful to develop a system to avoid the same thing happening in the future. Getting a pill box that has a different compartment for each day of the week is a common solution, since you can easily see whether you’ve taken that day’s pill if you’re unsure. You can also set reminders on your phone, laptop, or tablet that can help you remember to take your medication at the same time each day. If finances or logistics are an issue, your doctor or your insurance company may be able to recommend potential solutions like income-based discount programs or medication delivery services.

Addressing Concerns With Therapy

Medication may not be the appropriate course of action in every situation, as each individual is different. In addition, it’s rarely a comprehensive solution for mental health concerns on its own. In many instances, therapy may improve your success with antidepressants. A therapist may also be able to help you understand the risks of stopping medications abruptly. 

In most cases, whether you pursue professional therapeutic treatment in person or online is up to you. Research suggests that both formats can be equally effective for a wide variety of mental health concerns. That means you can typically choose the one that feels best for you. For example, if you’re having trouble locating a provider in your area, don’t have access to reliable transportation, or have a physical disability or other reason that it’s difficult to leave the house, online therapy can be a convenient option. It can also be helpful for those who have a busy schedule and no time to commute to therapy, or who simply prefer engaging in treatment from the comfort of home. 

If you’re interested in trying this method, an online therapy platform like BetterHelp may be worth considering. You can get matched with a licensed therapist who you can meet with via phone, video call, and/or online chat to address the challenges you may be facing.