Understanding Discontinuation Syndrome

Medication may be a recommended treatment option for some people living with depression 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 antidepressant discontinuation syndrome from psychotropic medications. 

Antidepressant discontinuation syndrome is a newly added disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) that can cause significant distress. 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, may minimize its effects. 

What is antidepressant discontinuation syndrome?

Antidepressant withdrawal can happen with different types of antidepressant medications, including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and tetracyclic antidepressants. According to the Canadian Medical Association Journal, around 20% of patients are affected by antidepressant discontinuation, but of them most experience mild symptoms. 

Sudden interruption or drastic reduction of one’s dosage of antidepressant therapy may cause symptoms of nausea and imbalance, such as dizziness or vertigo, as well as other disturbances, like vivid dreams and trouble sleeping. Some of these symptoms are common across the different classes of antidepressant medications. For this reason, a health professional may advise you to stop taking an antidepressant gradually if they’re making changes to your treatment plan to avoid or minimize discontinuation symptoms.

The BetterHelp platform is not intended for any information regarding which drugs, medication, or medical treatment may be appropriate for you. The content provides generalized information that is not specific to one individual. You should not take any action without consulting a qualified medical professional.

Is discontinuation the same as withdrawal?

In the past, discontinuation syndrome was referred to as “the withdrawal effect.” To some, this term contributed to the misconception that antidepressants were harmful substances, rather than medications to control mood and treat mental disorders. More recently, the term “discontinuation syndrome” has come into use instead.

What occurs with medication discontinuation is different from the withdrawal effect you might see with an addictive substance. Antidepressants aren't often considered addictive; people who are on them don't tend to engage in typical seeking behaviors to get more of them.

Instead, when one stops antidepressants, the brain suddenly no longer has the medication it's used to having—that is, medication that was helping the body perform its normal functions related to mood control. In a recent randomized clinical trial, those who were assigned to discontinue their medication had a higher risk of depressive relapse than those who continued with the treatment. 

Determining a suitable plan for serotonin reuptake inhibitor discontinuation with your doctor and therapist may help you avoid these effects. When the medication is no longer present in the brain, the natural neural processes take over the job completely. This process 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 insomnia, nausea, neurotransmitter imbalances, and other challenges.

Antidepressant or SSRI discontinuation symptoms 

Recognizing the symptoms of antidepressant discontinuation may make recovering from the condition easier. Different types of antidepressant medications include monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors (SSRI), and tricyclic antidepressants. Each affects the body differently. For example, tricyclic antidepressant discontinuation syndrome may include nausea, gait 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 a few medications within the category. However, treatment duration and dosage amount are also linked with the severity of symptoms and depressive relapse for those undergoing certain treatments, as well as other types. Those who have been taking the same medication for the longest period and at higher doses are at higher risk of antidepressant discontinuation syndrome when the 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 discontinuation syndrome, check your medications to make sure you've taken them as prescribed. Discuss this with your doctor immediately. Even if you haven’t missed a dose, it may still be worth contacting a healthcare professional to address the symptoms you’re experiencing and get help with the management of antidepressant discontinuation.

There are six main symptoms of discontinuation syndrome. The mnemonic device FINISH can make common antidepressant discontinuation symptoms easier to remember, including the following six letters: 

• F: Flu-like symptoms such as headache, lethargy, diarrhea, and appetite disturbances

• I: Insomnia or other sleep disturbances, such as trouble falling asleep or being awakened by nightmares

• N: Nausea and sometimes other related gastrointestinal symptoms, such as abdominal cramping, abdominal pain, and vomiting

• I: 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

• S: Sensory disturbances like blurred vision, nerve sensations like you’re being shocked with electricity, numbness, and paresthesia (a pins-and-needles sensation that results from pressure on a nerve)

• H: Hyperarousal, which is extreme alertness that makes every sensation seem as if it were multiplied many times—which may also be coupled with unusual emotions like irritability, anxiety, agitation, or sadness

In extreme cases, an individual may experience more severe symptoms, such as psychosis, catatonia, delirium, delusions, or hallucinations. These symptoms can be rare. However, seek professional help immediately if you notice any new behaviors or experiences. Symptoms of discontinuation syndrome may vary depending on the specific antidepressant you’ve been taking. For example, symptoms after selective serotonin reuptake inhibitor (SSRI) discontinuation in particular may include dizziness, gastrointestinal discomfort, lethargy, anxiety, low mood, sleep problems, and headaches.

Symptom timeline

The onset of discontinuation syndrome symptoms may begin within three days after you stop your medication abruptly. However, the timeline can vary for different people. In some cases, symptoms may occur within hours of the first missed dose. 

Symptom onset can depend on the medication’s half-life, which is the amount of concentration of the medication and the length of time it takes to leave the bloodstream. Antidepressants with a longer half-life may pose a lesser risk than medications with a shorter half-life because they take longer to clear the body’s systems. The symptoms may 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 these discussed next. 

Length of treatment

Your risk of developing discontinuation syndrome and whether it is mild or severe may depend partly on how long you've been taking the antidepressant. The condition may be more likely if you've been taking a medication for at least six weeks before you discontinue it. If you've been on the medication for many months or years, you may have a relatively high risk of symptoms. 

The medication's half-life

Abruptly stopping a medication with a short half-life may be more likely to result in more severe symptoms. The half-life of a medication is the amount of time it takes for the dosage in the body to be reduced by one-half. Medications have variable half-lives, and some remain in the bloodstream longer than others. Talk to your doctor to understand the half-life of your medications. 

Dosage

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

Common causes

Every individual’s situation is different, including how long they’ve been on antidepressants and what their other life circumstances are. For those reasons, the causes of discontinuation syndrome can vary widely. Below are a few potential risk factors.

Missed dosage

At first, you might have no trouble remembering to take your medications as directed. However, even one day of forgetfulness may lead to missing medication for a few days in a row. In this case, the medication can completely leave your system, causing discontinuation symptoms. Missed dosage may be more likely if you're on several medications and take them directly from your bottles each day instead of from a daily medication organizer. Missed doses may also occur when a person travels and forgets to bring their medications. 

Lack of medication

Discontinuation syndrome may happen when a person does not have their medication due to factors outside of their control. 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. A lack of medication could also occur if someone else often picks up your antidepressants from the pharmacy for you and they’re suddenly unable to pick them up.

Purposeful medication discontinuation

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 want to keep taking it. Perhaps you have other personal reasons for not wanting to continue. Deciding not to take medication is a personal choice, and some people may also benefit from other treatment options. 

According to the American Psychiatric Association, some people can improve their depression with lifestyle changes rather than medication. You also may choose to quit taking the medication because of some of the side effects. For example, antidepressants may cause mania in individuals with bipolar disorder. A doctor might decide to pull someone off these medications to stop the manic episode or look at different options. A person might also stop taking a medication if it was prescribed for a psychiatric misdiagnosis.

While acting as a result of these situations can be understandable, speak with your doctor or psychiatrist before making changes to your medications so that you can avoid the potential undesirable effects, such as flu-like symptoms, insomnia, and nausea, that can result from stopping abruptly.

Potential dangers

For some, discontinuation syndrome is not dangerous. However, in others, its symptoms can be uncomfortable and alarming. Unmanageable symptoms are rare, and they often disappear within days or a couple of weeks.

Severe physical effects can occur for some people. In addition, a risk of depression relapse and experiencing depression again is possible. If relapse occurs, more severe symptoms of depression are possible. In addition, rare symptoms of withdrawal or discontinuation syndrome, like psychosis, catatonia, delirium, delusions, or hallucinations, can cause life-threatening complications. Contact a doctor if you experience any severe changes in mood or behavior. 

What to do if you're experiencing discontinuation syndrome

If you suspect you have antidepressant discontinuation syndrome, contact your doctor or prescribing mental health care provider. If you aren't sure if your symptoms are due to withdrawal or discontinuation syndrome, or if resuming taking your antidepressant doesn't help, ask your doctor. Your provider may assess for any other coexisting diagnoses with similar symptoms. Do not adjust your medication without the advice or input of a medical professional. 

Your provider may make different suggestions based on your case. You may be able to alleviate discontinuation symptoms by taking the medication again as directed. However, it may not be possible to go back onto a medication once it has been stopped, especially in the case of a manic episode caused by someone with bipolar disorder taking the medication. 

For those who did not have severe complications on the medication, a doctor or psychiatrist may decide to alter the dosage or alter the type of medication. If you experienced withdrawal after SSRI discontinuation or 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 medication organizer with a different compartment for each day of the week may allow you to more easily see whether you’ve taken that day’s medication when you check.

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 everyone is different. In addition, medication is not often considered to be a comprehensive solution for mental health concerns on its own. Therapy may improve your success with antidepressants and help you avoid withdrawal symptoms after selective serotonin reuptake inhibitors are discontinued from your therapeutic treatment plan. 

Online and in-person therapy options are often available to individuals seeking support. Research suggests that both formats can be equally effective in treating various mental health concerns. If you’re having trouble locating a provider in your area, don’t have 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. These platforms may also be helpful for those with a busy schedule and no time to commute to therapy or those who prefer engaging in treatment from 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, or online chat to address the challenges you may be facing.