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Stopping antidepressants
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Mary Duenwald NYT
Thursday, May 27, 2004
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NEW YORK Now that the U.S. Food and Drug Administration has warned Americans taking antidepressants to be on the lookout for potentially harmful side effects, including severe restlessness and suicidal thinking, some people may end up stopping the drugs. But going off antidepressants can bring its own problems.
Stopping cold turkey can cause an array of troublesome symptoms, the most common being dizziness, which can last for days on end. Flu-like feelings, including nausea, headache and fatigue, are also common, as are intense feelings of anxiety, irritability or sadness. Some patients experience alarming sensations of tingling or burning in various parts of the body, ringing in the ears, blurred vision or flashing lights before the eyes. Some people even describe a feeling of shock waves pulsing through their arms and legs, as if they had been zapped with a jolt of electricity, a condition sometimes called lightning-bolt syndrome.
"The feeling can be really abrupt, like a quick jerk of the muscle," said Richard Shelton, a professor of psychiatry at Vanderbilt University. "It's not painful, but it can be very frightening to people."
Internet bulletin boards and Web sites devoted to antidepressant withdrawal chronicle the crying spells, vertigo and nightmares that people sometimes experience. "I feel like my brain is floating in Jell-O, slamming into the sides of my skull every time I move my head or my eyes," one person wrote. Another described palpitations, night sweats and "hideous nightmares."
To avoid such symptoms, or at least hold them to a minimum, the drugs need to be tapered off gradually in most cases, and that means quitting under a doctor's supervision. Psychiatrists say it is unwise for people who are taking antidepressants simply to quit on their own.
In its warning in March, the food and drug agency urged doctors to closely monitor patients taking antidepressants, especially during the first weeks of therapy or when changing dosage. Though an association between antidepressants and suicidal thinking or behavior has not been proved, unpublished studies suggesting the possibility of such a link in children and adolescents have caused concern. The agency is still investigating the issue.
The drugs most likely to produce withdrawal symptoms act on the brain chemical serotonin. These drugs work by blocking the action of a protein in the brain that normally transports serotonin out of the synapses, the spaces between brain cells. With the transporter protein blocked, serotonin lingers in the synapses, and that can have a positive effect on mood. When the drug is taken away, there is suddenly less serotonin in the synapses. Serotonin receptors in the brain, accustomed to a larger supply of the neurotransmitter, may take days or weeks to adjust, said Ephrain Azmitia, a psychopharmacologist at New York University.
"You get a precipitous drop in all the things that serotonin does in the brain, including its effects on appetite, sleep, sensory perception and emotions," Shelton said.
Not everyone experiences withdrawal symptoms. Studies suggest that only 10 percent to 20 percent of patients have significant problems, said Jerrold Rosenbaum, chief of psychiatry at Massachusetts General Hospital in Boston. And some patients find the effects less intense or bothersome than others.
Doctors say people who have been taking especially large doses of a drug for many years may be somewhat more vulnerable.
The withdrawal symptoms do not mean that antidepressants are addictive, experts say. People who are coming off the drug do not crave it, as addicts might crave heroin or cocaine, and they do not seek higher and higher doses over time. "There's a lot of misperception about that," said Alan Schatzberg, a psychopharmacologist who is chairman of psychiatry at Stanford University School of Medicine.
So, many doctors describe the effects produced by stopping antidepressants as a "discontinuation syndrome" rather than as withdrawal. Yet the symptoms can be troublesome enough to prompt some patients to go back on their medications. To help patients stop taking an antidepressant, most doctors use a strategy of gradually tapering down the dosage. Shelton said he often brings his patients down from the drugs in five-milligram increments, with each stage lasting from five days to a week. The riskiest period, Schatzberg said, comes at the end, when even small increments of tapering can have a big impact on serotonin. "The taper at the bottom end often needs to go slower than it does at the top end," he said.
Even when patients are entirely off the drugs, they may still experience some symptoms, but usually only for a few days and rarely for more than two weeks, doctors say. Sadness and anxiety that persist longer than that may be signs that a patient is experiencing a return of the depression. So it is important to distinguish withdrawal from a relapse of illness. "Just because you're stopping a drug," Rosenbaum said, "doesn't mean you don't need it."
The New York Times
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