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Recognising and managing antidepressant discontinuation symptoms

Peter Haddad is a consultant psychiatrist with Bolton, Salford and Trafford Mental Health NHS Trust (Cromwell House, Cromwell Road, Eccles, Salford, Manchester M30 0GT, UK. Email: peter.haddad{at}bstmht.nhs.uk) and an honorary senior lecturer at the University of Manchester. His clinical and research interests include the pharmacological treatment of affective disorders and schizophrenia and the safety and adverse effects of psychotropic medication. He was a member of the Guideline Development Group for the National Institute for Health and Clinical Excellence’s guidelines on bipolar disorder (2006). Ian Anderson is Senior Lecturer in Psychiatry at the University of Manchester and an honorary consultant psychiatrist with Manchester Mental Health and Social Care Trust, where he is Director of the Specialist Service for Affective Disorders. His clinical and research interests include the neurobiology and pharmacological treatment of bipolar and unipolar affective disorders. He has been involved in the British Association for Psychopharmacology’s evidence-based guidelines for depression, anxiety disorders and bipolar disorder.

Antidepressant discontinuation symptoms occur with all classes of antidepressant. A well-described discontinuation syndrome occurs with the selective serotonin reuptake inhibitors, common symptoms including dizziness, headache, nausea and lethargy. Rare antidepressant discontinuation syndromes include extrapyramidal syndromes and mania/hypomania. All these syndromes, even isolated discontinuation symptoms, share three common features that facilitate diagnosis; abrupt onset within days of stopping the antidepressant, a short duration when untreated and rapid resolution when the antidepressant is reinstated. Clinicians need to be familiar with strategies for the prevention and management of such symptoms. Preventive strategies include warning patients about the possibility of discontinuation symptoms, encouraging good antidepressant adherence and tapering antidepressants at the end of treatment. Most symptoms are mild and short-lived. Consequently symptoms that follow planned termination of an antidepressant can often be managed by providing an explanation and reassurance. More severe symptoms should be treated symptomatically or the antidepressant restarted, in which case symptoms usually resolve within 24 h. More cautious tapering can then follow.