Clinical management of Discontinuation Syndrome
Discontinuation syndrome is well known as a cluster of symptoms following the withdrawal of any antidepressant medication, especially second-generation antidepressants, such as Tricyclic antidepressants (TCAs), Monoamine oxidase inhibitors (MAOIs), and Selective serotonin reuptake inhibitors (SSRIs), particularly with more potent and short-acting SSRIs such as paroxetine and Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine.
Primary symptoms of SSRI discontinuation syndrome were divided by some scientists into six categories (sensory problems, disequilibrium, general somatic symptoms, GIT problems, sleep disturbance, and affective disorder symptoms). The most common of these symptoms typically include balance problems or vertigo, dizziness, nausea, cramps, diarrhea, headaches, and insomnia.
These symptoms may last any time between 1 and 2 weeks, are usually mild, and can quickly disappear after re-administration of the drug.
Less common symptoms were reported in some cases such as irritability, feeling disconnected, “electric shock” and/or “pinging” sensations, and hallucinations (visual and auditory).
The diagnosis of discontinuation syndrome is a challenging process because the symptoms can be mistaken for a relapse of the main condition, and that's why education of both physician and patient is very important to the decision and the management of drug discontinuation.
While the majority of the research agree that abruptly withdrawing medication can significantly increase the risk of discontinuation syndrome, however, the management of drug discontinuation varies somewhat between researchers, the majority of studies agree that tapering is the most effective strategy when it comes to the prevention and management of drug discontinuation syndrome. Nevertheless, many studies agree that tapering is dispensable if the patient has been taking an antidepressant only for 4 weeks or less, simply because that would not be enough time to develop a withdrawal reaction.
Consensus panel recommendations for clinical management of discontinuation syndrome emphasize gradual dose tapering by no more than 25% every 1–2 weeks but it's important to note this cannot guarantee to obviate a discontinuation syndrome, however, it does appear to lessen the symptoms.
If the discontinuation symptoms became severe, the drug should be re-administered and a slower taper (up to that 3 months) should be initiated. And in such cases, it's also recommended to switch to long-acting drugs such as fluoxetine.
Other recommendations include patient education about the syndrome. Patients need to know all the information regarding the possible symptoms, they also need reassurance that these symptoms are self-limiting side effects for a short time.
A study from 2005 found that patients who didn't know about the discontinuation symptoms experienced greater side effects during the discontinuation process.
Patient monitoring is equally an important step, particularly due to the concerns about suicidality associated with SSRI discontinuation
On the other hand, some researchers suggest that patients who are experiencing severe discontinuation syndrome symptoms (particularly insomnia) may benefit from a short course of symptomatic treatment with benzodiazepines.
Additionally, antipsychotic treatment may be useful for patients undergoing withdrawal mania. Whilst antimuscarinic agents could be useful in improving the GIT symptoms of the withdrawal.
CBT, Cognitive behavioral therapy has been found to be helpful in some cases throughout the discontinuation process.
References
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2. Renoir T. (2013). Selective serotonin reuptake inhibitor antidepressant treatment discontinuation syndrome: a review of the clinical evidence and the possible mechanisms involved. Frontiers in pharmacology, 4, 45. https://doi.org/10.3389/fphar.2013.00045
3. Haddad, P., & Anderson, I. (2007). Recognising and managing antidepressant discontinuation symptoms. Advances in Psychiatric Treatment, 13(6), 447-457. doi:10.1192/apt.bp.105.001966
4. van Geffen, E. C., Hugtenburg, J. G., Heerdink, E. R., van Hulten, R. P., & Egberts, A. C. (2005). Discontinuation symptoms in users of selective serotonin reuptake inhibitors in clinical practice: tapering versus abrupt discontinuation. European journal of clinical pharmacology, 61(4), 303–307. https://doi.org/10.1007/s00228-005-0921-x
5. Schatzberg, A. F., Blier, P., Delgado, P. L., Fava, M., Haddad, P. M., & Shelton, R. C. (2006). Antidepressant discontinuation syndrome: consensus panel recommendations for clinical management and additional research. The Journal of clinical psychiatry, 67 Suppl 4, 27–30.
6. Ogle, N. R., & Akkerman, S. R. (2013). Guidance for the discontinuation or switching of antidepressant therapies in adults. Journal of pharmacy practice, 26(4), 389–396. https://doi.org/10.1177/0897190012467210
7. Franco B. (2008) Fluoxetine for the treatment of SSRI discontinuation syndrome. International Journal of Neuropsychopharmacology, Volume 11, Issue 5, August 2008, Pages 725–726, https://doi.org/10.1017/S1461145708008493
8. Gabriel, M., & Sharma, V. (2017). Antidepressant discontinuation syndrome. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 189(21), E747. https://doi.org/10.1503/cmaj.160991
