Management of discontinuation syndrome

• management
  • treatment of discontinuation symptoms depends on
    • (i) whether or not further antidepressant medication is warranted and
    • (ii) the severity of the discontinuation symptoms
  • if further antidepressant treatment is warranted
    • then restarting the antidepressant will cause rapid resolution of the symptoms
  • if further antidepressant treatment is not clinically indicated then management depends on the severity of the discontinuation symptoms
    • majority of symptoms are mild and in these cases treatment usually requires only that the patient be reassured about their self-limiting nature
    • if symptoms are of moderate severity then can be treated symptomatically
      • e.g. insomnia may be treated with a short course of a benzodiazepine
    • if severe discontinuation symptoms then the antidepressant can be reinstated, symptoms will usually resolve within 24 h and then the antidepressant can be withdrawn more cautiously
      • always include an appropriate explanation of the symptoms to the patient and follow-up to ensure that the symptoms have resolved
    • if, when attempting to withdraw and stop an antidepressant, severe discontinuation symptoms appear either during or at the end of a taper
      • consider increasing the antidepressant dose back to the lowest dose that prevented their appearance, and then commencing a slower taper
        • some patients may require a very gradual tapers to prevent discontinuation symptoms reappearing
          
          
  • specialist advice may suggest a from current SSRI to fluoxetine, the SSRI with the longest half-life in the management of discontinuation symptoms related to an SSRI/venlafaxine
    • some case reports suggest that fluoxetine can suppress discontinuation symptoms associated with other SSRIs
      • if the switch is successful, fluoxetine can usually be stopped after several weeks of treatment without discontinuation symptoms reappearing
      • effectiveness of this strategy appears to reflect the long half-life of fluoxetine (1.9 days) and its active metabolite norfluoxetine, which has a half-life of 7-15 days

Reference:

• Renoir T. Selective Serotonin Reuptake Inhibitor Antidepressant Treatment Discontinuation Syndrome: A Review of the Clinical Evidence and the Possible Mechanisms Involved. Front Pharmacol. 2013; 4: 45.
• Haddad PM, Anderson IM. Advances in Psychiatric Treatment 2007; 13: 447-457
• Haddad, PMThe SSRI discontinuation syndrome. Journal of Psychopharmacology 1998; 12: 305-313.
• Tint, A., Haddad, P. M, Anderson, I. M. The effect of rate of antidepressant tapering on the incidence of discontinuation symptoms: a randomised study. Journal of Psychopharmacology 2007
• NICE (October 2009). Depression