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Discontinuation Syndrome
Sue Henderson
Definition
• Cluster of symptoms that may occur in
response to the reduction or cessation of
any antidepressant, but is more common
in antidepressants with a short half life and
when long term therapy is abruptly halted.
Cause
• Exact cause unknown
• Theory: CNS adapts to antidepressant
treatment and is disrupted by cessation.
Discontinuation V withdrawal
• Antidepressants are not:
• Habit forming
• Craving and drug seeking behaviour does
not occur upon discontinuation
Risk factors
• Incidence, severity variable - dependent - type of
antidepressant, duration treatment & rate of cessation
(Haddad, Anderson, & Rosenbaum, 2004).
• 20% of individuals taking antidepressants for at least 6
weeks and then stopping abruptly (rare under 6 – 8
weeks).
• More frequent in antidepressants with short half lives
(Paroxetine, Sertraline)
• Occurs less frequently - dose reduction, missed doses,
when swapping from one antidepressant to another.
• There is no association with age, sex or diagnosis (Warner,
Bobo, Warner, Reid, & Rachal, 2006).
Reasons for stopping abruptly
• Feel better (believe no longer need meds)
• Women who discover they are pregnant
(worry about effect on foetus)
• Troublesome side effects
• Believe not gaining any benefit (Warner, Bobo,
Warner, Reid, & Rachal, 2006).
Onset/Course
• On cessation most people experience mild
transient symptoms
• Mean onset: 2 days
• Mean duration: 5 days
• Complete resolution within 1 – 2 weeks
Discontinuation V re-emergence
clinical condition
• If symptoms abate on restarting the
antidepressant if is probably
antidepressant discontinuation syndrome.
FINISH
• Flu-like symptoms (Fatigue, Lethargy, General
malaise, Muscle aches/headaches, Diarrhoea)
• Insomnia
• Nausea
• Imbalance (Gait instability, Dizziness/lightheadedness, Vertigo
• Sensory disturbances (Paraesthesia, “Electric
shock” sensations, Visual disturbances
• Hyper-arousal (Anxiety, Agitation) (Berber, 1998)
Management
•
1.
2.
3.
3 major areas:
Prevention
Symptomatic treatment
Specific treatment
Prevention
• Before prescribed individual warned that
abrupt cessation may precipitate
discontinuation syndrome
• Reminded to talk to the prescriber before
stopping an antidepressant.
Symptomatic treatment
• analgesics for headache, insomnia or
agitation with a short term prescription of a
hypnotic and or benzodiazepine (Bailey, 2002).
Specific treatment
• Restart antidepressant and taper more
slowly
• If symptoms severe switch to fluoxetine
(longer half life antidepressant) which can
generally be stopped without major
problems (Haddad, Anderson, & Rosenbaum, 2004)
Review Questions
Which symptoms may indicate SSRI
discontinuation syndrome?
a. palpitations and hypertensive episodes
b. fever, tachycardia, and labile blood
pressure
c. dizziness, irritability, and tingling of the
face and hands
Review Question
Which one of the following antidepressants
is least likely to produce flu-like withdrawal
symptoms upon abrupt discontinuation?
a. Paroxetine (Paxil)
b. Imipramine (Tofranil)
c. Fluoxetine (Prozac)
d. Sertraline (Zoloft)
References
Bailey, K. P. (2002). Selective serotonin reuptake inhibitor
discontinuation syndrome. Journal of Psychosocial Nursing 40(12),
15-18.
Berber, M. J. (1998). FINISH: Remembering the discontinuation
syndrome. Flue-like symptoms, Insomnia, Nausea, Imbalance,
Sensory disturbance, and hyperarousal (anxiety/agitation). Journal
of Clinical Psychiatry, 59, 255.
Haddad, P. M., Anderson, I., & Rosenbaum, J. (2004). Antidepressant
discontinuation syndromes. In P. M. Haddad, S. Dursun & B. Deakin
(Eds.), Adverse syndromes and psychiatric drugs: A clinical guide
(pp. 183-205). Oxford: Oxford University Press.
Warner, C. H., Bobo, W., Warner, C., Reid, S., & Rachal, J. (2006).
Antidepressant discontinuation syndrome. American Family
Physician, 74(3), 449-456.