Antidepressants and stopping them properly

Antidepressants are among the most prescribed medications in the world, and the guidance on stopping them has changed substantially in recent years.

What they do

SSRIs and SNRIs are the most commonly prescribed classes.

Meta-analyses show benefit over placebo for depression, with the effect size larger in more severe depression and smaller in mild depression — which is why guidelines generally recommend psychological therapy first for mild presentations.

They are also effective for several anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder.

They take several weeks to produce full effect, which needs stating clearly since people frequently stop at two weeks concluding they do not work.

And they may increase anxiety, agitation and sleep disturbance in the first weeks, which is a recognised early effect requiring monitoring, particularly in young people.

Side effects

Common and frequently unspoken.

Nausea and gastrointestinal effects, usually settling.

Sleep disturbance in either direction.

Weight change.

Sexual dysfunction, which affects a substantial proportion, is frequently not raised by either party, and is a leading unspoken reason for stopping.

Emotional blunting, which is described by many patients and which is a legitimate reason to change treatment.

Hyponatraemia, particularly in older adults.

Increased bleeding risk, particularly with anti-inflammatories or anticoagulants.

Most of these are reasons to switch rather than to stop, since agents differ considerably and there are many options.

How long to take them

Guidance is reasonably consistent.

Continue for at least six months after remission for a first episode, since stopping earlier substantially increases relapse risk.

Longer for recurrent episodes, with maintenance treatment considered for people with multiple previous episodes.

Which means the common pattern of stopping as soon as mood improves is the most reliable route to relapse.

Equally, prescriptions frequently continue for years without review, which is the opposite problem, and periodic review is appropriate.

Stopping: what has changed

An area where guidance has been revised.

Withdrawal symptoms — increasingly termed discontinuation symptoms — were historically described as mild and brief.

Subsequent evidence and patient reports indicate that a meaningful proportion of people experience symptoms that are more severe and more prolonged, particularly after long-term use and with certain agents.

Guidance in several countries now recommends slower, individualised tapering, and acknowledges that symptoms can be significant.

Symptoms include dizziness, electric shock sensations, nausea, insomnia, vivid dreams, irritability, anxiety and flu-like symptoms.

Distinguishing withdrawal from relapse matters and is genuinely difficult: withdrawal typically begins within days of a dose reduction and improves if the dose is restored, whereas relapse develops more gradually over weeks.

Tapering

The practical approach.

Slower than most people expect, particularly at the lower end of the dose range.

Proportional reductions rather than fixed decrements, since receptor occupancy does not fall linearly with dose — which is why the final small reductions are frequently the hardest.

Liquid formulations and tablet cutting allow smaller steps where needed.

Pausing or stepping back if symptoms are difficult, rather than pushing through.

Timescales of months rather than weeks for long-term users.

And doing it with a prescriber, with a plan and a review point, rather than unilaterally.

What helps alongside

Both during treatment and when stopping.

Psychological therapy, which reduces relapse risk and which combining with medication outperforms either alone in more severe depression.

Mindfulness-based cognitive therapy specifically, which has evidence for preventing relapse in recurrent depression.

Exercise.

Sleep, including treating insomnia specifically.

Reducing alcohol.

Social contact.

And a plan for what to do if symptoms return, agreed in advance, which is the single most useful thing to have when stopping.

The cost picture

Straightforward.

Generic antidepressants cost very little.

Psychological therapy costs more and is free through public services in many countries at the cost of a wait.

Against which untreated depression costs substantially in lost income, relationships and health.

Economic evaluations consistently find treatment of depression to be highly cost-effective, principally through restored function.

What to ask

At the start and at review.

How long before I should expect to feel different?

What side effects should I expect, and which mean I should come back?

How long should I take this for?

When will we review it?

What is the plan for stopping when the time comes?

And are there alternatives, including therapy, that I should be doing alongside?

General information only, not medical advice. Never stop antidepressants abruptly — consult a qualified clinician to plan a taper, and seek urgent help if you have thoughts of harming yourself.