Discussing discontinuation

Prior to stopping any antidepressant medication, individuals should be informed of the potential risk of withdrawal symptoms. If a patient develops mild withdrawal symptoms, NICE recommends offering reassurance and continuing to monitor for any change in symptoms. Further dose reductions are not recommended until the discontinuation symptoms have ceased. In individuals experiencing severe symptoms, the guidelines recommend increasing the dose back up to the original level and re-trying in the future with more gradual dose reductions. 

It is important to remember that even if a patient experiences distressing withdrawal symptoms, it does not mean that they cannot stop antidepressants in the future. However, they will need to taper more slowly, with smaller reductions than previously.

The pharmacokinetics of the prescribed antidepressant also need to be considered when agreeing a withdrawal schedule. Antidepressants with short half-lives are most likely to cause severe discontinuation symptoms and therefore a longer withdrawal period with smaller dose reductions is necessary.

Antidepressants with longer half-lives (such as fluoxetine) are associated with a lower risk of withdrawal symptoms, which is why the NICE guidelines recommend that fluoxetine can be stopped over a much shorter time frame. For individuals prescribed a dose of 20mg daily, the guidelines recommend reducing down to 20mg a day on alternate days for a period before stopping completely. For those prescribed higher doses (40mg or 60mg daily), a gradual withdrawal is recommended. 

Practical issues

When reducing antidepressant doses hyperbolically, very small doses may need to be prescribed and administered towards the end of the withdrawal period. For such small doses there may not necessarily be tablet or capsule formulations available. The NICE guidelines acknowledge these practical concerns when reducing doses incrementally and recommend using liquid preparations for the smaller doses when these are available. 

When licensed liquid products are not available, unlicensed products may need to be considered. This is outside of the scope of this module but pragmatic approaches may need to be adopted by prescribers in partnership with the patient.

Pharmacists are ideally placed to advise prescribers on the availability of different dosage forms. In certain situations it may even be appropriate to prescribe a combination of formulations (i.e. tablet and liquids) to achieve a specific dose.