Updated NICE principles on stopping antidepressants
Updated NICE principles on stopping antidepressants
Although gradually reducing and tapering antidepressant doses can minimise the risk of discontinuation symptoms, guidance on how to do this is limited. Many of the manufacturers of antidepressants advise against abrupt cessation in their SPCs but offer little practical advice on how the patient should gradually taper and stop.
Previously, the general advice was to reduce antidepressant doses over a two- to four-week period, with linear reductions in dosage until stopped. There is now growing research to indicate that this linear dose reduction method may not be the most effective way to prevent discontinuation symptoms.
Lowering the dose of antidepressant medication over a period of 14 days does not significantly reduce discontinuation symptoms compared to abrupt discontinuation. And it has been found that 60 per cent of people are not able to taper their antidepressants to stop over a four-week period and much longer dose reduction times were needed (up to four months).
Let us now consider a case study involving a patient who had an unsuccessful antidepressant withdrawal using linear dose reductions.
Case study 1
Stuart is a 25-year-old man with a diagnosis of generalised anxiety disorder (GAD). He lives with his wife.
Medication: Paroxetine 30mg daily.
Stuart was diagnosed with GAD three years ago. Originally his GP prescribed sertraline but Stuart was unable to tolerate it due to nausea and diarrhoea. The sertraline was stopped and his GP prescribed paroxetine instead. Stuart tolerated the drug well and the dose was increased to 30mg daily. He has continued on this dose for two years.
Stuart feels that his anxiety is well controlled and over the past two years he has developed coping strategies to help manage his condition. He now feels that it is the right time to try to reduce and ultimately stop the medication. Stuart’s GP agrees and recommends reducing the dose to 20mg each day immediately and to stop completely the following week.
Stuart followed this advice but on reducing the dose he started to experience flu-like symptoms. He assumed he just had a cold and continued with the withdrawal plan, stopping the paroxetine completely as directed by his GP. However, he then began to experience electric shock-like sensations on the back of his neck and scalp.
These sensations became more intense and Stuart thought he may be having a stroke or some type of medical emergency. He felt his only option was to attend A&E, where the medical team eventually identified the problem as discontinuation symptoms. They recommended that Stuart increase his paroxetine dose back up to 30mg daily. Stuart was so distressed by this experience that he decided to continue taking the same dose of paroxetine indefinitely.