Chicago—Pharmacists should caution long-term users of antidepressants that they might have developed physical dependence on the drugs and could experience withdrawal symptoms when they discontinue the medications.

That’s according to a new report in the Journal of the American Osteopathic Association. It underscores the importance of prescribers using a tapering schedule when taking patients off the drugs.

Midwestern University Chicago College of Osteopathic Medicine–led researchers warn that abruptly stopping medication is rarely advisable.

“I understand that many people feel safe in that their depression or anxiety is continuously managed by medication. However, these are mind-altering drugs and were never intended as a permanent solution,” explained lead author Mireille Rizkalla, PhD. “Once the patient’s depression or anxiety has been resolved, the physician should guide them toward discontinuation, while providing non-pharmacologic treatments to help them maintain their mental health.”

The report points out that antidepressant discontinuation syndrome (ADS) can manifest itself as flulike symptoms, insomnia, nausea, imbalance, sensory disturbances often described as electric shocks or “brain zaps,” and hyperarousal.

While symptoms can occur with the discontinuation of any antidepressants, according to the authors, older, first-generation antidepressants often come with additional risks for more severe symptoms, including aggressiveness, catatonia, cognitive impairment, and psychosis. Across the board, discontinuation carries a risk for relapse of depression and anxiety, as well as suicidal thoughts, they add.

Withdrawal symptoms have clinically been called discontinuation syndromes, “with the intention to avoid any association between antidepressants and addictive drugs (with which the term withdrawal may be associated).

"Antidepressants are not considered to be addictive in the sense that users do not seek them to ‘get high’ but rather to alleviate symptoms of serious medical problems. However, with extended use, they can be notoriously difficult to quit because they can produce a state of physical dependence. Therefore, discontinuation can cause a group of symptoms that are very unpleasant and can lead patients to continue to seek the medications,” the researchers note.

The authors advise that ADS usually occurs within a few days of stopping an antidepressant and usually lasts 2 weeks or longer. ADS symptoms are more likely to occur after longer duration of treatment and with antidepressants that have shorter half-lives for elimination, such as paroxetine.

The article made several important points, including:
• ADS symptoms associated with tricyclic antidepressants are similar to those caused by selective serotonin reuptake inhibitors but also can include profound balance problems and parkinsonian features
• Serotonin-norepinephrine reuptake inhibitors, such as venlafaxine, can cause more severe ADS symptoms than those caused by selective serotonin reuptake (SSRI) inhibitors
• ADS symptoms associated with monoamine oxidase inhibitors may be more serious, including aggressiveness, catatonia, cognitive impairment, and psychosis, and may require more intensive management 

In light of information that about one-fourth of patients on antidepressants have been using them for a decade or more, “I think we have a real problem with patient care management, when it comes to prescribing antidepressants. We tend to put patients on an SSRI and more or less forget about them,” Dr. Rizkalla said.

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