Withdrawing from SSRI antidepressants: advice for primary care

Palmer et al’s article aiming to translate the recent change in NICE guidance to GPs is timely and useful.¹ Dr Butler’s negative response to the article is understandable given how big a shift the updated NICE guidance on stopping antidepressants represents from previous guidance.

While his personal experience is valuable double-blind randomised controlled trials demonstrate that 53.9% of patients who stop antidepressants will experience withdrawal effects.² The minimisation of these effects in guidelines for decades has meant that withdrawal effects are commonly mis-diagnosed as relapse.³ This is why there are currently tens of thousands of English patients seeking advice on how to stop antidepressants on peer support sites,⁴ rather than their doctors - hardly consistent with withdrawal effects being exaggerated by NICE.

Although it was considered thrifty to avoid prescription of liquid versions of medications, a shift in policy has been signalled by NICE which specifically recommends to GPs “if…slow tapering cannot be achieved using tablets or capsules, consider using liquid preparations if available.”⁵ 8 out of 10 of the most commonly used antidepressants are available as liquids; sertraline is available in liquid form as a “Special.”

Dr Butler rightly points out a difficulty with concentrated solutions of citalopram. However, he is mistaken in thinking that dilution is off-licence, as the manufacturer instructs that these ‘Oral drops should only be mixed with water, orange or apple juice’ which allows for making up dilutions.⁶

Furthermore, on the topic of off-licence prescriptions, which are common in practice, GMC guidance is clear that doctors are permitted to prescribe medications off-licence when “the dosage specified for a licensed medicine would not meet the patient’s need.”⁷ The Specialist Pharmacy Service for the NHS has a dedicated webpage to explain how to make up antidepressants tablets into suspensions.⁸

We should not be lulled into false security with fluoxetine: withdrawal effects have been demonstrated in half of those who stop fluoxetine,³ including some who develop a protracted and debilitating withdrawal syndrome.⁹

The difficulty many patients have in stopping antidepressants and the degree of trouble involved in doing so should make doctors much more cautious about prescribing them.¹⁰

References

As a person who has endured a lengthy and complicated withdrawal process from an antidepressant, I am delighted to see this issue gaining recognition. I thank the authors for their work.

We are starting to move from a position where antidepressant withdrawal is seen as rare and self-limiting, to one where we can acknowledge that, for a proportion of people, the withdrawal process can be extremely difficult. Furthermore, some people will continue to have problems long past the point that they got off the antidepressant. Some psychopharmacologists believe this is due to the adaptation that the brain has made to the drug. Examples of this are often seen in online fora where some people report difficulties for months or years after tapering.

While I welcome this work, more needs to be done to practically aid both prescribers and patients in safely stopping antidepressants. As noted in other letters, liquid forms are available for some drugs but not all, and they tend to be expensive.

The Netherlands has led the way in developing tapering strips which can provide a precise and reliable way to gradually taper. In the UK, we should be learning from such ground-breaking work, and I got the chance to speak with Professor Wendy Burn, the then President of the Royal College of Psychiatrists about this issue.

Some readers might be interested to know about tapering strips and how they can aid the prescriber in guiding patients safely and slowly off their antidepressants:

Royal College of Psychiatrists. Stopping antidepressants: Exploring the patient's experience

In their acclaimed article, Palmer and colleagues question how GPs should deal with those who experience withdrawal symptoms. In the Netherlands tapering medication has been developed to help GPs and other practitioners to do precisely that.¹ Tapering strips and stabilization strips enable them to flexibly prescribe and adjust personalized gradual and hyperbolic tapering schedules, based on shared decision making and proper self-monitoring. This tapering medication has been prescribed to more than 10.000 patients, allowing us to investigate whether and to what extent they have benefited from it. Because 60% of them had tried unsuccessfully tried to stop using an antidepressant in the past when they experienced severe withdrawal symptoms, it was possible to make within-subject comparisons between stop attempt(s) without and with the use of tapering strips.^2-4 These comparisons showed that about 70% of patients who were not able to stop in the past when they suffered from severe withdrawal were able to stop using tapering strips, the use of which resulted in much less withdrawal. Tapering strips and stabilization strips can also be prescribed to and used by patients in the UK.⁵

References

1. Groot & van Os. How user knowledge of psychotropic drug withdrawal resulted in the development of person-specific tapering medication. Ther Adv Psychopharmacol 2020; 10. https://doi.org/10.1177/2045125320932452.
2. Groot & van Os. Antidepressant tapering strips to help people come off medication more safely. Psychosis 2018; 10(2): 142-145. https://doi.org/10.1080/17522439.2018.1469163.
3. Groot & van Os. Outcome of Antidepressant Drug Discontinuation with Taperingstrips after 1-5 Years. Ther Adv Psychopharmacol 2020: 10. https://doi.org/10.1177/2045125320954609.
4. Groot & van Os. Successful use of tapering strips for hyperbolic reduction of antidepressant dose - a cohort study. Ther Adv Psychopharmacol 2021; 11. https://doi.org/10.1177/20451253211039327.
5. Tapering Strip. www.taperingstrip.com. 

The authors have provided valuable information regarding the clinical features of SSRI/antidepressant withdrawal syndromes. The reference to hyperbolic tapering in withdrawal regimes is of particular relevance to maximising the chances of success. The concern regarding increased risk of suicidal ideation is addressed; however, the life threatening problem of withdrawal induced akathisia may be an area worthy of discussion and increased awareness. Akathisia is vulnerable to misdiagnosis, not only of the original condition. The writhing restlessness, disorientation, intensity of suffering, and inability to describe what is happening may lead to misdiagnosis as serious mental illness (eg 'psychotic depression" and 'bipolar disorder') leading to psychotropic poly-pharmacy and increased intensity of akathisia.

Healy and colleagues¹ have identified the importance of awareness of post SSRI sexual dysfunction (PSSD):

"The data make it clear that SSRIs and SNRIs are potent disrupters of sexual function and that adverse sexual effects can sometimes persist for years or indefinitely after discontinuation of the drug. In some cases these effects only emerge, or worsen, when the drug is withdrawn. It also appears that post- treatment problems can occur after only a brief exposure to the drug".

"Post SSRI sexual dysfunction, and its mirror image, persistent genital arousal disorder can be life-changing, making it difficult or impossible to engage in normal intimate relationships, or even function in daily life'.

PSSD differs from depression induced sexual dysfunction. Genital anaesthesia/desensitisation being an important feature of PSSD.

"Neither patients nor health care professionals can reasonably be expected to know that the impact on sexual functioning could include profound genital numbness and the loss of ability to experience pleasure during orgasm".

Reference

1. Healy D.  Le Noury J. Mangin D. et al.  Citizen Petition: Sexual Side Effects of SSRIs and SNRIs. Int J Risk Safety Med. 2018; 29: 135-147.