Beyond Blue

Beyond Blue


When Should I Come Off My Antidepressant? 6 Things to Consider

posted by Beyond Blue

antidepressants.jpg

The question of whether or not you should start taking antidepressants is complex and difficult to answer. But even fuzzier is the question of when or if you should stop. Last May, NPR ran a piece called “Coming Off Antidepressants Can Be Tricky Business.” Joanne Silberner writes:

Several top psychiatrists say there’s just not enough data to say for sure when to try coming off an antidepressant. Drug companies generally test their new products for a few months or up to a year. They don’t spend much time looking into how to taper off their products. The dense informational inserts that come with prescription drugs have a lot of information on how to take the product, but no information on how to stop.

According to the Johns Hopkins Depression and Anxiety White Papers, antidepressant use involves three phases:

  • The acute phase which is when a person first begins antidepressants until she feels full benefit, usually four to 12 weeks after.
  • Then she goes on to a continuation phase, with the goal of preventing a relapse or a return to the depressive episode. This can last anywhere from four months to a year, usually taking the same amount of the drug as was figured out in the acute phase. If a person is symptom free after this, she may go off her antidepressants.
  • However, for people who meet the following criteria, a maintenance phase, lasting a year or longer, is needed, either at the regular dose or a smaller dose:
      • A history of three or more episodes of major depression
      • A history of severe depressive symptoms
      • Current dysthymia (chronic low-grade depression)
      • A family history of mood disorders
      • Current anxiety disorder
      • Substance abuse
      • Incomplete response to continuation treatment
      • A pattern of seasonal depressive symptoms

The decision of when to go off is highly individualized. There is no “one size fits all” rule of thumb. Although many studies indicate that a year or more of an antidepressant is needed to treat a major episode of depression or anxiety, there are certainly patients that have needed only a few months of drug therapy.

Says Silberner of NPR:

There’s enormous variation among people when they stop antidepressants. A person whose depression kicked in after a major life tragedy may do OK without drugs once life stabilizes. A person whose depression came out of the blue is likely to be at higher risk of chronic depression. And within all that, there’s basic biology — people react differently to drugs and to withdrawing from drugs.

The only rule that all doctors hold is that a person does not go off medication cold turkey, but by gradually lowering the dose. Stopping too suddenly puts you at risk for symptoms returning or for physical and mental withdrawal. Several of the newer antidepressants, especially, including Paxil, Luvox, Effexor, trazodone, Remeron, and Serzone will produce symptoms of dizziness, nausea, lethargy, headache, irritability, nervousness, crying spells, flu-like illness, and sleep or sensory disturbances–known as the “discontinuation syndrome” that occur within 24 to 72 hours after stopping the medication.

About 20 percent of people who abruptly stop taking an antidepressant after more than six weeks of treatment experience the discontinuation syndrome.

Whitney Blair Wyckoff of NPR lists these six suggestions from Dr. Richard Shelton, professor of psychiatry at Vanderbilt University, to keep in mind when considering coming off medication:

  1. Consider the severity of your illness. Those with the best odds are people who were mildly ill, who haven’t been ill many times in their lives, and whose symptoms didn’t affect their ability to function in a meaningful way.
  2. Never come off cold turkey.
    That’s a bad idea under most circumstances, and that’s, unfortunately, where doctors tend to see people having the most trouble. Shelton recommend that people always consult with whoever is prescribing drugs for them.
  3. Don’t be in a hurry.
    To be able to taper off an antidepressant medication successfully, you want to do it slowly. And by slowly, there are no absolute rules. So, it can take a month or six weeks or two months.
  4. Try to start coming off during the spring or summer.
    Withdrawing during the fall and winter can be a big problem — especially for people living in Northern states.
  5. Choose a time that isn’t significantly stressful.
    For example, people who are going through a divorce should wait a while before thinking about starting to ease off antidepressants.
  6. Be realistic.
    According to Sheldon, about 80 percent of patients discontinue their antidepressants in actual practice settings. But most of these patients relapse, and half restart their medications.

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  • http://AddaURLtothiscomment spareparts

    I have been off my meds 2 weeks, now. I got into a… sort of… “fight” with my PCP’s PA. When I discovered that the doctor’s office squandered 5 of 8 days’ worth of the last of my meds (by calling THEM per my pharmacist’s suggestion – they did NOT call me) because they wanted to “see” me before renewing.

    I get all that, blood testing and all, so that’s why I gave them 8 days. The PA said I had to come in when SHE said to, and would NOT work with me on an alternative time. She got really weird and ugly with me, actually.

    I just resent having my meds held over my head for ransom. It just exacerbated my resentment of being dependent on an antidepressant in the first place. Screw it and screw her, is pretty much how I feel at this point.

    The withdrawals are very hard on me. Getting on, getting off, getting on, getting off, based on insurance changes and if I even have insurance all. I just can’t do it anymore. I’ll just do without.

    My therapist thinks I should write PCP a letter, but I think it’s a waste of time. They don’t even care enough to talk to and/or work with their patients in the first place.

    Anyway, I like your blog. It helps me a lot. Thank you.

  • http://AddaURLtothiscomment Jean

    I have not taken my meds this year, at all, because of cost. After paying an individual health ins. policy fee each month (I am unemployed), I don’t have any money left to buy pricey pills. Anyway, I don’t think this particular med. was right for me – it made me sleep A LOT, and I stayed lethargic.

  • http://AddaURLtothiscomment Razz2

    The timing on this post is odd for me as I’ve just recently upped the dosage on my antidepressant. With the coming of fall that the shorter days I’m very mindful of my mood and can tell when it’s time to give things a boost. There was a time when I could go off my anti-depressants for the spring and summer months but that hasn’t been possible in years. Instead the goal is “maintenance” of an overall general feeling of “wellness”. Not happy skippy everything is great…. but more of I won’t fall apart when challenges hit.

    While it’s true that antidepressants can be very expensive there are those that aren’t and may be just as effective. It’s something you need to discuss with your doctor but my youngest was prescribed an older and much cheaper drug for her depression and it worked out well for her.

    Bottom line for me – I need them in order to function on a day to day basis. I’m not sure I’ll be every to go off them completely. I’m OK with that. In fact there would never be this kind of debate if it was about a thyroid or heart medication.

    Be good to you – Razz

  • http://AddaURLtothiscomment Sherry

    This is really a sore subject for me right now! It makes me so very angry what I have experienced recently. When the doctor put me on Paxil or should I say “convinced me that I need the help” She didn’t bother to tell me the H*## I would have to go through to get off of it. She didn’t even mention the side effects of getting off of it. Although I really needed help, if I had known what I was going to go through I never whould have taken the drug to begin with. I asked her how to wean myself off and she told me to start by skipping a day then go to every three days. This is soooo wrong…At least for me it was. That was much too quickly and I starting experiencing horrible withdrawal. Again I was never told about this withdrawal and how sick I could get. I had finally gotten a new job after being unemployed for a very long time I was trying to get off the paxil but was so dizzy and sick that I was afraid that I wouldn’t be able to work and I just couldn’t take that chance so I started taking the full dose again. Now it’s fall and this article says that’s a bad time to try to get off the meds. I was really thinking that I would be ok without the meds, but getting off seems like it is going to be a major deal. I did research and it looks like it will take a very long weaning off process. Any insight from anyone who has successfully weaned off paxil would be appreciated.

  • http://AddaURLtothiscomment Jayne

    A thank you to Razz!
    I, too, am one who will probably never be able to get off my medications after having gone through multiple deep depressive episodes in my life. “Be good to you”. Yes, indeed! =)Thank you!

  • http://AddaURLtothiscomment Margaret

    Sherry,
    This is not a good time of year to go off an antidepressant. Wait till Spring and if you and your PDoc think you’re ready, do it at a very slow pace.
    I’ve been taking an antidepressant for MANY years. There have been a few times when I successfully weaned myself off of it. BUT, as soon as something significant happened in my life, I started taking them again.
    I will probably be on meds. for the rest of my life, but that’s OK. It’s better than feeling miserable or having my behavior go off the charts.

    Blessings to you..

  • http://AddaURLtothiscomment spareparts

    Hi Jean,

    You mentioned the sleepy and lethargic thing. My PCP wanted to put me on Lexapro, which does this to me BADLY. It’s bad enough the lead weights on all my extremities I seem to carry now. She was just all fired up about putting me on Lexapro. It took almost all of my visit to convince her what I was taking was working FINE. I even take the generic one, so it was actually CHEAPER than the Lexapro…

    There must be some kind of something they get out of prescribing this certain or that certain drug. It’s hard to find doctors who are willing to work WITH the patients sometimes.

    We need to listen to Razz2, huh?? Thank you, Razz2!

  • http://AddaURLtothiscomment Debbie

    I am equally interested in reading about those of us who can’t seem to be off of a.d. anymore. I have tapered so many times, always resulting in those around me saying, “Hmmmm. Time to take your meds again.” Is it o.k. that some of us will never be off meds?

  • http://AddaURLtothiscomment aa

    Hi Sherry,

    I tapered off of 4 meds by mostly tapering at 10% of current dose every 4 to 6 weeks. It took nearly 4 years but I have been living med free now for over a year.

    I don’t have any proof of this but personally, I am convinced that many failures to get off of ADs are due to tapering too fast.

    If you or anyone want support in getting off of ADs, please go to http://survivingantidepressants.org/index.php?/index. It depends on donations and is not affiliated with any group. Commercial links are not allowed.

    Anyway, your doctor’s advice was horrible and is why people end up at withdrawal boards. Telling you to skip a day will cause withdrawal big time. Even drug companies will tell you that you need to take a consistent dose of the medicine every day.

    As far as when the right to withdraw is, there is no right time. Life is always going to throw curve balls at you and if you keep waiting for the perfect time to get off of meds, you never will.

    By the way Sherry, I am not being critical of you as it sounds like you need to give your body time to stabilize after your withdrawal h-ll.

    AA

    PS – I was essentially told I needed to be on meds for life. So if you want to get off and don’t have the “perfect” profile, please don’t let anyone discourage you from going against your wishes. Even tapering slowly isn’t easy but at least, it is doable.

  • http://AddaURLtothiscomment catherine mullen

    I think this is a very important topic. I find it madding that because I live in a high stress family environment decreasing and going off my medication always becomes full of peril. Everything will be going fine and then an unexpected negative event comes and blindsides me. These are events that are almost at a bizarre level and totally incomprehensible.

    What angers me most in these discussions is the lack of active research on monthly or yearly psychoactive medication. The daily struggle one must fight to take medication that changes on brain cells is difficult.
    The stigma seems to be worse now and I am frustrated that I can’t go back to my past life of no meds except for vitamins.

  • http://AddaURLtothiscomment Roby Mitchell MD

    Anyone dealing with psychiatric disorders(depression,manic/depression,schizophrenia,ADD/ADHD,bipolar disorder) Should get “The Thyroid Solution by Ridha Arem M.D. Most of these disorders improve or completely go away with proper thyroid replacement. Blood test can appear normal when you are hypothyroid. Other associations with depression include: vitamin D deficiency(major cause of seasonal affective disorder),low magnesium,poor amino acid absorption due to low production of hydrochloric acid(amino acids are the building blocks of neurotransmitters like serotonin and norepinephrine. The book “The Mood Cure” by Julia Ross explains this connection),DHA deficiency(DHA is the molecule in fish oil that is so important for normal brain function) and B vitamin deficiencies.

  • http://www.drfitt.com Roby Mitchell MD

    Medical literature clearly shows that exercise works as well or better for mild/moderate depression than drugs. The over-the-counter supplement tryptophan is the amino acid the brain uses to make serotonin. This works very well for some and it improves sleep.

  • http://AddaURLtothiscomment D Alexander

    My daughter had been on MANY antidepressants over a 3 year period…I noticed that not only was she gaining weight rapidly, she couldn’t sleep, having nightmares….and developed chronic anxiety…she had her meds changed, dosages increased…etc….I finally felt like she needed an intervention….she slowly weaned herself OFF all the meds…and now she feels much better, is sleeping and the chronic anxiety disappeared!!! She is taking a niacin supplement which she feels helps her stay in a positive frame of mind…. A 100% positive difference!!! You can find a lot of information on niacin for depression on the web. I hope this will help someone else who is debating on getting off those meds…the rule is to SLOWLY wean yourself off…even if it takes a couple of months!

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