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Monday, August 03, 2009

Stopping antidepressants can cause side effects

Recognizing withdrawal symptoms and working with your doctor are key.
By Regina Nuzzo
August 3, 2009

Source: LA Times

Ryan Yorke, now 21, started taking Paxil after an out-of-the-blue panic attack his freshman year of high school. At first it worked great. But he gained weight and had other problems -- he started acting up in school and failing classes, for example. So after a year, he -- along with his mother and his psychologist -- decided it was time to stop.

Every time he reduced his dose, things got out of control, says his mother, Laurie Yorke, a registered nurse and now an administrator of paxilprogress.org, an antidepressant-withdrawal support site.

After the first big dose drop, Ryan slashed his wrists in front of his mother in the living room. "It was a six-hour psychotic episode. He was quoting Shakespeare and saying he wanted to die," she recalls.

A few weeks later, after more gradual dose changes, Ryan was still so sensitive to light and sound that he taped shut the window shades in his bedroom. His memory and concentration were poor. He dropped out of school and got his GED later, after the withdrawal process was over.

Mental health professionals aren't sure how many people have problems when stopping antidepressant medication. It's not even clear how to define the cluster of withdrawal symptoms people report, or even what causes the effects.

"It's a difficult corner of the field," says Dr. Kenneth Duckworth, medical director of the National Alliance on Mental Illness and psychiatry professor at Harvard Medical School. "It's hard to know whether the person's depression is worsening or if they're having a variation on a discontinuation syndrome."

Knowing what to look out for when you and your doctor start the stopping process (which the medical community terms "antidepressant discontinuation syndrome") can help minimize issues.

All approved antidepressant medications either come with documented discontinuation problems or a manufacturer's warning of the possibility. Typical symptoms can depend on the class of antidepressant.

Drugs that affect serotonin levels -- selective serotonin reuptake inhibitors, or SSRIs, such as Prozac, and serotonin-norepinephrine reuptake inhibitors, or SNRIs, such as Effexor -- can cause dizziness, upset stomach, headache and flu-like symptoms when stopped. Some people also report electric-shock sensations that zap through the body.

Other serotonin-stopping symptoms can mimic those of depression: lethargy, sleep problems, sadness, anxiety and thoughts of suicide.

Tricyclic antidepressants, which were introduced in the 1950s and include Sinequan and Tofranil, can trigger withdrawal symptoms similar to those of SSRIs and SNRIs. But since these drugs work on dopamine as well as serotonin and norepinephrine, stopping them can cause balance problems or Parkinson's-like tremors.

Even more dramatic are problems from quitting the oldest kind of antidepressants: monoamine oxidase inhibitors, or MAO inhibitors. These work on several brain chemicals; withdrawal symptoms include agitation, nightmares, aggression and psychosis.

Many people have no symptoms when they quit taking antidepressants. And any problems are usually mild and short-lived, Duckworth says. But sometimes the effects can be so bad as to require time off work or, rarely, to send people to the emergency room.

Estimates vary as to how often problems will happen. And some of the symptoms that patients report may not in fact be linked to withdrawal from the drug. One clinical trial from 1995 found that 35% of patients taking Paxil had mild to moderate discontinuation symptoms -- but so did 14% of patients who had been taking a placebo.

Symptoms usually appear within three days after a change in dose and disappear after two weeks, says Dr. Christopher Kratovchil, an American Psychiatric Assn. spokesman and psychiatry professor at the University of Nebraska Medical Center. A 1993 study of the SSRI Luvox found that the average number of symptoms shot up within the first few days after a missed dose, peaked during the fifth day and then gradually dwindled over the next week or so.

Doctors can't really predict who will have problems. One study in 2002 found that women were likely to have more severe symptoms, but other studies have found no gender difference. Genetics likely plays a role.

Some drugs get more complaints than others. In a 2006 study of antidepressant-withdrawal calls to a help line in England, about 40% were from people who had problems stopping Paxil, and about 14% were from those quitting Effexor. No other drug accounted for more than 10% of calls.

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