When Breaking Up Is Hard to Do

In a perfect world—one where bosses never chewed out employees, friendships and marriages never crumbled, recessions didn’t exist, and we were all blessed with Forrest Gump’s optimism (not to mention Tom Hanks’s bank account)—perhaps no one would use antidepressants. Perhaps they’d never have been invented at all.

But in this world, stuff happens. Jane, a Westchester resident, knows it only too well. Last year, a health crisis forced her to take a job leave and undergo several painful operations. In the midst of her ordeal, her best friend died. The one-two punch left Jane, 50, feeling sorrowful and anxious: “I’d wake up late at night and sit at my kitchen table, crying. I missed my friend and regretted that I hadn’t been able to be there more for her at the end.” Therapy eased her mind, as did Effexor, an antidepressant her psychiatrist prescribed. “He felt it would help, but warned me that ‘they don’t call it SideEffexor for nothing,’” she recalls. “He said we’d have to work together when it came time for me to stop using it, because the discontinuation can cause flu-like symptoms.”

Indeed, nine months later, when they agreed it was time to initiate the process by halving her dose, that’s exactly what happened. “It wasn’t more than two days before I started having dizzy spells, even in my sleep, and throbbing headaches,” she says. “A few days later, I had to pull over while driving, because I got queasy. I was surprised at how swiftly my body reacted.” Slowing the taper fortunately helped, and she still thinks the drug did her far more good than harm. “But even with my doctor’s heads-up, I hadn’t anticipated the way I’d actually feel,” she says. “It’s one thing to hear you might get dizzy or have a night sweat; it’s another to dream you’re sitting on a record turntable, spinning like crazy, then wake up in pajamas that are sticking to your skin.”

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Brain Teaser
Luckily, most patients can get off antidepressants without problems. But Jane’s experience is far from unheard of. In fact, it has a name: antidepressant discontinuation syndrome, defined as a constellation of symptoms some patients develop when they abruptly stop taking, reduce, or skip a dose of an antidepressant they’ve been on for at least five to six weeks. “People sometimes call it ‘antidepressant withdrawal,’ but that can be misleading,” says Jay Draoua, MD, an assistant professor of psychiatry in the Department of Psychiatry and Behavioral Health Sciences at New York Medical College in Valhalla. “Antidepressants aren’t addictive in the conventional sense—patients don’t exhibit antidepressant-seeking behaviors, or develop a tolerance and need ever-higher doses to achieve the same effects.”

Antidepressant discontinuation can cause a range of mental and physical effects, and can do so swiftly—within days, or sometimes even just hours, of a missed or reduced dosage. Besides the symptoms Jane endured, other common ones include fatigue, insomnia, anxiety, agitation, visual disturbances, and what patients call “brain zaps”—strange sensations of an electrical shock to the head and body, says Alexander Lerman, MD, an attending psychiatrist at Northern Westchester Hospital in Mount Kisco.

No one knows exactly why any of this occurs, though there is a theory. Antidepressants work by boosting the brain’s levels of neurotransmitters—chemicals that brain cells use to communicate with each other and which can help regulate moods. It’s thought that when a person takes antidepressants, sites in the brain that receive these transmitters become less active. Yet, when the person stops or cuts back on antidepressants and the neurotransmitter supply drops, these receptors don’t automatically step up their game. This imbalance, until the receptor sites readjust, potentially gives rise to unpleasant symptoms.

About 20 percent of antidepressant users will experience some symptoms of discontinuation. But when it comes to bad breakups, not all antidepressants are created equal. Discontinuation syndrome is mostly linked to a category of antidepressants called SSRIs, or selective serotonin reuptake inhibitors. These medicines specifically lift the brain’s levels of serotonin, a neurotransmitter that fosters a sense of well-being. (Among the most popular SSRIs are Prozac, Celexa, Lexapro, and Paxil, to cite just some examples among many.) And even among these, there’s variability: Prozac, for example, which leaves the body relatively slowly, is unlikely to cause discontinuation-related distress; Paxil, which has a short half-life, is far more apt to cause issues. Certain other antidepressants, called SNRIs (which include Effexor and Cymbalta, though again the list runs longer) target both serotonin and a neurotransmitter called norepinephrine, and, as illustrated by Jane’s story, cases of discontinuation syndrome have been reported with them, too.

It’s important to note, though, that any antidepressant may trigger discontinuation syndrome to some degree. Biochemistry aside, there’s an emotional aspect to stopping that may play into this, says Anthony Stern, MD, an attending psychiatrist at Northern Westchester Hospital and at Montefiore Hospital in the Bronx. “The patient has formed an attachment to the medication. It’s helped him feel better, and a trusted healer has prescribed it. So he’s developed a transferential relationship to the pills—they’re representative of the physician herself, almost like a totem,” he explains. Not that discontinuation syndrome is a psychosomatic ailment, but “on some level, there’s that psychology going on, too.”

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Keeping Drawbacks on the Down Low?
Given that so many Americans are on antidepressants—more than 27 million, it’s estimated, making them the most commonly prescribed type of medication in the nation—how is it that discontinuation syndrome isn’t more widely known? Many doctors dismiss the idea of a conspiracy on the part of pharmaceutical companies, pointing out that drug makers are under obligation to report side effects to the FDA. Dr. Lerman concurs, but adds that, in general, when it comes to negative data regarding antidepressants, “there seems to be no special rush to broadcast it, either.”

He points to a study published in the New England Journal of Medicine in 2008, which tracked 74 FDA-registered antidepressant studies (though not studies necessarily pertaining to discontinuation syndrome). The authors’ findings: all but one of the 38 trials with positive outcomes were eventually published in medical journals, while of the 36 with negative results, only three made it into the medical literature intact. Of the remainder, 11 were published in a way that put a positive spin on them, the paper’s authors contended, while 22 weren’t published at all. The researchers, led by a team at Oregon Health & Science University, couldn’t tell if this was because the authors and sponsors never submitted their manuscripts for publication, or if editors declined to run them, or some combination of the two was in play. Their conclusion, whatever the case, was unsettling: “Selective reporting of clinical trial results may have adverse consequences for researchers, study participants, health care professionals, and patients.”

Even the trials themselves have limitations, according to Dr. Lerman. “They’re all done on a twelve-week basis,” he says. “I generally treat people who respond to an antidepressant for at least a year.” Perhaps it’s no surprise, then, that some side effects only become widely known, even to the manufacturers themselves, over the course of time, and through widespread usage. “Sometimes they’re discovered well after the medication is already on the market,” Dr. Draoua notes.

Strategies for a Softer Landing
It’s easy to get spooked by stats and anecdotes, yet the doctors stress that antidepressant discontinuation syndrome affects only a fraction of patients—and that those who need these medications shouldn’t avoid them because of that fear. “I don’t think the risk of the syndrome should outweigh the risk of a serious depression, which can have a major impact on a person’s health,” Dr. Draoua says. Adds Dr. Lerman, “You can always make adjustments to address discontinuation difficulties.” Some ways to help ensure a good outcome:

Never change or stop taking your prescribed dose of an antidepressant without consulting your doctor. “People sometimes stop using their medication and also never go back to their physician,” Dr. Stern says. Whether you’re having difficulty affording your prescription, or are simply feeling better and think you don’t need it anymore, stopping on your own is a recipe for trouble, since suddenly abandoning meds can be a jolt to your system. If finances are an issue, don’t be embarrassed about telling your doctor, says Dr. Draoua. “We’re sensitive to it. We can prescribe generics if possible, for instance, and some large retailers like Wal-Mart often have very good prices.” And, if it’s side effects that are making you skip or ditch your meds, don’t be shy about discussing that, either. “A patient needs to feel okay bringing up those issues, including sexual side effects,” says Dr. Lerman. “That way, we can try to make adjustments to ease the problems.” says Dr. Lerman.

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Resist the urge to self-diagnose antidepressant discontinuation syndrome. “There’s no substitute for talking to your physician when you’re experiencing problems after a change in your antidepressants,” Dr. Draoua says. In fact, not doing so can be dangerous: “Irritability, sleeplessness, and agitation, for example, could mean things other than discontinuation syndrome—it could also be the onset of bipolar disorder, which is dangerous and may require hospitalization. You could also be experiencing a return of the depression, if there’s been a lag of a few weeks between when you stopped your medication and when you began having symptoms.” Or you may end up getting needless tests. “I’ve had patients come in and tell me they got an MRI for their chronic headaches, but they hadn’t informed anyone that they’d stopped taking their antidepressants, which could be the cause,” Dr. Lerman says.

Keep in close touch with your physician and be patient. One common remedy for discontinuation syndrome is to go back up to your original dosage (with your doctor’s blessing) and taper down more slowly. “For someone who’s on Paxil, I may reduce his dosage by just a single milligram every two weeks if he’s having problems,” Dr. Lerman says. Or he said he may try switching a patient over to Prozac, which has little to no association with the syndrome, and taper him or her off of it instead. There are other options, too, including using a longer-acting compound of the med you’re on, or a liquid form that can be more easily reduced, if available—so work with your doctor to find the best tactic for you.

Eat a balanced diet and get plenty of sleep. Mom was right! “It’s always good advice,” says Dr. Draoua, “and it’s especially wise during times when your body is under stress.”

Above all, don’t lose heart if you experience some symptoms of discontinuation. “The important thing to know—and your doctor can help reassure you of this—is that the condition is reversible, certainly not life-threatening, and should run its course in a few days to a couple of weeks,” Dr. Draoua says. Uplifting thoughts for those who sometimes have too few.

Writer/editor Deborah Skolnik lives in Scarsdale. She eagerly awaits the invention of the ultimate antidepressant: a chocolate bar that makes you both richer and thinner.

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