I get numerous inquiries about how to stop antidepressants. I get the impression that most people want to stop on their own, and not in collaboration with their psychiatrist. As always, I recommend that you change medicine only after consultation with your doctor. If you don’t feel like your doctor will listen to you, then you need to consider changing doctors . . . or, perhaps, listening to them about what their advice is (they may be right, you know).
There are no hard and fast rules for stopping medication. The factors that I consider when I decide on a taper schedule include the following: 1) how well is the patient doing, 2) how difficult are the side effects, 3) how long the patient has been on the medicine, 4) the ultimate goal.
1) How well is the patient doing? If a patient is not doing well, I tend to get them off the medicine more quickly, presumably to get started on a new medicine. For example, if someone is not doing well on Celexa (citalopram) 40 mg, I might bring them down quickly to start another antidepressant, such as Cymbalta. I might have them take 20 mg for 5 days, 10 mg for 5 days, then switch over to Cymbalta. If someone is doing well and we are really trying to get them off medicine and keep them off medicine, I will taper slowly–sometimes infuriatingly slowly. For example, if someone has done very well on 40mg of Celexa and we are trying to get them medication free, I might lower it by 10 mg every month or two until they are off. Now that means a 3-6 month taper, but if there is no reason to hurry, don’t hurry. Going slowly increases the chances for success. Going to quickly increases the chances for a need to restart the medicine–and recurrent relapses of symptoms may indicate a need for lifelong treatment (something most people want to avoid).
2) How difficult are the side effects? Can you guess my answer? If the side effects are difficult, taper quickly. If the side effects are not so difficult, taper more slowly.
3) How long has the patient been on the medicine? If you have been on an antidepressant for a long time and are getting off, it makes sense to taper slowly. If you have been on it only for a short time, I will tend to go more quickly.
4) The ultimate goal. If the plan is to get someone off medicine completely, I will go very slowly (as outlined above). If I am switching to another medicine, I will go more quickly.
So you see, there are multiple factors involved, but only two options. I will tend to go more quickly on a taper if someone is not doing well, if they have lots of side effects, if they have only been on the medicine for a brief period of time, and if I am switching to another medicine. I will go more slowly if the have done well, have minimal side effects, been on the medicine for a while, and if the ultimate goal is to get off medicine entirely. The other factor that ties in here for a few of the medicines is discontinuation syndrome. If the actual taper causes discomfort, I will switch more quickly if the ultimate goal is a medication change (the new medicine should reduce or eliminate the discontinuation syndrome). Conversely, if there are discontinuation syndrome symptoms and I am trying to stop medicine entirely, I will go very, very, VERY slowly. It is important to remember that when you stop an antidepressant, there is the risk of a return of symptoms (depression/anxiety) and the possibility of suicidal thoughts. For that reason, it is best done in consultation with your doctor.
–Dan Hartman, MD
Question:
I have been working with my psychiatrist on tapering off Lexapro, which I was on for at least three years (at 10mg/day). (I had good success on Lexapro but a lot of fatigue, perhaps due to the REM suppressing quality of the med.) I am still on Wellbutrin. We tapered down to 5mg, then to 2.5mg. He thought my symptoms wouldn’t last long, but it’s been 27 days since my last 2.5mg dose, and I still am having problems. My main question is: can symptoms ebb and flow, and go one day or more and then return, and last for a few hours and then subside? If not, then my symptoms must be due to some other factor, and I would need to see a doctor ASAP to diagnose it. I felt fine for several days last week, but now I am having headaches, palpitations, nausea, crying too easily, anxiety, etc. (I tried to reach my psych but he is on vacation, as is his office partner.) Please Help! Thanks!
Carol–From your description of the timeline, I doubt that the fatigue palpitations, headache, etc are leftovers from the Lexapro. A med like Lexapro is out of your system in days and the side effects should subside. If these are symptoms that were present before the Lexapro, it may just indicate a return of symptoms that would be treatable with another SSRI or an SNRI (like Cymbalta). Make sure you are taking the Wellbutrin in the morning (it, too, can alter sleep patterns if taken too late in the day).
If there is the thought that the symptoms you describe are “withdrawal” symptoms (could be but it would be unusual at this stage), you could either go back on a low dose of Lexapro and come off more slowly, or go on Prozac which has a very very low rate of discontinuation problems.
Also, I would have a word with your doc . . . it is unacceptable to go out of town and to not have reasonable back-up. Unacceptable.
–DH MD
Benzodiazepines need to be discontinued very slowly…they, in most cases, cannot be switched abruptly..
Just had to add that in, even if the subject is about antidepressants..
Thank you both for your replies. It has been about a year and a half since I wrote, but I just came across this thread and thought I’d provide an update.
I did wind up increasing the dose of Lexapro and then tapering off more gradually, and that worked much better. Additionally, at some point my doctor changed my SSRI to Prozac, so that may have helped too, if it overlapped with the withdrawal of Lexapro (I can’t recall). I was very surprised at how sensitive I was to discontinuation. I’ve always considered myself to have a strong constitution.
By the way, none of these symptoms (nausea, headache, palpitations) were present before I went on antidepressants, so perhaps the psychiatric community should track this issue to see if many people have had a similar reaction to discontinuation of SSRIs.
Thank you very much. It was an awful experience and I am feeling so much better now.
On a somewhat related subject, in case anyone is not aware, bupropion (Wellbutrin) can cause tremor. When my dose was increased from 150mg to 300mg my hands trembled. When I went back to the 150mg dose, the tremor stopped.
Additionally, patients should be warned that SSRIs can delay the onset of REM sleep. I have chosen to continue taking SSRIs because being fatigued is much better than being depressed, but it took me years to realize that my SSRI could be contributing to my frequent drowsiness.