Difficulty stepping down

How much do we understand how coming off antidepressants works?
20 January 2020

Interview with 

Roma Riaz-Ul-Haq, CPFT Psychiatrist


Close up of a doctor's coat, with a stethoscope and a pocket full of pens


Psychiatrist Roma Riaz-Ul-Haq is concerned that not enough is understood about coming off these drugs. She spoke with Katie Haylor...

Roma - Unfortunately the evidence is only limited, and most of the evidence that we are relying on is anecdotal, coming from influential professionals who have lately come up and shared their own personal experience, how difficult it was for them to come off the antidepressants. Also, some of the surveys that have been done lately to know people's experiences. Yes, there is a difficulty when people stop antidepressants suddenly. However, this is something that can be dealt with, and people have come off medication successfully and are living normal day to day life.

Katie - So what rough proportion of the people that you see who are on antidepressants, might struggle to come off them?

Roma - It's hard to put that in numbers, but there are certain factors that influenced that. First of all, it varies from person to person. Secondly, a lot of it is to do with  how the antidepressants act. Some of the antidepressants take a longer time to be released in the blood and are steady for a longer time, which causes less of a problem with withdrawal. Whereas other antidepressants which break down quickly and are quick to release in the blood, do not last longer in the blood and are more likely to cause withdrawal symptoms.

Katie - Do you know who's most likely to struggle? Does it break down by age or gender or anything like that?

Roma - One of the things that people have experienced is that some of the personal characteristics such as apprehension around stopping medication can affect some symptoms of withdrawal. And the little evidence that we have do not support that age is a factor that contributes to it. So generally speaking, if someone has been taking the antidepressant medication for a longer time, the body gets adjusted to that, which would mean coming off as slow as we possibly can, to give the body enough time to adapt to the new changes.

Katie - Do we know anything about whether withdrawal is related to the severity of the depression? Are we just talking really extreme severe cases of depression where withdrawal's a problem, or is it a problem also in milder cases of depression?

Roma - So far the limited evidence that we have do not support this. There's no link that has proved to be between the severity of depression to severity of withdrawal symptoms.

Katie - Can people get hooked on antidepressants? Does dependence or addiction factor in this conversation?

Roma - To answer that, we need to be very clear about the characteristics of something we can say can cause dependence. First of all, the drugs which cause dependence do cause cravings if they're not taken. Secondly, there's a need to take more in order to get the same effect. Fortunately, with antidepressants it does not come with those properties so they do not cause dependence.

Katie - But I guess that doesn't necessarily mean there isn't a fear around the subject.

Roma - I think a lot of fear generally patients do express about stopping medication is that, firstly, they think the depression would come back. Secondly, a lot of it is to do with the apprehension around withdrawal symptoms,  what they might start feeling or experiencing once the medication is stopped. But we as clinicians do empower the patients, try and educate them, try and monitor them to make the right choices.

Katie - But are those symptoms pretty obviously different from relapse into depression? Because I guess that's another thing you absolutely want to avoid if you can.

Roma - So that's one of the challenges clinically to differentiate relapse from withdrawal. Now we know some of the symptoms do overlap, like some of the mood symptoms, some of the cognitive symptoms, some of the physical symptoms. However, what's crucial is that with withdrawal, the onset of symptoms is usually within hours rather than days or weeks. And also the physical symptoms are more pronounced, more distinguished, as compared to the relapse. But yeah, this is one area which needs careful monitoring, it needs to be explored more, patients need to feel confident, the experiences that they're going through what it actually is.

Katie - Could you summarise the areas in which you think we really do need to learn more?

Roma - It's from the very basics, really. We need to learn more about what are the mechanisms of action in terms of withdrawing from antidepressants. And I think from a realistic and a practical perspective, as a clinician, I would really like to have more answers to the questions that I get asked about why it's happening, how long it would take, what are they exact guidelines to reduce medication. There's a lot that needs to be explored.


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