Antidepressants Diagnostic Features
Antidepressants Diagnostic Features
Discontinuation symptoms may occur following treatment with tricyclic antidepressants (e.g., imipramine, amitriptyline, desipramine), serotonin reuptake inhibitors (e.g., fluoxetine, paroxetine, sertraline), and monoamine oxidase inhibitors (e.g., phenelzine, selegiline, pargyline)(Blier and Tremblay 2006; Delgado 2006; Demyttenaere and Haddad 2000; Fava 2006; Haddad 2001; Haddad and Qureshi 2000; Kaymaz et al. 2008; Mavissakalian and Perel 1999; Schatzberg et al. 2006; Shelton 2006; Warner et al. 2006). The incidence of this syndrome depends on the dosage and half-life of the medication being taken, as well as the rate at which the medication is tapered. Short-acting medications that are stopped abruptly rather than tapered gradually may pose the greatest risk. The short-acting selective serotonin reuptake inhibitor (SSRI) paroxetine is the agent most commonly associated with discontinuation symptoms, but such symptoms occur for all types of antidepressants(Fava 2006; Haddad 2001; Warner et al. 2006).
Unlike withdrawal syndromes associated with opioids, alcohol, and other substances of abuse, antidepressant discontinuation syndrome has no pathognomonic symptoms. Instead, the symptoms tend to be vague and variable(Blier and Tremblay 2006; Delgado 2006; Demyttenaere and Haddad 2000; Fava 2006; Haddad 2001; Haddad and Qureshi 2000; Kaymaz et al. 2008; Mavissakalian and Perel 1999; Schatzberg et al. 2006; Shelton 2006; Warner et al. 2006) and typically begin 2–4 days after the last dose of the antidepressant. For SSRIs (e.g., paroxetine), symptoms such as dizziness, ringing in the ears, “electric shocks in the head,” an inability to sleep, and acute anxiety are described. The antidepressant use prior to discontinuation must not have incurred hypomania or euphoria (i.e., there should be confidence that the discontinuation syndrome is not the result of fluctuations in mood stability associated with the previous treatment). The antidepressant discontinuation syndrome is based solely on pharmacological factors and is not related to the reinforcing effects of an antidepressant. Also, in the case of stimulant augmentation of an antidepressant, abrupt cessation may result in stimulant withdrawal symptoms (see “Stimulant Withdrawal” in the chapter “Substance-Related and Addictive Disorders”) rather than the antidepressant discontinuation syndrome described here.
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