Understanding Antidepressant Medications Part 2: When and How to Safely Stop Them
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Author: Dr. David Gardner, Professor & Community Psychiatry Research Director, Department of Psychiatry, Dalhousie University, and Executive Member of the Network
Are you or someone you know taking an antidepressant? Is it time to think about stopping it? In Part 1 of this article, the focus was on the potential benefits and harms of antidepressants. In this, the second of a 2-part article, you’ll learn about when and how these medications can be safely stopped.
Meet Celine and Hiroshi
Celine, 70 years old
Celine is 70 years old and lives on her own. Physically she is quite well. She often describes herself as feeling all alone. She has had several episodes of depression in the past twenty years. She also experiences anxiety that increases during periods of depression. Some of her episodes lasted much longer and were more severe than others. She finds it very difficult to leave her home during these episodes. Her energy is low, she is unable to enjoy or look forward to pretty much anything, and she experiences a lot of shame and self-doubt. Antidepressants have been helpful but typically take months to help her feel better. Her last period of depression persisted for over a year. She tried different antidepressants before finding one that worked and whose side effects she could tolerate. She’s been taking that same antidepressant for nearly five years now. At a recent visit with her doctor, she reported that her mood was good overall but did acknowledge that her emotions felt a little “numb”.
Hiroshi, 67 years old
Hiroshi is a 67-year-old former businessman who retired from work three years ago. In his various positions, Hiroshi frequently entertained clients over lunches, dinners, and day-long golf events that often involved alcohol. He prided himself in being busy and useful. Upon retirement, he continued drinking alcohol and his mood and self-assured approach to life took a rapid turn. Encouraged by his wife and brother, Hiroshi spoke with his family doctor about how he’d been feeling. He was diagnosed with depression and was advised to reduce his alcohol use. He was prescribed and willingly took an antidepressant, and he decided to completely stop drinking alcohol. Gradually, over a few weeks, Hiroshi noticed how much better he felt. A year later, at a doctor’s appointment, he described his new hobbies, exercise routine, satisfaction with sleep, and how he enjoyed helping his family. He was content with being retired and asked if this was a good time to stop his antidepressant.
How Long Should I Take an Antidepressant For?
How long you should take an antidepressant depends on several factors. Most important are the severity of the episode, how long it took for symptoms to resolve, your past experiences with depression or anxiety, and your own preference about whether to continue or stop. Just like Celine and Hiroshi, each person’s situation is different. If it is the first time you are experiencing depression, the general recommendation is to continue treatment for at least 6 months after your symptoms have resolved.1,2 For most people, it can take from 3 to 6 months to achieve the full response to treatment. We are therefore talking about a total period of roughly 9 to 12 months before contemplating stopping treatment. This is also true when treating anxiety disorders, such as social anxiety disorder and generalized anxiety disorder.3,4 Many people benefit from taking antidepressants for a longer period, including the option of taking it for life. Others stop treatment without any ill-effects from doing so. However, there are risks both with continuing treatment and with stopping it.
What Are the Benefits and Risks of Stopping Antidepressants?
It is very important to reassess the potential benefits and harms of continuing an antidepressant on a regular basis. You could reassess every six months, for example. Exactly when to do this review is flexible and should be planned and discussed with your health care provider, including your doctor, pharmacist, or nurse.
Listed here are important considerations when deciding to stop or continue taking an antidepressant that is working well for you:
| Benefits of stopping | Risks of stopping |
|---|---|
|
|
Stopping your antidepressants can relieve ongoing side effects. Some side effects are more obvious (e.g., sexual side effects, feeling sleepy during the day) and others can go unnoticed (e.g., numbing of emotions). Antidepressants can also interact with other medications and substances, leading to a wide range of side effects and possibly even resulting in hospitalization. Stopping an antidepressant helps to avoid these issues, especially for people taking several other medications.
However, stopping an effective antidepressant has two important possible consequences: going through a period of withdrawal, and risking a return of symptoms. Fortunately, these risks can be minimized.
Antidepressant Withdrawal
Antidepressants vary in terms of their possible withdrawal symptoms. For example, bupropion causes few problems when stopped. Others can cause a collection of symptoms, often referred to as a withdrawal syndrome. This is more likely to happen when:
Abruptly stopping the long-term use of an antidepressant (e.g., “going cold turkey”).
Taking antidepressants known as selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs). Examples include citalopram, duloxetine, escitalopram, paroxetine, sertraline, and venlafaxine.
Common antidepressant withdrawal symptoms include (5,6):
Return of Symptoms
Antidepressants not only treat depression and anxiety but also lower the risk of them coming back if you continue taking them. That’s why antidepressants should be continued after symptoms resolve.7-9 By staying on an antidepressant that you have responded well to you are cutting the risk of a return of symptoms by about half.7,9 The advantage of continuing antidepressant therapy appears to apply whether you have taken the antidepressant for a shorter or longer period of time.7,9 For some people, it is possible to reduce the risk of relapse by completing a course of cognitive behaviour therapy (CBT) when the antidepressant is being stopped.10 A specific version of CBT called “mindfulness-enhanced cognitive behaviour therapy” is recommended. It can be started shortly before beginning to gradually reduce the dose of the antidepressant. Studies show that completing a course of this type of psychotherapy along with a gradual dose reduction of the antidepressant can avoid the increased risk of relapse when stopping an antidepressant. You can learn about it at This Way Up, which is an Australian provider of free, internet-delivered CBT programs.11
Celine and Hiroshi
Each person has a different risk for experiencing a relapse of depression. What’s more, a person’s degree of risk can change over time. Based on their past experiences of depression and other considerations, Celine’s risk for a future episode of depression is higher than Hiroshi’s.
Celine
Celine has had multiple episodes of depression in the past. Her response to treatment can be slow and recently she had a difficult time finding an effective antidepressant. She also has ongoing anxiety symptoms, a condition that increases the risk for depression. And, she describes feeling that her emotions seem to be somewhat numbed. This can be an unresolved symptom of depression or it may be a subtle side effect of the antidepressant. What is most important is that since responding to her current antidepressant, she has not had a relapse of depression for five years. While stopping the antidepressant could help determine if it’s the cause of her numbed emotions, Celine may prefer to continue the antidepressant to lower the risk for experiencing another episode of depression.
Hiroshi
Hiroshi lowered his risk of depression by stopping his use of alcohol and has adjusted to being retired. He had responded well to his antidepressant and had only a single diagnosed episode of depression in his life. His risk of relapse is relatively low after stopping treatment because of this history and also because of several factors protecting him from future episodes of depression, including satisfactory sleep, exercise, and having strong social connections.
How to Stop Antidepressants Safely
Antidepressants affect the quantity and actions of neurotransmitters in our body. Over time, the body makes several physiological adjustments in response to the presence of the antidepressant. Likewise, when the antidepressant is no longer present in the body, physiological changes take place in its absence. These are believed to be the cause of the withdrawal syndrome. Whenever possible, stopping antidepressant treatment should be done slowly to allow the body to adjust gradually. There are very few reasons for stopping antidepressants abruptly. An urgent medical issue is one reason. Otherwise, for everyone else, a slow gradual reduction is strongly recommended.5,12 This will avoid or minimize withdrawal symptoms. There are various ways to gradually reduce the dose and stop antidepressant treatment.12 Here, they are categorized into four main approaches. Methods 1 and 2 apply to most people. You can start with either Method 1 or 2. If you start with Method 1 and have difficulty, switch to Method 2 before moving on to Method 3 or 4. Some people are more sensitive to the withdrawal effects of stopping antidepressants and will benefit from using either Method 3 or 4, both of which are more involved. Each of the four methods are described below using an example of a person taking 20 mg/day of an antidepressant.
Before stopping an antidepressant, be sure to consult with your health care provider to discuss and plan the best approach for you.
Method 1: The Staircase
Each dose decrease is the same and the time between dose decreases is the same.
A visual representation of the staircase method
Example:
Week |
Dose (mg/day) |
|---|---|
1 |
20 |
2 |
15 |
3 |
10 |
4 |
5 |
5 |
0 |
