Psychotherapeutic Drugs

Psychotherapeutic Drugs
Chapter 16 Psychotherapeutic Drugs Copyright © 2017, Elsevier Inc. All rights reserved.

Psychotherapeutic Drugs
Used in the treatment of emotional and mental disorders Ability to cope with emotions can range from occasional depression or anxiety to constant emotional distress. When emotions significantly affect an individual’s ability to carry out normal daily functions, treatment with a psychotherapeutic drug is a possible option. Copyright © 2017, Elsevier Inc. All rights reserved.

Psychotherapeutic Drugs (Cont.)
Three main emotional and mental disorders Anxiety Affective disorders Psychoses Copyright © 2017, Elsevier Inc. All rights reserved.

Psychotherapeutic Drugs (Cont.)
Types of psychotherapeutic drugs Anxiolytic drugs Mood-stabilizing drugs Antidepressant drugs Antipsychotic drugs Copyright © 2017, Elsevier Inc. All rights reserved.

Copyright © 2017, Elsevier Inc. All rights reserved.
Anxiety Unpleasant state of mind characterized by a sense of dread and fear May be based on actual anticipated experiences or past experiences May be exaggerated responses to imaginary negative situations Copyright © 2017, Elsevier Inc. All rights reserved.

Anxiety Disorders Six major anxiety disorders (persistent anxiety) Obsessive-compulsive disorder (OCD) Posttraumatic stress disorder (PTSD) Generalized anxiety disorder (GAD) Panic disorder Social phobia (social anxiety disorder) Simple phobia Copyright © 2017, Elsevier Inc. All rights reserved.

Affective Disorders (Mood Disorders)
Changes in mood that range from mania (abnormally pronounced emotions) to depression (abnormally reduced emotions) Some patients may exhibit both mania and depression: bipolar disorder (BPD) Copyright © 2017, Elsevier Inc. All rights reserved.

Psychosis Severe emotional disorder that impairs the mental function of the affected individual to the point that the individual cannot participate in activities of daily living. Hallmark: loss of contact with reality Examples Schizophrenia Depressive and drug-induced psychoses Copyright © 2017, Elsevier Inc. All rights reserved.

Anxiolytic Drugs Reduce anxiety by reducing overactivity in central nervous system (CNS) Benzodiazepines Depress activity in the brainstem and limbic system Miscellaneous drug: buspirone (BuSpar) Nonsedating and non–habit forming May have drug interaction with selective serotonin reuptake inhibitors (SSRIs) (serotonin syndrome) Do not administer with MAOIs Copyright © 2017, Elsevier Inc. All rights reserved.

alprazolam (Xanax) diazepam (Valium) lorazepam (Ativan)
Benzodiazepines alprazolam (Xanax) diazepam (Valium) lorazepam (Ativan) Copyright © 2017, Elsevier Inc. All rights reserved.

Benzodiazepines: Adverse Effects
Benzodiazepines’ adverse effects are an overexpression of their therapeutic effects Decreased CNS activity, sedation Hypotension Drowsiness, loss of coordination, dizziness, headaches Nausea, vomiting, dry mouth, constipation Others Copyright © 2017, Elsevier Inc. All rights reserved.

Benzodiazepines: Overdose
Dangerous when taken with other sedatives or alcohol Treatment is generally symptomatic and supportive. Flumazenil (Romazicon) may be used to reverse benzodiazepines’ effects. Copyright © 2017, Elsevier Inc. All rights reserved.

Benzodiazepines: Interactions
Alcohol and CNS depressants can result in additive CNS depression and even death. More likely to occur in patients with renal or hepatic compromise Copyright © 2017, Elsevier Inc. All rights reserved.

Alprazolam (Xanax) Most commonly used as an anxiolytic Indicated for GAD, short-term relief of anxiety symptoms, panic disorder, and anxiety associated with depression Adverse effects: confusion, ataxia, headache, and others Interactions: alcohol,oral contraceptives, and others Copyright © 2017, Elsevier Inc. All rights reserved.

Diazepam (Valium) Indications: relief of anxiety, management of alcohol withdrawal, reversal of status epilepticus, preoperative sedation, and as an adjunct for the relief of skeletal muscle spasms Avoid in patients with hepatic dysfunction. Adverse effects: headache, confusion, slurred speech, and others Interactions: alcohol, oral contraceptives, and others Copyright © 2017, Elsevier Inc. All rights reserved.

Lorazepam (Ativan) Intermediate-acting benzodiazepine Can be given by IV push; useful in the treatment of an acutely agitated patient Continuous infusion for agitated patients who are undergoing mechanical ventilation Used to treat or prevent alcohol withdrawal Copyright © 2017, Elsevier Inc. All rights reserved.

Miscellaneous Anxiolytic
buspirone (BuSpar) Unknown mechanism of action Administered on a scheduled basis Adverse effects Paradoxical anxiety Blurred vision Headache Nausea Copyright © 2017, Elsevier Inc. All rights reserved.

Mood-Stabilizing Drugs
Lithium carbonate and lithium citrate Other drugs may be used in combination with lithium Benzodiazepines Antipsychotic drugs Antiepileptic drugs Dopamine receptor agonists Copyright © 2017, Elsevier Inc. All rights reserved.

Lithium Drug of choice for the treatment of mania It is thought to potentiate serotonergic neurotransmission Narrow therapeutic range: acute mania—lithium serum level of 1 to 1.5 mEq/L; maintenance serum levels should range between 0.6 and 1.2 mEq/L Levels exceeding 1.5 to 2.5 mEq/L begin to produce toxicity, including gastrointestinal (GI) discomfort, tremor, confusion, somnolence, seizures, and possibly death. Keeping the sodium level in the normal range (135 to 145 mEq/L) helps to maintain therapeutic lithium levels. Copyright © 2017, Elsevier Inc. All rights reserved.

Lithium (Cont.) Adverse effects Most serious adverse effect is cardiac dysrhythmia Other effects: drowsiness, slurred speech, epilepsy-type seizures, choreoathetotic movements (involuntary wavelike movements of the extremities), ataxia (generalized disturbance of muscular coordination), and hypotension Long-term treatment may cause hypothyroidism. Copyright © 2017, Elsevier Inc. All rights reserved.

Audience Response System Question
Before administering lithium to a patient, it is most important for the nurse to assess which laboratory value? Blood sugar Sodium Urine osmolality Hematocrit Correct answer: B Rationale: Lithium may become toxic if the patient has hyponatremia. The sodium level should be assessed in patients receiving lithium therapy to prevent toxicity. Copyright © 2017, Elsevier Inc. All rights reserved.

Antidepressants Tricyclic antidepressants Monoamine oxidase inhibitors (MAOIs) Second-generation antidepressants SSRIs Serotonin-norepinephrine reuptake inhibitors (SNRIs) Copyright © 2017, Elsevier Inc. All rights reserved.

Tricyclic Antidepressants
Have largely been replaced by SSRIs as first-line antidepressant drugs Considered second line For patients who fail with SSRIs or other newer generation antidepressants As adjunct therapy with newer generation antidepressants amitriptyline (Elavil) Copyright © 2017, Elsevier Inc. All rights reserved.

Tricyclic Antidepressants: Mechanism of Action
Block reuptake of neurotransmitters, causing accumulation at the nerve endings It is thought that increasing concentrations of neurotransmitters will correct the abnormally low levels that lead to depression Copyright © 2017, Elsevier Inc. All rights reserved.

Tricyclic Antidepressants: Indications
Depression Childhood enuresis (imipramine) OCDs (clomipramine) Adjunctive analgesics for chronic pain conditions, such as trigeminal neuralgia Copyright © 2017, Elsevier Inc. All rights reserved.

Tricyclic Antidepressants: Adverse Effects
Sedation Impotence Orthostatic hypotension Others Older patients Dizziness, postural hypotension, constipation, delayed micturition, edema, muscle tremors Copyright © 2017, Elsevier Inc. All rights reserved.

Tricyclic Antidepressants: Overdose
Lethal: 70% to 80% die before reaching the hospital CNS and cardiovascular systems are mainly affected. Death results from seizures or dysrhythmias. Copyright © 2017, Elsevier Inc. All rights reserved.

Tricyclic Antidepressants: Overdose (Cont.)
No specific antidote Decrease drug absorption with activated charcoal. Speed elimination by alkalinizing urine. Manage seizures and dysrhythmias. Provide basic life support. Copyright © 2017, Elsevier Inc. All rights reserved.

Amitriptyline (Elavil)
Oldest and most widely used of all the TCAs Original indication was depression Commonly used to treat insomnia and neuropathic pain Contraindications: known drug allergy, pregnancy, and recent myocardial infarction Adverse effects: dry mouth, constipation, blurred vision, urinary retention, and dysrhythmias Copyright © 2017, Elsevier Inc. All rights reserved.

Monoamine Oxidase Inhibitors (MAOIs)
Nonselective: isocarboxazid, phenelzine, and tranylcypromine Selective: selegiline Rarely used for depression Used for Parkinson’s disease Disadvantage: potential to cause hypertensive crisis when taken with tyramine Copyright © 2017, Elsevier Inc. All rights reserved.

MAOIs and Tyramine Ingestion of foods or drinks with tyramine leads to hypertensive crisis, which may lead to cerebral hemorrhage, stroke, coma, or death Avoid foods that contain tyramine! Aged, mature cheeses (cheddar, bleu, Swiss) Smoked, pickled, or aged meats, fish, poultry (herring, sausage, corned beef, salami, pepperoni, paté) Yeast extracts Red wines (Chianti, burgundy, sherry, vermouth) Italian broad beans (fava beans) Copyright © 2017, Elsevier Inc. All rights reserved.

Selegiline Transdermal Patch (Emsam)
Selective MAO-B inhibitor Indicated for major depression Contraindication includes known drug allergy. Adverse drug effects Avoid exposing the patch to external sources of heat or prolonged direct sunlight because heat speeds absorption. Copyright © 2017, Elsevier Inc. All rights reserved.

Second-Generation Antidepressants
vortioxetine (Brintelix) Fewer adverse effects than TCAs and MAOIs Very few drug–drug or drug–food interactions Still take about 4 to 6 weeks to reach maximum clinical effectiveness Now considered first-line drugs for depression Mechanism of action: inhibition of serotonin reuptake and possible effects on norepinephrine and dopamine reuptake Copyright © 2017, Elsevier Inc. All rights reserved.

Second-Generation Antidepressants (Cont.)
Indications Depression BPD, obesity, eating disorders, OCD, panic attacks or disorders, social anxiety disorder, PTSD, premenstrual dysphoric disorder, the neurologic disorder myoclonus, and various substance abuse problems such as alcoholism Copyright © 2017, Elsevier Inc. All rights reserved.

Second-Generation Antidepressants (Cont.)
Adverse effects: insomnia (partly caused by reduced rapid eye movement sleep), weight gain, and sexual dysfunction Copyright © 2017, Elsevier Inc. All rights reserved.

Second-Generation Antidepressants: Serotonin Syndrome
Copyright © 2017, Elsevier Inc. All rights reserved.

Bupropion Originally indicated for treatment of depression; now also indicated as an aid in smoking cessation Sometimes added as an adjunct antidepressant for patients experiencing sexual adverse effects secondary to SSRI therapy Zyban: approved for smoking cessation treatment and was the first nicotine-free prescription medicine used to treat nicotine dependence Copyright © 2017, Elsevier Inc. All rights reserved.

Citalopram (Celexa) One of the most commonly used SSRIs Treatment of depression and OCD Discontinuation syndrome Adverse effects: anxiety, dizziness, drowsiness, insomnia, and others Copyright © 2017, Elsevier Inc. All rights reserved.

Duloxetine (Cymbalta)
Indications: depression, GAD and pain resulting from diabetic peripheral neuropathy or fibromyalgia Adverse effects: dizziness, drowsiness, headache, GI upset, anorexia, and hepatotoxicity Drug interactions: SSRIs and triptans (increased risk of serotonin syndrome) and alcohol (increased risk of liver injury) Can worsen uncontrolled angle-closure glaucoma . Copyright © 2017, Elsevier Inc. All rights reserved.

Fluoxetine (Prozac) Prototypical SSRI Indications: depression, bulimia, OCD, panic disorder, and premenstrual dysphoric disorder Contraindications: known drug allergy and concurrent MAOI therapy Adverse effects: anxiety, dizziness, drowsiness, insomnia, and others Copyright © 2017, Elsevier Inc. All rights reserved.

Mirtazapine (Remeron)
Promotes the presynaptic release of serotonin and norepinephrine in the brain Sedation Indications: depression, including that associated with BPD, reducing the sexual adverse effects in male patients receiving SSRI therapy, and appetite stimulant Contraindication: drug allergy and MAOIs Adverse effects: drowsiness, abnormal dreams, dry mouth, constipation, increased appetite, and asthenia Drug interactions: additive CNS depressant effects with alcohol and CYP inhibitors Copyright © 2017, Elsevier Inc. All rights reserved.

When patients are taking selective SSRIs for the first time for depression, which is most important to monitor for during the first few weeks of therapy? Hypertensive crisis Suicidal thoughts Convulsions Orthostatic hypotension Correct answer: B Rationale: Some studies have indicated a higher risk for suicide during the first few weeks of antidepressant therapy. Copyright © 2017, Elsevier Inc. All rights reserved. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

When providing teaching for a patient who is prescribed a selective SSRI, which statement will the nurse include? The SSRI will work faster than the older tricyclic antidepressants. The SSRI will have an immediate beneficial effect on the patient’s depression symptoms. The SSRI will not work well for severe cases of depression. The SSRI may take several weeks to have a beneficial effect. Correct answer: D Rationale: It may take several weeks to see the therapeutic effects of SSRIs. Copyright © 2017, Elsevier Inc. All rights reserved. Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

Antipsychotics Drugs used to treat serious mental illness Drug-induced psychoses, schizophrenia, and autism Also used to treat extreme mania (as an adjunct to lithium), BPD, depression that is resistant to other therapy, certain movement disorders (e.g., Tourette’s syndrome), and certain other medical conditions (e.g., nausea, intractable hiccups) Have been known as tranquilizers or neuroleptics Copyright © 2017, Elsevier Inc. All rights reserved.

Antipsychotics (Cont.)
Conventional, or first-generation: phenothiazines Second-generation Atypical antipsychotics Copyright © 2017, Elsevier Inc. All rights reserved.

Antipsychotics: Mechanism of Action
Block dopamine receptors in the brain (limbic system, basal ganglia), areas associated with emotion, cognitive function, motor function Dopamine levels in the CNS are decreased. Result: tranquilizing effect in psychotic patients Copyright © 2017, Elsevier Inc. All rights reserved.

Positive and Negative Symptoms of Schizophrenia
Positive symptoms: hallucinations, delusions, and conceptual disorganization Negative symptoms: apathy, social withdrawal, blunted affect, poverty of speech, and catatonia All antipsychotics show efficacy in improving the positive symptoms of schizophrenia. Conventional drugs are less effective in managing negative symptoms. Atypical antipsychotics have improved efficacy in treating both positive and negative symptoms. Copyright © 2017, Elsevier Inc. All rights reserved.

Indications: Antipsychotic Drugs
Psychotic illness, most commonly schizophrenia Anxiety and mood disorders Prochlorperazine: antiemetics Copyright © 2017, Elsevier Inc. All rights reserved.

Adverse Effects: Antipsychotic Drugs
Agranulocytosis and hemolytic anemia CNS effects Drowsiness Neuroleptic malignant syndrome (NMS) Extrapyramidal symptoms (EPS): pseudoparkinsonism-akathisia, acute dystonia-treated with benztropine (Cogentin) and trihexyphenidyl (Artane) Tardive dyskinesia Copyright © 2017, Elsevier Inc. All rights reserved.

Adverse Effects: Antipsychotic Drugs (Cont.)
NMS Potentially life threatening High fever, unstable blood pressure (BP), myoglobinemia EPS Involuntary muscle symptoms similar to those of Parkinson’s disease Akathisia (distressing muscle restlessness) Acute dystonia (painful muscle spasms) Treated with benztropine (Cogentin) and trihexyphenidyl (Artane) Copyright © 2017, Elsevier Inc. All rights reserved.

Tardive dyskinesia (TD) Involuntary contractions of oral and facial muscles Choreoathetosis (wavelike movements of extremities) Occurs with continuous long-term antipsychotic therapy Copyright © 2017, Elsevier Inc. All rights reserved.

Haloperidol (Haldol) Indications: long-term treatment of psychosis Contraindications: hypersensitivity, Parkinson’s disease, and in patients taking large amounts of CNS depressants Oral, intramuscular, intravenous Useful in treating patients with schizophrenia who were nonadherent with their drug regimen Copyright © 2017, Elsevier Inc. All rights reserved.

Atypical Antipsychotics
clozapine (Clozaril) risperidone (Risperdal) olanzapine (Zyprexa) quetiapine (Seroquel) ziprasidone (Geodon) aripiprazole (Abilify) paliperidone (Invega) iloperidone (Fanapt) asenapine (Saphris) lurasidone (Latuda) Copyright © 2017, Elsevier Inc. All rights reserved.

Atypical Antipsychotics: Mechanism of Action
Block specific dopamine receptors: dopamine-2 (D2) receptors Also block specific serotonin receptors: serotonin 2 (5-HT2) receptors This is responsible for their improved efficacy and safety profiles. Copyright © 2017, Elsevier Inc. All rights reserved.

Clozapine (Clozaril) Selectively blocks the dopaminergic receptors in the mesolimbic region of the brain Associated with minor or no EPS Adverse effects: blood dyscrasias Copyright © 2017, Elsevier Inc. All rights reserved.

Risperidone (Risperdal)
Indication: schizophrenia, including negative symptoms Adverse effects: minimal EPS at therapeutic dosages of 1 to 6 mg/day Risperdal Consta: long-acting injectable form; lasts approximately 2 weeks Invega Sustenna: long-acting injection; lasts 1 month Copyright © 2017, Elsevier Inc. All rights reserved.

Herbal Products: St. John’s Wort
Used for depression, anxiety, sleep disorders, nervousness May cause GI upset, fatigue, dizziness, confusion, dry mouth, photosensitivity Severe interactions if taken with MAOIs and SSRIs; many other drug interactions Food–drug interaction with tyramine-containing foods Copyright © 2017, Elsevier Inc. All rights reserved.

Herbal Products: Ginseng
Three varieties; has been used for more than 5000 years Uses: stress reduction, improvement of physical endurance and concentration May cause elevated BP, chest pain, palpitations, anxiety, insomnia, headache, GI symptoms Interactions with anticoagulants, immunosuppressants, anticonvulsants, antidiabetic drugs Copyright © 2017, Elsevier Inc. All rights reserved.

Psychotherapeutic Drugs: Nursing Implications
Before beginning therapy, assess the physical and emotional status of patients. Obtain baseline vital signs, including postural BP readings. Obtain liver and renal function tests. Copyright © 2017, Elsevier Inc. All rights reserved.

Psychotherapeutic Drugs: Nursing Implications (Cont.)
Assess for possible contraindications to therapy, cautious use, and potential drug interactions. Assess for level of consciousness, mental alertness, and potential for injury to self and others. Check the patient’s mouth to make sure oral doses are swallowed. Copyright © 2017, Elsevier Inc. All rights reserved.

Provide simple explanations about the drug, its effects, and the length of time before therapeutic effects can be expected. Advise patients to avoid abrupt withdrawal. Advise patients to change positions slowly to avoid postural hypotension and possible injury. Copyright © 2017, Elsevier Inc. All rights reserved.

The combination of drug therapy and psychotherapy is emphasized because patients need to learn and acquire more effective coping skills. Only small amounts of medications should be dispensed at a time to minimize the risk of suicide attempts. Simultaneous use of these drugs with alcohol or other CNS depressants can be fatal. Copyright © 2017, Elsevier Inc. All rights reserved.

Antidepressants Many cautions, contraindications, and interactions exist pertaining to the use of antidepressants. Inform patients that it may take several weeks to see therapeutic effects. Monitor patients closely during this time, assess for suicidal tendencies, and provide support. Assist older adult and weakened patients with ambulation and other activities because falls may occur because of drowsiness or postural hypotension. Copyright © 2017, Elsevier Inc. All rights reserved.

Antidepressants (Cont.) Tricyclics may need to be weaned and discontinued before undergoing surgery to avoid interactions with anesthetic drugs. Monitor for adverse effects and discuss with patients. Encourage patients to wear medication ID badges naming the drugs being taken. Copyright © 2017, Elsevier Inc. All rights reserved.

Antidepressants (Cont.) Caffeine and cigarette smoking may decrease effectiveness of medication therapy. With MAOIs, instruct patients and family regarding tyramine-containing foods and signs and symptoms of hypertensive crisis. Copyright © 2017, Elsevier Inc. All rights reserved.

Antipsychotics—phenothiazines Instruct patients to wear sunscreen because of photosensitivity. Tell patients to avoid taking antacids or antidiarrheal preparations within 1 hour of a dose. Inform patients to avoid alcohol and other CNS depressants with these medications. Copyright © 2017, Elsevier Inc. All rights reserved.

Antipsychotics—phenothiazines (Cont.) Long-term haloperidol therapy may result in tremors, nausea, vomiting, or uncontrollable shaking of small muscle groups; report these symptoms to the physician. Copyright © 2017, Elsevier Inc. All rights reserved.

Antipsychotics—phenothiazines (Cont.) Oral forms may be taken with meals to decrease GI upset. These drugs may cause drowsiness, dizziness, or fainting; instruct patients to change positions slowly. Copyright © 2017, Elsevier Inc. All rights reserved.

Monitor for therapeutic effects Monitor mental alertness, cognition, affect, mood, ability to carry out activities of daily living, appetite, and sleep patterns. Monitor potential for self-injury during the delay between the start of therapy and symptomatic improvement. Copyright © 2017, Elsevier Inc. All rights reserved.

Monitor for therapeutic effects (Cont.) For anxiolytics Improved mental alertness, cognition, and mood Fewer anxiety and panic attacks Improved sleep patterns and appetite Less tension and irritability; fewer feelings of fear, impending doom, and stress More interest in self and others Copyright © 2017, Elsevier Inc. All rights reserved.

Monitor for therapeutic effects (Cont.) For antidepressants Improved sleep patterns and nutrition Increased feelings of self-esteem Decreased feelings of hopelessness Increased interest in self and appearance Increased interest in daily activities Fewer depressive manifestations or suicidal thoughts or ideations Copyright © 2017, Elsevier Inc. All rights reserved.

Monitor for therapeutic effects (Cont.) For antipsychotics Improved mood and affect Alleviation of psychotic symptoms and episodes Decreased hallucinations, paranoia, delusions, garbled speech, and inability to cope Copyright © 2017, Elsevier Inc. All rights reserved.

Case Study A patient is admitted to the emergency department. The patient’s heart rate is 112 beats/min. He is sweating and has muscle tremors and is agitated. The patient says, “I was depressed and took more of the pills the doctor gave me so I would feel better.” What does the nurse suspect is happening with this patient? What treatment does the nurse expect to implement? Along with completing a full assessment, the nurse would need to ask the patient what medication he was prescribed, how long he has been taking the medication, and how much of the medication he currently has taken. Based on the presenting signs and symptoms, the nurse would include serotonin syndrome as a highly possible reason for the patient’s presenting symptoms. The treatment for serotonin syndrome includes discontinuation of all SSRIs and supporting the patient to maintain homeostasis. Copyright © 2017, Elsevier Inc. All rights reserved.

Case Study (Cont.) The patient was admitted to the hospital for observation and has now recovered. Which information will the nurse include in patient teaching about SSRIs? It usually takes 4 to 6 weeks until you will experience benefits from the medication. The patient must avoid foods that contain tyramine. If the patient develops an upset stomach when taking this medication, he should discontinue use. The patient should take the medication at bedtime to enhance sleep. Correct answer: A Rationale: Patients should be taught that the time period for SSRIs to take effect is 4 to 6 weeks. These medications can cause GI upset, and taking them with food is recommended. SSRIs should be taken in the morning to prevent any sleep disturbances. Copyright © 2017, Elsevier Inc. All rights reserved.

Case Study (Cont.) Several months later, the patient returns to the health care provider’s office for follow-up regarding use of the SSRI. The patient tells the nurse that he is feeling better and stopped taking the SSRI yesterday. He doesn’t plan on taking the medication again. When talking with the patient, which knowledge should guide the nurse’s response? Drug dependency will develop, so it is appropriate to stop therapy after a few months. Drug therapy must be stopped as soon as the patient feels better to avoid serotonin syndrome. The patient is the best person to determine when the drug therapy should end. A 1- to 2-month taper period is indicated to prevent adverse effects of abrupt drug discontinuation. Correct answer: D Rationale: A taper period of 1 to 2 months is needed to prevent the development of adverse effects of withdrawal from the medication, which include dizziness, diarrhea, and a worsening of the depressive mood disorder. Serotonin syndrome is a result of taking too much of the medication. The patient and the provider should determine together when is the optimal time for drug discontinuation. There is no evidence of drug dependency associated with use of SSRIs. Copyright © 2017, Elsevier Inc. All rights reserved.

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