1. Discontinuation Syndrome Sue Henderson

2. Definition Cluster of symptoms that may occur in response to the reduction or cessation of any antidepressant, but is more common in antidepressants with a short half life and when long term therapy is abruptly halted.

3. Cause Exact cause unknown Theory: CNS adapts to antidepressant treatment and is disrupted by cessation.

4. Discontinuation V withdrawal Antidepressants are not: Habit forming Craving and drug seeking behaviour does not occur upon discontinuation

5. Risk factors Incidence, severity variable - dependent - type of antidepressant, duration treatment & rate of cessation (Haddad, Anderson, & Rosenbaum, 2004). 20% of individuals taking antidepressants for at least 6 weeks and then stopping abruptly (rare under 6 – 8 weeks). More frequent in antidepressants with short half lives (Paroxetine, Sertraline) Occurs less frequently - dose reduction, missed doses, when swapping from one antidepressant to another. There is no association with age, sex or diagnosis (Warner, Bobo, Warner, Reid, & Rachal, 2006).

6. Reasons for stopping abruptly Feel better (believe no longer need meds) Women who discover they are pregnant (worry about effect on foetus) Troublesome side effects Believe not gaining any benefit (Warner, Bobo, Warner, Reid, & Rachal, 2006).

7. Onset/Course On cessation most people experience mild transient symptoms Mean onset: 2 days Mean duration: 5 days Complete resolution within 1 – 2 weeks

8. Discontinuation V re-emergence clinical condition If symptoms abate on restarting the antidepressant if is probably antidepressant discontinuation syndrome.

9. FINISH Flu-like symptoms (Fatigue, Lethargy, General malaise, Muscle aches/headaches, Diarrhoea) Insomnia Nausea Imbalance (Gait instability, Dizziness/light- headedness, Vertigo Sensory disturbances (Paraesthesia, “Electric shock” sensations, Visual disturbances Hyper-arousal (Anxiety, Agitation) (Berber, 1998)

10. Management 3 major areas: 1.Prevention 2.Symptomatic treatment 3.Specific treatment

11. Prevention Before prescribed individual warned that abrupt cessation may precipitate discontinuation syndrome Reminded to talk to the prescriber before stopping an antidepressant.

12. Symptomatic treatment analgesics for headache, insomnia or agitation with a short term prescription of a hypnotic and or benzodiazepine (Bailey, 2002).

13. Specific treatment Restart antidepressant and taper more slowly If symptoms severe switch to fluoxetine (longer half life antidepressant) which can generally be stopped without major problems (Haddad, Anderson, & Rosenbaum, 2004)

14. Review Questions Which symptoms may indicate SSRI discontinuation syndrome? a. palpitations and hypertensive episodes b. fever, tachycardia, and labile blood pressure c. dizziness, irritability, and tingling of the face and hands

15. Review Question Which one of the following antidepressants is least likely to produce flu-like withdrawal symptoms upon abrupt discontinuation? a. Paroxetine (Paxil) b. Imipramine (Tofranil) c. Fluoxetine (Prozac) d. Sertraline (Zoloft)

16. References Bailey, K. P. (2002). Selective serotonin reuptake inhibitor discontinuation syndrome. Journal of Psychosocial Nursing 40(12), 15-18. Berber, M. J. (1998). FINISH: Remembering the discontinuation syndrome. Flue-like symptoms, Insomnia, Nausea, Imbalance, Sensory disturbance, and hyperarousal (anxiety/agitation). Journal of Clinical Psychiatry, 59, 255. Haddad, P. M., Anderson, I., & Rosenbaum, J. (2004). Antidepressant discontinuation syndromes. In P. M. Haddad, S. Dursun & B. Deakin (Eds.), Adverse syndromes and psychiatric drugs: A clinical guide (pp. 183-205). Oxford: Oxford University Press. Warner, C. H., Bobo, W., Warner, C., Reid, S., & Rachal, J. (2006). Antidepressant discontinuation syndrome. American Family Physician, 74(3), 449-456.