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Understand the facts

 

Scientific research has long suggested that the reduction or discontinuation, both gradual and abrupt, of antidepressants determines the appearance of withdrawal symptoms. Usually the patient interprets these symptoms as a recurrence of the disease following therapy reduction. On the contrary, this phenomenon has been described as caused by the abstinence from SSRI (Selective Serotonin Reuptake Inhibitor) antidepressants and SNRI (Serotonin and Noradrenaline Reuptake Inhibitor) antidepressants. Withdrawal symptoms occur after 24 - 96 hours after the drug has been reduced or discontinued and may last several weeks but also months or years. Below is a list of withdrawal symptoms that may arise:

 

General symptoms	Flue-like symptoms, sweating, chills, hot flashes, fatigue, weakness, tiredness, drowsiness
Visaul symptoms	Altered vision, fogged vision
Cardiovascular symptoms	Dizziness, empty head, palpitations, difficulty in breathing
Gastroenteric symptoms	Diarrhea, stool loss, abdominal pain, nausea, vomiting, lack of appetite
Sensorial symptoms	Tinglings, electric shock sensation, shock in the brain, itching, taste alteration, tinnitus
Neuromuscular symptoms	Shocking, restlessness, muscle stiffness, muscle pain, tremor, neuralgia, muscle spasms, sensations like facial bites, difficulty in coordinating movements
Cognitive symptoms	Confusion, amnesia, disorientation, poor concentration
Affective symptoms	Anxiety, agitation, tension, panic, depression, intensification of suicidal ideation, irritability, impulsivity, aggression, anger, tears, rapid mood swings, derealization, depersonalization
Psychotic symptoms	Visual and auditory allucinations
Sleep plroblems	Insomnia, vivid dreams, nightmares, hypersonnia
Sexual symptoms	Premature ejaculation, genital hypersensitivity

 

Adapted from Chouinard G, Chouinard VA. New Classification of Selective Serotonin Reuptake Inhibitor Withdrawal. Psychotherapy and Psychosomatics 2015;84(2):63-71

 

Withdrawal after reduction or discontinuation of SSRI or SNRI can be stu-typed into three syndromes which are described in detail below:

 

1. WITHDRAWAL NEW SYMPTOMS

The commonest withdrawal new symptoms which occur after the reduction or discontinuation of antidepressants acting on the serotonin system such as Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs) are: nausea, headache, sleep problems, anxiety, poor concentration, agitation, irritability, depressed mood, flu-like symptoms, dizziness, palpitations, diarrhea, electric shock sensation through the brain or along the body, confusion, myoclonus, premature ejaculation.

 

2. REBOUND WITHDRAWAL SYMPTOMS

Rebound withdrawal symptoms correspond to the recurrence of the original symptoms but at a greater intensity.

For example, if a person had undergone antidepressant therapy to treat depression, depression soon returns after the reduction or discontinuation of the antidepressant treatment and is more intense than before the treatment.

If a person undertook antidepressant therapy to treat anxiety, then anxiety is back and is more intense than before the treatment. The same is true if the reason for the therapy was panic, agitation, insomnia, irritability, obsessions, compulsions, and so on.

These symptoms usually appear between 36 and 96 hours after having reduced or discontinued an antidepressant therapy based on Selective Serotonin Reuptake Inhibitors (SSRIs) or Serotonin and Noradrenaline Receptor Inhibitors (SNRIs) and can last up to 6 weeks. The symptoms are reversible, thus there is no permanent damage to patients.

The patient's suffering can be reduced with adequate pharmacological or psychotherapeutic interventions.

 

3. PERSISTENT POST-WITHDRAWAL DISORDER

 

Persistent post-withdrawal disorder is characterized by the recurrence of the original symptoms which, however, present both with greater intensity and together with new symptoms, which means symptoms that the patient has never suffered before.

For example, if antidepressant therapy was taken to treat depression, depression rapidly recurs after the reduction or discontinuation of the antidepressant treatment, it is more intense than before and is associated with other non-depressive symptoms, such as for instance panic.

These symptoms usually appear between 24 hours and 6 weeks after having reduced or discontinued an antidepressant therapy based on Selective Serotonin Reuptake Inhibitors (SSRIs) or Serotonin and Noradrenaline Receptor Inhibitors (SNRIs) and can last months. The symptoms are persistent but reversible, thus there is no permanent damage to patients.

The patient's suffering can be reduced with adequate pharmacological or psychotherapeutic interventions.

To be noted that since 2006, persistent sexual side effects after SSRIs and SNRIs discontinuation have been described. These sexual manifestations have been rapidly identified as a syndrome called Post-SSRI Sexual Dysfunction (PSSD), that is a sexual dysfunction caused by both SSRIs and SNRIs, characterized by decrease or absence of libido, genital anesthesia, numbness in nipples, orgasmic disorders (i.e., anorgasmia or anhedonic orgasm), erectile dysfunction, delayed or premature ejaculation, testicular pain or atrophy (in males), lack of lubrication (in females) and by psychological symptoms such as anhedonia, difficulty in concentrating, memory problems, inability to experience sexual attraction to the sight, touch, or idea of a sexual partner.

The symptoms may last months or even years. Recently, it has been described the case of a patient in which PSSD symptoms were part of a persistent postwithdrawal disorder. This case rises the suspicious that PSSD might be a withdrawal syndrome occurring after decrease/discontinuation of SSRIs or SNRIs and that withdrawal symptoms might include a wider variety of sexual manifestations which are currently under-reported.

 

 

If you are interested in reading more click the following links:

 

• Antidepressant Withdrawal: An Unknown Disorder?
• Clinical guidelines on antidepressant withdrawal urgently need updating
• The Emerging Role of Clinical Pharmacopsychology

 

 

 

REFERENCES

 

last update: 04-Apr-2022