Health - SSRI Withdrawal Syndrome

[Jatelka]

The following criteria define the SSRI (or SNRI) withdrawal syndrome:

Criterion A: A course of treatment in which an SSRI (or venlafaxine) is stopped
or interrupted or the dose is reduced after a period of 4 weeks or more.

Criterion B: Two or more of the following symptoms develop within 1 to 10 days
of criterion A (except for fluoxetine in which case the symptoms must develop
within 28 days):

(a) dizziness or light headedness
(b) nausea and/or vomiting
(c) headaches
(d) lethargy
(e) anxiety and/or agitation
(f) tingling (parasthesias), numbness or "electric" shock-like sensations in the
head or limbs
(g) tremors
(h) sweating
(i) insomnia
(j) irritability
(k) vertigo (dizziness)
(l) diarrhea

Criterion C: The symptoms of criterion B cause clinically significant distress
or impairment in social, occupational, or other important areas of functioning.

Criterion D: The symptoms are not due to a general medical condition or the
direct physiological effects of another substance (e.g., a medication or a drug
of misuse) that has been recently commenced, stopped, or altered in dosage.

Criterion E: The disorder is not better accounted for by an exacerbation/
relapse/recurrence of the psychiatric disorder for which the SSRI was
prescribed.

Adapted from:
Haddad PM The SSRI discontinuation syndrome: literature review and provisional
diagnostic criteria. Presented at: XXIst Collegium Internationale
Neuro-Psychopharmacologicum Congress. July 12-16, 1998; Glasgow, Scotland.
Reprinted in International Drug Therapy Newsletter. 1998, 33, 46.
Visit Depression Central

Revised 12/5//04

The cause of withdrawal syndrome following discontinuation of SSRIs is unknown, but the electric shock sensations reported with neck flexion are identical to Lhermitte's sign, which appears with dysfunction of the posterior spinal cord. This suggests change at a neuronal level.

It has been proposed that inhibition of reuptake initially increases the synaptic concentration of serotonin. Exposure to high concentrations of 5-HT, even for as short as five weeks, may cause down-regulation of receptors. When the SSRI is discontinued the concentration of 5-HT falls. The lower level of 5-HT is insufficient to provide an adequate agonist stimulus for the down-regulated receptors, resulting in withdrawal syndrome. Inhibition of 5-HT and norepinephrine receptors may be involved in withdrawal symptoms from venlafaxine.

Paroxetine possesses muscarinic antichoninergic activity and may cause withdrawal symptoms via the same mechanism as the tricyclic antidepressants. Compared to other SSRIs, paroxetine is the most pharmacologically selective antagonist at the 5-HT reuptake site.

The withdrawal syndrome usually subsides within several weeks of discontinuation in most reports. Withdrawal syndrome is most likely to occur in patients who receive SSRIs with a short half-life. A long half-life of the parent compound and/or active metabolite leads to a more gradual withdrawal. The onset of symptoms following abrupt discontinuation or taper is within one to seven days.

The optimum tapering regimen for each agent has yet to be determined by comparative clinical trials. Here is one suggestion (Skaehill and Welch, 1997)

Fluoxetine

Reduce by 5 mg every two weeks until dose is 5 mg/day, then 2.5 mg every two weeks

Fluvoxamine

Reduce by 25 mg every two weeks until dose is 25 mg/day, then 12.5 mg every two weeks

Paroxetine

Reduce by 10 mg every two weeks until dose is 10 mg/day, then 5 mg/day every two weeks

Sertraline

Reduce by 25 mg every two weeks until dose is 25 mg/day, then 12.5 mg every two weeks

Venlafaxine

Reduce by 25 mg every two weeks until dose is 25 mg/day, then 12.5 mg/day every two weeks ,

Paroxetine appears to be the SSRI most likely to cause withdrawal syndrome, with fluvoxamine and sertraline a close second, possibly due to their high inhibition constants and their shorter half-lives. Published fluoxetine withdrawal reports are scarce, possibly due to the long half-life of fluoxetine and the active metabolite norfluoxetine.

Hope this is of some help/interest

SWIM'll post a literature review in the archives (or at least she would if there was an SSRI section)

Reputation Comments on this post:

It's really great that this got brought up, not many people realize that this happens

[Alfa]

I added the category.

[Powder_Reality]

SWIM had to endure an absolutley hellish withdrawal from his combination of SSRI's and antidepressants. SWIM stopped taking his medications and about a week later, it hit him. HARD. SWIM was watching his friend play Need for Speed Underground, and for some reason the combination of the fast moving images and bright colours made him really nauseous. He knew what was coming and ran to the bathroom. SWIM puked violently for a couple minutes, and then spent another 15 or so hugging the toilet, quite similar to his reaction if he's drank too much. SWIM slowly walked back out to the living room and just collapsed on some cushions, instantly passing out. When he woke up, he could hardly move without getting nauseous. SWIM took a taxi home, and the 10 minutes it took to get there felt like an hour. SWIM thought that he was going to puke all over the window. When he got home he proceded to immediately puke what little fluid was left in his stomach into his toilet. SWIM retreated to the comforts of his own couch and immediately passed out again. Sleep was really the only thing that he could do at this point. SWIM couldn't move without wanting to puke. After a couple of hours of sleep, SWIM woke up abruptly, puked a little bit more, and once again passed out. For about three more days, SWIM just sat on his couch, trying to eat any kind food and keep it down. SWIM missed a couple days of work and blew off a job interview that he had. These just weren't options. All in all it was a complete nightmare, but he was glad to get off the meds; SWIM has always felt and still does to this day that he didn't need them.

[FrankenChrist]

Ween yourself off SSRI's slowly over the course of many weeks. 3/4ths, halves, 1/4ths, 1 dose every two days, etc

[Lehendakari]

This is what I did for withdrawing paxil:

I quit cold turkey. Problems started after 1 day off. I tried to hold till it was too annoying and then I took a small amount (10mg). I felt ok pretty quick and then tried to hold again as long as possible and repeat the cycle with longer periods off and taking smaller amounts everytime.

It worked very well for me

[chemicaljustice]

SWIM has come off Effexor (venlafaxine) 300 mg/day in aprox 5 weeks (way too fast) a few years ago and he can confirm almost all the above symptoms. The withdrawel symptoms started when he stopped using the last dosage (not during lowering the dosage). The dosage was gradually lowered to 25 mg/day during these 5 weeks. The last dosage taken was 25 mg.
Especially the "electric shock sensations" during movement were very anoying. Every time SWIM tried to make a movement this was preceeded by a shock sensation from the extremity that was to be moved to the back of the head. Next to that excessive sweating and extreme nightmares were experienced during the withdrawel. The symptoms lasted for aprox 4 days and after that SWIM was able to function normally again.
Although the withdrawel symptoms were not a picknick, they're doable. Stay at home. Take enough rest and try not to think too much about things that elevate your stress-level (this seemed to increase the nausea experienced by SWIM). In SWIM's experience they'll get better after day 2-3.

[hi-dro]

close friend of mines been taking venlafaxine xl 150mg for about 2years or so to help with his social phobia,generalized anxiety and deppressional problems.
hes tried other antideppressants b4 ven but only ever achieved moderate results for his symptoms... but he says as soon as he started on the 150mg dose of ven it really helped relieve some of his depression at some of his worse times and he says thats its the closest hes ever come to feeling mentally stable while on this drug......really sounds good doesnt it......
But things arent as good as they seem as this drug is def not for playing about with as if he accidentally misses a daily dose the withdraw effects kick in under 5hours and yes pretty much that whole list of withdrawl problems floods into his mind and body,
these incl elec shocks inside head,dizzyness,extremly deppressed,anxiety,feeling wierd,energy/strength levels deminish,feeling very unstable,angry,frustration,runny nose,flu like symptoms,
seems a very strange drug ven to induce this reaction.......
my mate in question has induldged in the odd nite of recreational drug use in his life and tells me that the come down off drugs hes taken recreationally has never ever made him feel like he does when he misses a dose of his ven.
he also admits he fears hes physically and mentally addicted to these tablets because of the withdraw effects and the tablets seem to work less and less on his deppression symptoms,but he has to take them to be able to operate on a basic level.

[DrMuffy]

Well, i had been taking an SSRI (prozac 20mg) for about 2 years, and when i stopped, i never really got a withdrawal symtoms. All that fancy medical shit just confuses me, but it does sound right, but i think the even bigger problem with SSRI withdrawal is the psycological (totally spelled wrong) withdrawal; knowing you smart drug is gone, and your depression might come back. Its a safety blanket for most pepl, and when it get taken away, those fears and anxiety just build up inside you until you finnally just stop worrying bout it.

[azrael2600]

swim has known many people who have suffered withdrawls from quiting antidepressant. swim had a friend who was a recovering alcohlic and was living at a sober living home at the time . He was sober for a little over one year. after quiting drinking a doctor had prescibed him 60 mg's of paxil a day. he was on the drug throughout his sobriety. He felt that he was feeling better and didn't need it anymore, so swim's friend quit the paxil cold turkey. He was in for more than he imagined. He said quiting the paxil was harder for him than quiting the drinking. swim can't remeber what swim's friend symptoms were since it was so many years ago. But swim remeber's that swim's friend was having a pretty shitty time quiting it. Also swim saw a documentary on cable TV a few years ago on a video diary of a girl trying to quit paxil. She had weened herself to a low dosage. and every time she quit she would still go through horrible withdrawls and would find herself taking the paxil again to avoid feeling the withdrawls. Also a very close friend of swim was diagnosed with depression, and was prescibed cymbalta. swim's friend felt like they were feeling better and quit taking it cold turkey as did swim's other friend. swim's friend said that they felt like electric zaps were flowing through random parts of thier body at random times.

[ojos_de_brujo]

Swim has been on several SSRI's and SNRI's. She never had any noticable improvement of her depression. After 6 years of using them (sometimes forced) she decided it had been enough. Psy's kept on changing the drug but after a dozen of them you get he idea they won't ever work. So Swim quit, she was so disgusted with the drug she quit instantly. It was very hard for a week. Trembling, nausea, ...
But Swim was very glad to finally get rid of them. After a few weeks Swim felt better than she had felt in years.
Swim doesn't really get this.
Swim was started on antidepressants 6 years ago after failing exams, during the exam period she had used Adderal, after it she had been on benzo's (valium) and had kicked them.
Swim feels the depressed feeling afterwards was chemicaly induced, but not realy severe. After starting on SSRI's, it started going down, Swim became boulemic, cut herself, had a suicide attempt... This behaviour stopped after stopping the SSRI's. Swim must also say she was adviced strongly not to quit them.Threats were made by doctors and psy's. (if you don't take your medication you will be admitted to a mental hospital)
Swim knows this is off topic, but she really wonders why these drugs would not work on her.
And she also wonders why psychiatrists would insist on keeping taking them. (because they get gifts from the drug companies)

[baron samedi]

SWIM has been on SNRI's for 7 years now and has experienced the head zaps, insomnia, depression and feeling weird everytime he has missed a dose, for whatever reason.
It seems efexor has particularly extreme withdrawls, and SWIM is concerned that when he does stop for good his withdrawl symptoms will last even longer because of the time he's been taking them.

[ojos_de_brujo]

Effexor was the last AD Swim took. She ad been taking AD for 6 years.
She did not lower her dose, but stopped instantly. Stubborn as she is when she makes a decision.
The withdrawals lasted about a week. Swim has experienced worse withdrawals than Effexor.
If SWIY would gradually lower his dose, it probably won't be so bad.

[baron samedi]

yes SWIM hopes that will be the case, he doesn't think he could stop completely as he's on a high dose.
he just hears alot of scare stories about effexor, comparing WD symptoms to heroin etc.

[ojos_de_brujo]

That's complete bullshit. Whoever said that is pulling your leg.
Swim's been through both and one can not compare WD symptoms.
Heroin WD is physically very hard, vomiting and such. AD withdrawal seems to be more working on the nervous system.

Swim stopped at once, but doesn't advice this to others. Lower SWIY's dose gradually.

Don't be scared. There is actually a very easy way to stop SWIY's WD- symptoms if he can't handle them: take an effexor.

[baron samedi]

Thanks for the reassurance ojos. The thing about heroin is just the sort of view that gets posted on mental health/prescription med message boards. SWIM himself has never had to face heroin withdrawl so had no idea whether or not such claims were an exageration.
People always seem to emphasize that effexor is the worst anti-depressant when it comes to withdrawl, and the sheer length of time SWIM has been taking it is a concern for him as is the high dose he takes.
Guess SWIM will not know how his mind or body will react until he takes the plunge and reduces his dose for a lengthy period.

[dancingbear]

SWIM is trying to come off Prozac as we speak. SWIM's decided to try first with the method of taking his normal daily dose (20mg) every other day.

Wish him luck.

[DrMuffy]

Originally Posted by dancingbear

SWIM is trying to come off Prozac as we speak. SWIM's decided to try first with the method of taking his normal daily dose (20mg) every other day.

Wish him luck.

Well SWIdr was prescribed Prozac 30 mgs a day for at least three years and he just randomly tied to quit cold turkey. It was bad, but not nearly as bad as some other drug withdrawals. Below is a 30 day schedule on quiting Prozac and SWIY can quit more rapidly since it has its long half-life. Technically, one could quit Prozac faster and still not go through WDs. Also, it would be great if you had a pill cutter, because the fractions of the pill become really small and ould be hard to calculate dosage.

Day 1: Take your average dose
Day 2: Take 3/4 average dose
Day 3: Take 2/3 average dose
Day 4: Take 3/4 average dose
Day 5: Take 2/3 average dose
Day 6: Take 1/2 average dose
Day 7: Take 1/3 average dose
Day 8: Take 1/2 average dose
Day 9: Take 1/3 average dose
Day 10: Take 1/4 average dose
Day 11: Take 1/3 average dose
Day 12: Take 1/4 average dose
Day 13: Take 1/3 average dose
Day 14: Take 1/4 average dose
Day 15: Take 1/6 average dose
Day 16: Take 1/4 average dose
Day 17: Take 1/6 average dose
Day 18: Take 1/4 average dose
Day 19: Take 1/6 average dose
Day 20: Take 1/8 average dose
Day 21: Take 1/6 average dose
Day 22: Take 1/8 average dose
Day 23: Take 1/6 average dose
Day 24: Take 1/8 average dose
Day 25: Take 1/10 average dose
Day 26: Take 1/8 average dose
Day 27: Take 1/10 average dose
Day 28: Take 1/8 average dose
Day 29: Take 1/10 average dose
Day 30: NO MORE PROZAC!!!!

This is an easy semi-fast schedule for quiting prozac. One cannot do it that fast with most other SSRIs because Prozac has a very long half-life. If SWIY wants, he can go through the quitting process faster because some metabolize faster than others. HOPE THIS HELPS!!!

[dancingbear]

Thank you, friend!

My Prozac comes in capsules (powder), so I guess the method would be to mix the powder into liquid and drink portions of it according to the schedule.

[DrMuffy]

^^^^^^
No problem SWIbear, im just glad a acually can hep you. Getting off prozac is actually a paice of cake compared to some of SSRI's like Effexor (venlafaxine) or Paxil (paroxetine) thats what we do jee, so if (UTFSE (Use The Forum Search Engine) and don't find anything hrlpgul or that answers then start a thread with a descriptive title, or a post a thread related your question(s)questions. This is a friendly helpful community, with alot of very inteligent/experienced people come to talk about how "SWIM" uses alot of drugs There are othe sub forum which people can talk freely like the "Some For All: Forum. Don't forget "SWIY" (Someone who isn't You) id always talkng to SWIM when illegal subjects come up. Everyone here at these forum don't partivipate in illegal activities Sorry I got of track on what was supposed to be a litttle "your welcome" post, but what can a say, SWIdr has been doing alot of drugs haha (you should have seen the first draft of this post, spelling errors drive me crazy until SWIdr just does sme more drugs to mellow out lol)! Also sorry for getting off topic towards the end, lets get back to SSRI's.

[dancingbear]

Cheers! Swim is glad to see friendly ppl around here.

[DrMuffy]

Originally Posted by dancingbear

Cheers! Swim is glad to see friendly ppl around here.

And I am very pleased that you have decided to be come an "almost" member now, since your still a newbies. Once you get silver membership, which shoud be very soon if I can help it you'll be able to access alot more forums. But seriously, we are breaking the rules now so Im just gonna get back on the topic.

Here's just a little history on SWIdr which lead him to SSRI's:
At the age of 12 in the 7th grade his dad passed away from medicl complicationHe was already seeing a counsier (sp?) but about a year after his dad died he bagan going to a $200 per hourpsyciatrist (sp?) which did NOT help much exept for give me some good meds.
He was prescriing .25 mg xanax once a day along with an every other day 10mg Ambien trial to get my sleep trck back to normal.
After a year of severe clinical depression and several attempts of suicide, SWIdr was put into a hospitol for like a week and tha when it all began. They started doing all hese blood tese on my, and i was just so doped up I didn; care. As soon as he check out of he hospitol, SWIdr had o start aking rozac for his depression because it was a "magic" pill which made veryone heppy
He first started 5 mgs a day along with .5 clonazepam twice daily. But in a month or so the prozac dosage escalated to 80 mgs a day plus the .5 mgs clonazepam and 6.25 mg of Ambien for insomnia ever other day.
A year after that when he was graduating from high school he decided to quit all he meds could turkey and b natural. Haha, well that was basically hell on earth so i started up again, exept I just started take 30 mg Prozac(for longterm anxiety and depression), 1mg Clonazepam for daily anxiety and 12.5 Ambien CR every other day (for insomnia), not to mention he took alot of herbal medications too.

Well now he is totally Prozac and depression free. Of course he still want to keep his banzo and ambien prescription due to the delectable side-effects. SWIdr live a normal colledge student life (exept there alot more drug use lol).

[dancingbear]

Thanks for sharing!

SWIM's been on 20mg a day Prozac for 3-4 years now. He hasn't been diagnosed officially, but has diagnosed himself to be mildly bipolar. His Prozac-taking started as a result of stressful work life, screwed-up relationships and general bad vibes in life at the time, resulting in depression and anxiety.

SWIM's now living a fairly stable and content life, and feels he wouldn't be here without the Prozac. It really helped him. Prozac has helped him to build a stronger and more focused personality. Now SWIM wants off the thing, though, for he wishes to feel his existence without the aid of a chemical wheelchair.

And, we must not forget, SWIM's occasional enjoyment of psychedelics is severely reduced by Prozac. Naturally, that isn't the main reason of quitting the thing.

Reputation Comments on this post:

Good conversations!

[DrMuffy]

Yes SWIdr would have to say Prozac is the best of all the SSRI's. He bleleive its the only SSRI approved for treatment for people under 18. It has a long half life though, which can be either good or bad. SWIdr has noticed that it has ruined his ecstasy trip because they both work serotonin, but SWIdr doesn't do X that much and should have known better to mix the two beforehand.
SWIdr has also self diagnosed and actually has a doc app coming up to do some tess to see if hes bi-polar (Manic Depression). But lots of people think they have that because it has such a wide range of symptoms. 5-HTP (as said before) can help when quitting SSRI's, also St. Johns Wort has naturally occuring serotonin so SWIY might want to research that if he wants a substitute or something. If SWIY doesn't mind me asking, why is SWIY quiting Prozac sense it seems to be helping?

Reputation Comments on this post:

Good, sensible discussion!

[dancingbear]

No, SWIM doesn't mind SWIY asking, on the contrary.

As said, Prozac does have its side effects, one of the most important of them for a psychedelic aficionado being the reducement of the effects of certain chemicals and entheogens. This is most applicable in the case of LSD and DMT, both of which SWIM does not want to live without.

Naturally, there are other side effects, too. SWIM just wants to live his life without those.

[DrMuffy]

Yeah I know what you mean, the first couoke of month I experiencecd alot of Prozac which were quite unpleaserable, exept more energy during the day... Months later the side effects seemed to dissapate and became less anoying/noticable. One tme i just felt like i was all better (derpression wise) and quit cold turkey to experience natural hapiness. Of cure it was just the opposite and SWIdr got back on it. When I turned 18 my psyciatrist (sp?) offered me a plethora of SSRI's, and I gladly said no to everyone. He like sticking to natural remedies when it comes to mental and physical health. He is now living a deopression-free life, although SWOdr has become dependent on drugs in gerneral, haha.

Side note, about 2 weeks after SWIdr weened himself off Prozac, he made a stup mistake and potentiated tramadol (Ultram with out tylonol) with DXM, and ended up threatening suicide and was detained and had a nice (haha) trip to the hospitol where they pumped his stomach, not to mention many other things like Catscan, MRI, etc. So the moral of this edit/note is evewn if SWIY feels good , dont quit an SSRI unless under doc supervision, because bad thing can happen....