SSRI discontinuation syndrome, a specific withdrawal syndrome, occurs during discontinuation or a reduction in dose or after stopping the use of antidepressants (SSRIs). SSRI discontinuation syndrome is characterized by the development of specific physical or psychological withdrawal symptoms. Both are also possible. When the antidepressant is taken again in the usual amount, the symptoms subside quickly.
What is SSRI discontinuation syndrome?
SSRI discontinuation syndrome is a symptom complex that occurs when SSRIs, a selective reuptake inhibitor, are suddenly discontinued. Due to the long-term administration of SSRIs, the most commonly used antidepressant, there is an increased concentration of serotonin in the cerebrospinal fluid. From this, a tolerance develops in the body, as the organism adapts to the increased serotonin levels accordingly. If the SSRIs are abruptly no longer taken, this leads to a serotonin deficiency. As a result, the symptoms arise, which, however, cannot be compared to an addictive reaction, since the SSRIs are not addictive. A new equilibrium is established during the transition phase in which the withdrawal symptoms occur. This phase can vary in length and the symptoms vary in severity as well.
Causes
Exactly how SSRI withdrawal syndrome is triggered has not been adequately elucidated. A homeostasis disturbance is suspected, i.e., that an artificial stable state is created due to the continuous intake of SSRIs. However, if the antidepressant is discontinued, the body falls into an imbalance. The trigger of the symptoms is considered to be the disturbance in the hormone balance caused by the withdrawal of the SSRI. Serotonin, the neurotransmitter, and its receptors have numerous functions in the body, which explains the many different withdrawal symptoms. The serotonin transporter is no longer blocked after the drug is discontinued, so serotonin is again more readily absorbed into the nerve cell and serotonin concentrations drop relatively suddenly. The receptors do not change immediately, as these processes require days to weeks. Consequently, an imbalance occurs, which leads to the symptoms. The expectations and fears of the individual do not play a role as triggers, but they do have an impact on how SSRI discontinuation syndrome is experienced, felt, and managed. The duration of taking the antidepressant can also promote the development of SSRI discontinuation syndrome. Starting at four weeks, there is a risk that SSRI discontinuation syndrome will develop if the person stops taking the substance.
Symptoms, complaints, and signs
SSRI discontinuation syndrome is associated with various physical and/or psychological symptoms. These include sleep disturbances, because serotonin regulates sleep. In addition, because the neurotransmitter serotonin affects the gastrointestinal tract and there are numerous serotonin receptors in the intestinal mucosa, diarrhea or constipation may occur when the antidepressant is suddenly discontinued. Other symptoms that may occur with SSRI discontinuation syndrome include circulatory problems, dizziness, balance problems, sensory disturbances, a physical malaise, mood swings, muscle spasms, aggressive behavior, severe depression, mania, and even suicidal thoughts. In some patients, especially those on long-term medication or a high dose, it is also possible that long-term symptoms may occur even after the SSRI discontinuation syndrome has ended, such as milder confusion, poor short-term memory, concentration problems, and tinnitus. Severe symptoms such as psychomotor agitation, depersonalization, sexual dysfunction, and extreme anxiety are also possible. According to patient reports, long-term symptoms in SSRI discontinuation syndrome usually improve significantly within two years after SSRI discontinuation.
Diagnosis and disease progression
If SSRI discontinuation syndrome is suspected, it is possible to confirm the diagnosis with the help of a validated symptom checklist (DESS). This was developed in clinical trials and effectively helps to correctly record the discontinuation symptoms. For this purpose, it is recommended to work through the list before the SSRIs are discontinued. Subsequently, the statements can be compared well with the symptoms that occur after discontinuation of the antidepressant.This is to avoid bias due to poor recall by the patient. If at least three discontinuation symptoms reappear or worsen, SSRI discontinuation syndrome is present.
Complications
SSRI discontinuation syndrome results in various physical and psychological symptoms. Because of the serotonin deficiency, many people may experience sleep disturbances and occasionally gastrointestinal symptoms, such as diarrhea or constipation. As the condition progresses, circulatory problems may also occur, as well as balance and sensory disturbances, which increase the risk of accidents and falls. Possible psychological complications include mood swings to manic depression and suicidal thoughts. Extreme anxiety, depersonalization, and sexual dysfunction are also possible. In some patients, SSRI discontinuation syndrome results in late effects such as concentration problems, tinnitus, and poorer short-term memory. In most cases, these long-term symptoms persist for one to two years before gradually subsiding. Serious complications are unlikely as part of treatment. However, the medications typically prescribed occasionally cause side effects. For example, benzodiazepines can cause impaired memory, perception, and reaction time. Headaches and drowsiness are also typical complaints. In addition, there is a risk of drug dependence. Rapid discontinuation of the medication can cause psychological disorders such as depressive moods or mania. The use of antidepressants can cause fatigue, personality changes, and occasionally gastrointestinal symptoms.
When should you see a doctor?
SSRI discontinuation syndrome always requires treatment by a doctor. There can be no self-healing in this process, so treatment by a doctor is essential. This is the only way to prevent and limit further complications. A doctor should be consulted if the affected person exhibits the usual withdrawal symptoms of the drug. This often involves diarrhea or constipation, and severe sleep problems may also occur. If these symptoms occur, a doctor should be consulted in any case. Dizziness or cramps in the muscles can also indicate SSRI discontinuation syndrome and should be examined by a doctor. It is also not uncommon for those affected to exhibit confusion or tinnitus. Anxiety may also indicate the syndrome and must be evaluated by a physician. The diagnosis and treatment of SSRI discontinuation syndrome is usually carried out by a psychologist. It cannot be universally predicted whether complete recovery will occur. However, life expectancy is usually not reduced.
Treatment and therapy
Treatment of symptoms depends on the severity of the SSRI withdrawal syndrome. Also playing a role is whether further treatment with antidepressants is planned after SSRI discontinuation. In the latter case, restarting medication usually leads to success. For those patients who are no longer taking an antidepressant, therapy is based on the severity of symptoms. In mild cases, sedation and relaxation may be helpful. For moderate withdrawal symptoms, benzodiazepines are often used. In cases where SSRI withdrawal syndrome triggers severe symptoms, restarting the medication and later discontinuing the SSRIs in smaller increments may bring success. Switching to a long-acting SSRI that is easier to discontinue is also often helpful.
Prevention
SSRI discontinuation syndrome is preventable in that antidepressants should generally never be stopped abruptly. In principle, treatment with the drug must be discontinued gradually. This means that the dose should be gradually reduced before discontinuation. A minimum duration of SSRI tapering of two to four weeks is generally recommended. This tapering reduces the likelihood that SSRI discontinuation syndrome will occur; however, it does not prevent it with certainty.
Follow-up
Follow-up care for SSRI discontinuation syndrome depends on the severity of withdrawal symptoms. If they are mild, relaxation methods will help. If moderate in severity, patients should follow physician recommendations for benzodiazepine use.In severe cases, doctors often advise to take the medication again. It is very important to adhere exactly to the recommended medication. Subsequent discontinuation takes place in small steps. If necessary, the doctor may suggest follow-up treatment with antidepressants. Abrupt discontinuation is generally not advisable, so patients should expect a discontinuation phase of two to four weeks. They therefore need patience to reduce the syndrome as far as possible. By exercising, preferably outdoors, they feel distracted and no longer perceive the symptoms so clearly. At the same time, sport helps to regulate the metabolism. The activation of serotonin leads to a better mood for those affected, and at the same time they regain more control over their bodies. Patients often suffer from a lack of sleep, but the outdoor activities make them more likely to get tired and accordingly find it easier to rest and fall asleep. Regular rest periods promote a regular sleep rhythm.
Here’s what you can do yourself
In the case of a clearly diagnosed SSRI discontinuation syndrome, the treating physician or psychologist will provide symptom-oriented treatment and, if necessary, prescribe medication, depending on the severity of the symptoms. He may also recommend an SSRI again, which is easier to discontinue after a certain treatment period. However, patients who want to consistently avoid an SSRI in the future should have a lot of patience, as it can take a relatively long time for the serotonin balance in the body to rebalance without the influence of medication. The most helpful things to do with SSRI discontinuation syndrome are exercise and lots of movement in the fresh air. On the one hand, sports activities distract from the symptoms, and on the other hand, sports regulate the metabolism and activate serotonin production. This improves both mood and body awareness. At the same time, sufficient sport makes people tired, which is particularly helpful for patients who suffer from a lack of sleep as a symptom. For them, it is also important to establish regular rest periods and always go to bed at the same time. In this way, after some time, their body will find its way back to a regular sleep and wake rhythm. According to recent research, a healthy diet also helps with disturbances in the serotonin balance and the resulting tendency to depression.