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Instructions for halting ssris
DAVID HEALY MD FRCPsych
N WALES DEPT of PSYCHOLOGICAL MEDICINE
SSRI stands for selective serotonin reuptake inhibitor. This does not mean
these drugs are selective to the serotonin system or that they are in some
sense pharmacological y “clean”. It means they have little effects on the
norepinephrine/noradrenaline system. There are 8 Serotonin reuptake
Venlafaxine in doses up to 150mg is an SSRI. Over 150 mg it also inhibits
noradrenaline reuptake. Duloxetine is a potent serotonin reuptake inhibitor but
not selective to the serotonin system.
SSRI withdrawal symptoms break down into two groups.
The first group may be unlike anything you have had before:
Dizziness – “when I turn to look at something I feel my head lags behind”.
Electric Head - which includes a number of strange brain sensations –
“its almost like the brain is having a version of goose pimples”
Electric Shock-like Sensations – Zaps – like being prodded with a cattle prod
Other Strange Tingling or Painful Sensations
Dreams, including Agitated Dreams or other Vivid Dreams
Hal ucinations or other visual or auditory disturbances
The second group are symptoms which may lead you or your physician
to think that al you have are features of your original problem. These include:
Depression and Anxiety – these are the commonest 2 withdrawal symptoms
More general y there is an intolerance of stress.
Any difficulties present may wax and wane and this can be demoralising.
IS THIS WITHDRAWAL?
There are three ways to distinguish SSRI withdrawal from the nervous
problems that the SSRI might have been used to treat in the first instance.
First if the problem begins immediately on reducing or halting a dose or
begins within hours or days or perhaps even weeks of so doing then it is more
likely to be a withdrawal problem. If the original problem has been treated and
you are doing wel , then on discontinuing treatment no new problems should
show up for several months or indeed several years.
Second if the nervousness or other odd feelings that appear on reducing or
halting the SSRI (sometimes after just missing a single dose) clear up when
you are put back on the SSRI or the dose is put back up, then this also points
towards a withdrawal problem rather than a return of the original il ness.
When original il nesses return, they take a long time to respond to treatment.
The relatively immediate response of symptoms on discontinuation to the
reinstitution of treatment points towards a withdrawal problem.
Third the features of withdrawal may overlap with features of the nervous
problem for which you were first treated - both may contain elements of
anxiety and of depression. However withdrawal wil also often contain new
features not in the original state such as pins and needles, tingling sensations,
electric shock sensations, pain and a general flu-like feeling.
Before starting to withdraw, it should be noted that many people wil have no
problems on withdrawing. Some wil have minimal problems, which may peak
after a few days before diminishing. Symptoms can remain for some weeks
or months. Others wil have greater problems, which can be helped by the
Final y however there wil be a group of people who are simply unable to stop
whatever approach they take. Some others wil be able to stop but wil find
problems persisting for months or years afterwards. It is important to
recognise this latter possibility in order to avoid punishing yourself. Specialist
help may make a difference for some people in these two groups, if only to
provide possible antidotes to attenuate the problems of ongoing SSRIs such
HOW TO WITHDRAW
If there are any hints of problems on withdrawal from SSRIs, the management
of withdrawal is something to be done in consultation with your physician. You
may wish to show this to your doctor. Over-rapid withdrawal may be
medical y hazardous, particularly in older persons.
Many doctors suggest you withdraw by taking one pil every other day for a
few weeks before stopping. There is no guideline that advocates this or
evidence that supports it and the approach is misguided.
One of the first steps to consider is getting a liquid formulation of your
antidepressant. This can be done by asking your doctor to approach the local
primary care pharmacist who can make an application to one of the specialist
companies such as Martindale’s or Rosemount that can make up a liquid
formulation of almost any antidepressant you might be on – see below.
There are 2 theories about what leads to dependence and withdrawal that
dictate slightly differing management plans.
One theory is that the relatively short half life of paroxetine and venlafaxine
make these two drugs more problematic. This leads to a withdrawal strategy
that advocates switching from paroxetine or other drugs to fluoxetine.
The second is that paroxetine and venlafaxine are relatively more potent
serotonin reuptake inhibitors and this theory leads to a switch to less potent
serotonin reuptake inhibitors such as citalopram or one of the older
Either approach is facilitated by having access to treatment in liquid form.
Paroxetine, fluoxetine and imipramine come in liquid form and anyone having
difficulties with withdrawal should insist on access to the liquid form of one of
these drugs or a special formulation of the drug they are on.
Convert to a liquid form of the drug you are on. If this is paroxetine
20mg then reduce by a comfortable amount in weekly steps – see below.
This may mean reducing as little as 1 mg per week and being prepared to
stop and stabilize if things get too difficult. For some people depending on
the drug and their own physiology, there may be a need to go very slowly,
The Reduced Potency Approach
Taking this approach, the best option is to change to Imipramine
100mg. This comes in 25mg and 10 mg tablets and also in liquid form. It is
the first serotonin reuptake inhibitor. It is much less potent than the SSRIs,
and has been used widely for children for a range of problems.
Another option is to have a mixture of 50 mg imipramine with 10 mg
The Half-Life Approach
Convert the dose of SSRI you are on to an equivalent dose of Prozac
liquid. Seroxat/Paxil 20mg, Efexor 75mg, Cipramil/Celexa 20mgs,
Lustral/Zoloft 50mgs are equivalent to 20mg of Prozac liquid. The rationale
for this is that Prozac has a very long half-life, which helps to minimise
withdrawal problems. The liquid form permits the dose to be reduced more
One drawback to this approach is that some people become agitated
on switching to fluoxetine in which cases one option is take a short course of
diazepam until this settles down. This agitation might be caused by exposure
to fluoxetine or because for some people the substitution does not cover
withdrawal from their original drug. If the agitation gets better when the dose
of fluoxetine is reduced then its more likely to be caused by fluoxetine, if it
gets worse, then it is more likely to be linked to withdrawal.
Yet another option is to change from paroxetine or whatever the
original drug was to a mixture of half the previous dose of the original drug
and the other half in the form of fluoxetine. The next step is to reduce
gradual y the dose of the original drug and after that to reduce the fluoxetine.
Stabilise on one of these options for up to 4 weeks before proceeding.
For uncomplicated withdrawal, it may be possible to then drop the dose
If there has been no problem with step 2, a week or two later, the dose
can be reduced to half of the original.
Alternatively if there has been a problem with the original drop, the
dose should be reduced by 1 mg amounts in weekly or two weekly
From a dose of fluoxetine 10mgs liquid or tablets or imipramine 10mg
tablets or liquid, consider reducing by 1mg every week over the course of
several weeks - or months if need be. (a syringe is helpful in reducing the
If there are difficulties at any particular stage the answer is to wait at
that stage for a longer period of time before reducing further.
Complexities of Withdrawal
Some people are extremely sensitive to withdrawal effects. If there are
problems with step 1 above, return to the original dose and from there reduce
Withdrawal and dependence are physical phenomena. But some people can
get understandably phobic about withdrawal particularly if the experience is
literal y shocking. If you think you have become phobic, a clinical psychologist
or nurse therapist may be able to help manage any phobic element.
Self-help support groups can be invaluable. Join one. If there is none nearby,
consider setting one up. There wil be lots of others with a similar problem.
An alternate approach is to substitute St John’s Wort or an antihistamine for
the SSRI, as these both have serotonin reuptake inhibiting properties. If a
dose of 3 tablets of St John’s Wort is tolerated instead of the SSRI, this can
then be reduced slowly – by one pil per fortnight or even per month or by
If withdrawal problems appear to ease off and then come back, it is worth
checking whether this was because the affected person was co-incidental y
treating themselves with something like St John’s Wort or an antihistamine.
Some people for understandable reasons may prefer this approach. But it
needs to be noted that St John’s Wort and the antihistamines come with their
While SSRI withdrawal may not be a problem for some people, for others it
can last months and indeed years – possibly 2-4 years. Even if it endures for
months/years, it does seem likely to clear up in the long run.
In the case of enduring problems, being active is probably important. An
enduring problem is likely to be underpinned by some brain change that can
only be reversed by encouraging activity in that brain area through physical
and mental activity. Gentle but regular exercise and involvement in activities
rather than withdrawal seems more likely to stimulate silenced brain areas
If it seems impossible to withdraw and the option is to stabilise on an SSRI for
the foreseeable future, at this point there is no clear indicator as to whether
there is a best SSRI to stabilise on. In terms of ongoing problems paroxetine,
sertraline, venlafaxine and duloxetine are associated with a high frequency of
problems on withdrawal and on this basis seem poor fal -back options.
Fluoxetine is associated with proportional y the greatest frequency of reports
of drug seeking or “addictive” behaviours, and is problematic from this point of
view. By default this leaves citalopram as a fal back option.
Companies have tried to label withdrawal problems as discontinuation
problems or discontinuation syndromes, because of the negative perceptions
The problems posed by withdrawal may stabilise to the point where you can
get on with life. But whether it is or is not possible to withdraw, it is important
to note ongoing problems and to get your physician or someone to report
them if possible to the appropriate bodies – such as the FDA/MHRA. New
health problems such as diabetes or raised blood lipid levels may have a link
to prior or ongoing treatment. If your doctor won’t report these problems, you
should if you live in a place where this can be done.
There are clear effects on the heart from SSRIs and from some there are
likely to be cardiac problems during the post-withdrawal period. Such
problems if they occur should be noted and recorded. SSRIs can also
increase the risks of haemorrhage, especial y if combined with aspirin, and of
SSRIs are wel -known to impair sexual functioning. The conventional view
has been that once the drug is stopped, functioning comes back to normal.
There are indicators however that this may not be true for everyone. If sexual
functioning remains abnormal, this should be brought to the attention of your
physician, who wil hopeful y report it.
Withdrawal may reveal other continuing problems, similar to the ongoing
sexual dysfunction problem, such as memory or other problems. It is
important to report these. The best way to find a remedy is to bring the
problem to the attention of as many people as possible.
The single most important group who need to be aware of al these issues are
women of child-bearing years. A very large number of pregnancies happen in
an unplanned fashion and are several weeks advanced before the woman is
aware of the situation. SSRIs, and paroxetine in particular, are now clearly
linked to a number of problems in pregnancy, among which are an increased
frequency of birth defects, an increased rate of miscarriage, premature birth,
low birth weight, a neonatal withdrawal syndrome and pulmonary
One of the biggest problems of SSRI dependence involves women who are
on treatment and unable to stop who wish to become pregnant. Getting off an
SSRI at present seems more difficult for women than men, even with the
incentive of wishing to become pregnant.
1. Rosemont Pharmaceuticals (Tel 0113 244 1999)
Amitriptyline 10mg/5ml, 25mg/5ml, 50mg/5ml
2. Cardinal Health, Martindale (Tel 0800 137 627)
This manufacturer wil prepare any antidepressant on request.
3. Large chain pharmacies like Boots or Rowlands may have their own supplier of liquid
“Ask Dr. J” The “Ask Dr. J” columns are authored monthly by Jennifer Christian, MD, MPH, President of Webility Corporation. See previous columns at www.webility.md. Dr. J’s columns also appear in the monthly Bulletin of the Disability Management Employer Coalition (DMEC). To purchase a book of Dr. J’s collected columns, go to www.dmec.org. The columns often summarize iss
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