Conversations with clients about antidepressant withdrawal and discontinuation

The issue of antidepressant withdrawal has received increased scientific and public interest over the last several years.¹ Clinical practice guidelines suggesting that withdrawal symptoms tend to be mild and likely to resolve without treatment in a few short weeks are no longer consistent with the evidence,^2–5 and ignore the experiences of some service users.⁶ Indeed, the latest changes to the National Institute for Care and Health Excellence (NICE) depression guidelines recommend that mental health providers inform clients about the potential for severe and long-lasting withdrawal symptoms.⁷ Facing rising rates of long-term antidepressant use across the US and UK,³ the lack of evidence of a favorable risk–benefit ratio for long-term use,⁸ and increased public awareness of these issues,⁹ mental health providers may benefit from guidance concerning how to initiate discussions about the risks of antidepressant withdrawal.

By initiating these conversations, mental health providers, including psychiatrists, psychologists, counselors, family physicians, and social workers, can be honest about the limitations of the current science, and play an important role in limiting overuse and mitigating harm to clients. Qualitative research with those taking antidepressants for longer than 9 months who were given medical advice to discontinue antidepressants suggests that fear of recurrence and belief in an underlying serotonin deficiency or chemical imbalance,¹⁰ create barriers to discontinuation and prevent clients from following medical advice.¹¹ Mental health workers can speak directly to these concerns and misunderstandings by providing robust informed consent and accessibly presenting the state of the research on this issue and discontinuation strategies.

The following example of such a conversation is intended to provoke a much-needed discussion among providers about how best to present this information to clients. The example assumes a situation where a client was previously diagnosed with major depressive disorder (MDD) and has been taking an appropriate dose of a selective serotonin reuptake inhibitor (SSRI) for 3 years. However, the client has now met conditions for remission for the last year and is otherwise in good physical and mental health. The client has received medical advice from their psychiatrist to discontinue the medication but expressed concerns and hesitations about stopping. Working with the multidisciplinary team of providers, the client’s counselor agrees to initiate a psychoeducational discussion about antidepressant discontinuation and withdrawal with the client. The information provided in the example is informed by research that has systematically gathered information about patient expectations about stopping an antidepressant and the topics patients perceived as most useful to discuss in a consultation regarding discontinuation.¹² However, professionals should exercise their clinical judgment to tailor these conversations to each individual.

Psychoeducational antidepressant discontinuation and withdrawal presentation to client

Discuss Current Functioning, Hopes and Fears, and Validate Concern: I understand that you have expressed hesitation about coming off your current antidepressant. Your concern is completely under-standable and many others in similar situations have expressed hesitation as well. You have felt your mood improve while taking this drug and it is normal to worry about relapse and the effect that discontinuing might have on your mood and whether your previous symptoms might return. Additionally, the process of coming off the antidepressant can be challenging without support. Perhaps you have had previous experiences with reducing or missing your dose that have been unpleasant. I would like to offer to review the advantages and disadvantages of discontinuing your antidepressant and to support you in this process if you decide to discontinue. If you would like, I could take some time now to discuss this topic with you and talk through your concerns.

Psychoeducation on Theoretical Mechanism of Antidepressants: I will quickly give an overview of the theory of how SSRI antidepressants, like the one you are taking, affect the brain and then address some common misconceptions. Current theories suggest that SSRI antidepressants increase the amount of the chemical serotonin available in your brain by preventing or “inhibiting” the “reuptake” of serotonin. If less serotonin is reabsorbed then this means more is available to act on your brain cells. It is thought that it is this increased level of serotonin that has a positive effect on mood; however, this is unproven. In addition, it is commonly stated that depression is the result of a “chemical imbalance,” but the evidence does not support this theory.¹³ This means that the improvement you have seen in your mood may not be solely or directly a result of the drug’s effects and that the level of serotonin in your brain after coming off antidepressants does not necessarily dictate your mood. In addition, your brain may also change in response to a placebo, your environment, relationships, and through psychotherapy.

Inform on Potential Withdrawal Effects and Strategies: After using an SSRI long-term, it is thought that the brain may adapt to this by reducing the effect of serotonin. This may mean that it could take more of the drug to have the same effect, although this is unclear. This may also be why, when the amount of the drug is decreased, or stopped completely, withdrawal symptoms occur. These symptoms vary between individuals and can depend on the antidepressant taken. There are a range of symptoms that some people may experience, but these do not affect everyone. Symptoms may include anxiety, flu-like symptoms, insomnia, nausea, dizziness, electric shock-like sensations called “brain zaps,” muscle spasms, agitation, emotional blunting, and sexual dysfunction. For some people these symptoms are relatively mild and brief, but for others they can be severe and long lasting. It is common for people to plan for a slow and managed reduction of their antidepressant dose over 2–4 weeks. However, to lessen the potential for withdrawal symptoms, the newest research suggests that tapering by amounts that become increasingly small can be a valuable strategy. This means slowly reducing the dosage over a longer period, like several months. Whichever strategy you decide, it is important to work with a medical professional who understands your concerns and can guide you through reducing your dosage. It will be beneficial to have regular check-ups throughout this process.

Following this discussion, providers should inquire about what may have been unclear and what questions this conversation brought up for them. It is important that providers be open to hearing clients’ frustration with the lack of information about these issues that they may have been provided at the outset, and be honest about the limitations of the current science. Research suggests that the quality of the relationship between the provider and service-user impacts expectations about taking or coming off a medication.¹⁴ As a result, the professional can significantly affect the experience of discontinuation and contribute to the effectiveness of the intervention. Therefore, it is recommended that providers utilize motivational interviewing skills throughout these conversations by expressing empathy, normalizing the ambivalence about discontinuing, and supporting self-efficacy and optimism. For additional information, providers may want to reference the new “Guidance for Psychological Therapists: Enabling conversations with clients taking or withdrawing from prescribed psychiatric drugs,” developed by the Council for Evidence-based Psychiatry (available at: https://prescribeddrug.info/guidance-for-psychological-therapists).¹⁵ Service users may also benefit from peer support and information provided by networks for those discontinuing antidepressants including Surviving Antidepressants, the Withdrawal Project, Inner Compass, and Mad in America.