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References

376 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 3 difficult to stop.13 At-­risk patients (see above) may need a slower taper. Agomelatine can probably be stopped abruptly without provoking withdrawal symptoms but should be slowly withdrawn as a matter of principle – all psychotropic drugs should be slowly withdrawn where possible. Many people suffer symptoms despite slow withdrawal and even if they have received adequate education regarding withdrawal symptoms.7,17 This may be because hyperbolic tapering is not employed (see section on stopping antidepressants in this chapter). How to treat14–16,23 There are few systematic studies in this area. Treatment is pragmatic. If symptoms are mild, reassure the patient that these symptoms are common after discontinuing an antidepressant and will pass in a few days or weeks. If symptoms are severe, reintroduce the original antidepressant (or another with a longer half-­life from the same class) and taper gradually while monitoring for symptoms.6 Some evidence supports the use of anticholinergic agents in tricyclic withdrawal24 and fluoxetine for symptoms associated with stopping paroxetine,25 sertraline,25 clomipramine26 or venlafaxine27 – fluoxetine, with active metabolites, having a much longer plasma half-­life, seems to be associated with a lower incidence of discontinuation symptoms than other similar drugs.7 The use of alternative classes of medications (e.g. shortterm symptomatic use of a benzodiazepine) has been suggested for the treatment of anxiety and insomnia.28 References

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  6. National Institute for Health and Care Excellence. Depression in adults: treatment and management. NICE guideline [NG222]. 2022 (last reviewed September 2024, last checked November 2024); https://www.nice.org.uk/guidance/ng222.
  7. Fava GA, et al. Withdrawal symptoms after selective serotonin reuptake inhibitor discontinuation: a systematic review. Psychother Psychosom 2015; 84:72–81.
  8. Berigan TR. Bupropion-­associated withdrawal symptoms revisited: a case report. Prim Care Companion J Clin Psychiatry 2002; 4:78.
  9. Berigan TR, et al. Bupropion-­associated withdrawal symptoms: a case report. Prim Care Companion J Clin Psychiatry 1999; 1:50–51.
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  11. Curtin F, et al. Moclobemide discontinuation syndrome predominantly presenting with influenza-­like symptoms. J Psychopharmacol 2002; 16:271–272.
  12. Ricken R, et al. Tranylcypromine in mind (part II): review of clinical pharmacology and meta-­analysis of controlled studies in depression. Eur Neuropsychopharmacol 2017; 27:714–731.
  13. Gahr M, et al. Withdrawal and discontinuation phenomena associated with tranylcypromine: a systematic review. Pharmacopsychiatry 2013; 46:123–129.
  14. Lejoyeux M, et al. Antidepressant withdrawal syndrome: recognition, prevention and management. CNS Drugs 1996; 5:278–292.
  15. Haddad PM, et al. Recognising and managing antidepressant discontinuation symptoms. Adv Psychiatr Treat 2007; 13:447–457.
  16. Haddad PM. Antidepressant discontinuation syndromes. Drug Saf 2001; 24:183–197.
  17. Tint A, et al. The effect of rate of antidepressant tapering on the incidence of discontinuation symptoms: a randomised study. J Psychopharmacol 2008; 22:330–332.
  18. Ogle NR, et al. Guidance for the discontinuation or switching of antidepressant therapies in adults. J Pharm Pract 2013; 26:389–396.

Depression and anxiety disorders CHAPTER 3 19. Meijer WE, et al. Spontaneous lapses in dosing during chronic treatment with selective serotonin reuptake inhibitors. Br J Psychiatry 2001; 179:519–522. 20. van Geffen EC, et al. Discontinuation symptoms in users of selective serotonin reuptake inhibitors in clinical practice: tapering versus abrupt discontinuation. Eur J Clin Pharmacol 2005; 61:303–307. 21. Kramer JC, et al. Withdrawal symptoms following discontinuation of imipramine therapy. Am J Psychiatry 1961; 118:549–550. 22. Read J. How common and severe are six withdrawal effects from, and addiction to, antidepressants? The experiences of a large international sample of patients. Addict Behav 2020; 102:106157. 23. Wilson E, et al. A review of the management of antidepressant discontinuation symptoms. Ther Adv Psychopharmacol 2015; 5:357–368. 24. Dilsaver SC, et al. Antidepressant withdrawal symptoms treated with anticholinergic agents. Am J Psychiatry 1983; 140:249–251. 25. Benazzi F. Re: Selective serotonin reuptake inhibitor discontinuation syndrome: putative mechanisms and prevention strategies. Can J Psychiatry 1999; 44:95–96. 26. Benazzi F. Fluoxetine for clomipramine withdrawal symptoms. Am J Psychiatry 1999; 156:661–662. 27. Giakas WJ, et al. Intractable withdrawal from venlafaxine treated with fluoxetine. Psychiatr Ann 1997; 27:85–93. 28. Fava GA, et al. Understanding and managing withdrawal syndromes after discontinuation of antidepressant drugs. J Clin Psychiatry 2019; 80:19com12794.

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