55 - Troubleshooting

Troubleshooting

Depression and anxiety disorders CHAPTER 3 A cautious initial rate of reduction is prudent. The rate of withdrawal can be sped up if symptoms are tolerable. If severe withdrawal symptoms are precipitated by the first step down, then the process may be set to be a difficult one. The first reduction is perhaps the most important. Withdrawal symptoms should be monitored for 2–4 weeks for all patients, or until symptoms have resolved. Monitoring may take the form of simple measures of symptoms each day (e.g. out of 10), which may be more convenient than using long standardised measurement such as the Discontinuation–Emergent Signs and Symptoms scale.25 Further reductions should be titrated against the tolerability of this experience. If the initial reduction was tolerable and withdrawal symptoms were absent or have resolved by the end of this monitoring period, continue reducing dose by the same proportion (worked out on the last dose used; see example regimens in Box 3.2). If symptoms were intolerable, then the taper should proceed at a slower rate. If severe, this may require reinstatement of the previous dose, a period of stabilisation and then a more cautious reduction schedule. Troubleshooting If withdrawal symptoms become intolerable at any point, either hold the current dose for longer to allow them to resolve or, if very unpleasant, increase to the last dose at which the symptoms were tolerable and remain there until symptoms resolve. After stabilisation, tapering will need to be more gradual, with reductions made by smaller amounts. Some patients find they cannot reduce at more than 5% of the last dose per month. If a patient experiences distressing withdrawal symptoms, it does not indicate that they cannot stop antidepressants but that they will need to taper more slowly, with smaller reductions than they have been undertaking. Owing to the long half-­life of fluoxetine, withdrawal symptoms can be delayed by weeks, so careful attention should be paid to this. (For reasons that may relate to brain elimination half-­lives even shorter-­acting antidepressants can present with delayed-­ onset withdrawal effects.)26 As the withdrawal period is spread over a longer period, larger reductions of fluoxetine may be relatively tolerable,7 but fluoxetine cannot be said to be ‘self-­tapering’ for long-­term users and so should not be stopped abruptly. Box 3.2  A simplified guide to tapering sertraline according to an exponential pattern The range of reductions provided is equivalent to about 10–25% dose reductions at each step. Some patients may require smaller reductions and others may tolerate larger reductions at a faster rate. ■ ■Reduce dose by 25–50mg every 2–4 weeks until reaching 50mg per day, then ■ ■Reduce by 5–10mg every 2–4 weeks until reaching 15mg per day, then ■ ■Reduce by 1.5–3mg every 2–4 weeks until reaching 6mg per day, then ■ ■Reduce by 0.5–1mg every 2–4 weeks until reaching 2mg per day, then ■ ■Reduce by 0.25–0.5mg every 2–4 weeks until completely stopped. This process normally takes between 3 months and 3 years but in some people can require longer periods.