# 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.
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■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
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■Reduce by 0.5–1mg every 2–4 weeks until reaching 2mg per day, then
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■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.