The Unhappy Side of Anti-Depressants
Weighing the risks
For dual diagnosis addicts, it’s especially important to treat both the addiction and the depression. “I prescribe SSRIs for both depression and anxiety.” Mooney says. “If symptoms are mild, I will wait several weeks to see if they resolve on their own with ongoing sobriety. If the individual has had a history of clinically significant depression or anxiety in the past - even during prolonged periods of sobriety - this is another indication that symptoms are more likely to persist and medications may be helpful.”
Columbia’s Ball says that assessing priorities is key. The risks of not treating a mood disorder are far greater than the risks of SSRI discontinuation, owing to the fact of depression and substance dependence being the “toxic duo behind suicide,” he says. And, he adds, an unmanaged mood disorder keeps an addict in a state of constant risk of relapse.
“A rule of thumb is, any drug that changes the brain when you take it chronically can and will produce some type of withdrawal when you stop it,” says R. Andrew Chambers, director of the Laboratory for Translational Neuroscience of Dual Diagnosis & Development at the Indiana University School of Medicine. “The question is, how big of a deal is it? I think that the discontinuation syndrome from SSRIs is really pretty minor league stuff” compared to the risks associated with not treating the underlying depression or anxiety in addicts.
Is it real?
There are a lot of unknowns when it comes to SSRI discontinuation syndrome, mainly because the symptoms overlap with other disorders. Often, people will stop their meds early due to bad side effects or because they don’t feel they’re working. In this case, the sufferer may experience a depression relapse, and confuse it with discontinuation symptoms.
Harvard Medical School has some helpful ways to tell the difference. Discontinuation symptoms emerge within days to weeks of stopping the medication or lowering the dose, whereas relapse symptoms develop later and more gradually. Discontinuation symptoms often include physical complaints that aren’t commonly found in depression, such as dizziness, flu-like symptoms, and abnormal sensations. Discontinuation symptoms disappear quickly if you take a dose of the antidepressant, while drug treatment of depression itself takes weeks to work. Discontinuation symptoms resolve as the body recalibrates, while recurrent depression continues and may get worse.
Sometimes, post-acute withdrawal symptoms (PAWS) from the former drug of abuse can linger and be misinterpreted as SSRI discontinuation. Sometimes the symptoms can be confused if the addict has relapsed and is using while still on the SSRI. Other factors that might not be reported come into play, too: Are you drinking caffeine, or smoking cigarettes? Are you taking other prescription medications that may be interacting with your antidepressant?
And, some people may simply be more sensitive to any effect, whether side or discontinuation. “In my experience, people with anxiety are actually more aware of side effects,” Chambers says. “On the other hand, it’s quite the opposite with people with addiction or dual diagnosis. Actually, those folks are in some ways less concerned with side effects - they’re quite used to putting stuff in their bodies and not really caring.”
It’s also plausible that someone might inadvertently exaggerate discontinuation symptoms. “Some people may over-interpret minor symptoms, but then you also have a large group who seem to be incredibly insensitive to their own internal emotional states,” Ball says. Chambers says he’s never treated or had a colleague treat someone who has had “brain shocks,” so he’s skeptical that it is as common as people believe. “For the vast majority of people, [SSRI discontinuation syndrome] is so subtle that no one notices it,” he says.
Long-term “withdrawal” effects
Most cases of discontinuation syndrome last between one and four weeks. However, up to about 15 percent of people have symptoms that persist for months. Paroxetine (Paxil) and venlafaxine (Effexor) seem to be particularly difficult to discontinue, with reports of prolonged withdrawal syndrome lasting over 18 months for paroxetine.
Ball admits that these symptoms can be “disruptive,” and can last for “a year or more,” based on how fast one tapers. However, Chambers doesn’t believe it. “When people talk about the SSRIs changing the brain in some way, [and] you have some sort of prolonged withdrawal, I don’t buy that,” he says. “I think that it’s more likely that the underlying psychiatric [disorder] is going to linger a lot longer.”
Regardless of who “agrees” with what patients are feeling, all those interviewed acknowledged that prescribing doctors do need to have more conversations about possible discontinuation effects of SSRIs and other antidepressants. Mooney already practices this with her patients. “I discuss potential relapse triggers in the context of therapy, which include low mood, stress, anxiety, and physical discomfort,” she says. “By having this discussion and staying in close contact with patients should symptoms emerge, we can usually avoid or mitigate the majority of potential problems associated with antidepressant discontinuation.”
Additionally, there is more evidence that taper rates need to be lengthened, and dosages reduced uber-gradually compared to how they’re typically decreased now. In fact, recent data from narcoleptic patients using SSRIs suggest that antidepressant discontinuation lasts over three months, and that current taper rates are far too short.
Finally, more studies need to be done, not only on antidepressant discontinuation syndrome, but also the effects of long-term use of antidepressants on mental health outcomes. “A handful of studies is almost never enough to know anything,” Chambers says. The trick - beyond getting the NIH to fund these studies - will be recruiting big enough cohorts and designing tests that rule out the many confounding factors to teasing out the true effect of the antidepressant alone.
As a plastic organ, the brain is capable of adapting to significant change, and thank goodness for that. “Coming from a dual diagnosis perspective, in many ways, addictive drugs are far more capable of altering the brain than any of our treatment drugs; and yet even with those drugs, if someone quits using and stays abstinent, they can recover,” Chambers says. “If people achieve true sobriety and sustain that, they can recover.”