What to expect when SSRIs are discontinued
November 1, 1999 2 minutes read
What to expect when SSRIs are discontinued
When selective serotonin reuptake inhibitors (SSRIs) are abruptly discontinued, patients may come in to the ED with symptoms including dizziness, nausea, lethargy, and headache, says Robert Knies Jr., RN, MSN, CEN, clinical nurse specialist for emergency services at HealthSystem Minnesota in St. Louis Park. Other symptoms to watch for: anxiety, irritability, memory problems, and anorexia.
Commonly prescribed SSRIs include:
• fluoxetine, or Prozac (Eli Lilly and Co., Indianapolis);
• fluevoxamine, or Luvox (Solvay Pharmaceuticals, Marietta, GA);
• paroxetine or Paxil (SmithKline Beecham, Philadelphia);
• sertraline or Zoloft (Pfizer, New York City).
Those psychotropic medications need to be discontinued gradually, and a "time-off" period is needed before a new drug is started, says Knies.
The older tricyclic antidepressants were well-known for their anticholinergic, sedative, and orthostatic hypotensive side effects, says Clyde Miyagawa, PharmD, clinical pharmacy specialist in critical care at University Hospital in Cincinnati.
"These agents were relatively effective, but compliance was poor, secondary to their side effect profile," he explains. "This class of agents has been all but abandoned in favor of the newer SSRIs."
In general, SSRIs have minimal anticholinergic, sedative, and orthostatic hypotensive effects, notes Miyagawa. "However, insomnia, somnolence, nervousness, anxiety, nausea, diarrhea, headache, and tremor have been reported in 10% to 30% of patients taking these agents."1
Side effects fall into the following five groups: gastrointestinal and general somatic distress, sleep disturbances, disorders with motor abilities, behavioral irregularities, and various other side effects, such as cardiac arrhythmias.2
Symptoms may overlap and make the diagnosis difficult. Symptoms such as depressed mood, agitation, or irritability may be mistaken for a relapse of depressive symptoms, notes Knies.3 Patients may get a reaction several days after they stop a medication. "With a lot of drugs, not only psychotropics, you need that lag period in between for the body to metabolize the drug."
Many drugs are fat soluble and take a long time to metabolize, he says. "It’s well-documented in the Physicians’ Desk Reference [published by Medical Economics in Montvale, NJ] that you shouldn’t stop one drug and start another one on the same day," Knies says.
Be proactive in identifying patients with discontinuation reactions by questioning them about specific medications, and then initiate supporting interventions, urges Knies. "Treat symptoms and restart SSRIs with subsequent gradual withdrawal."
References
1. Nelson JC. Safety and tolerability of the new antidepressants. J Clin Psychiatry 1998; 58:26-31.
2. Dilsaver SC, Greden JF, Snider RM. Antidepressant withdrawal syndromes: Phenomenology and pathophysiology. Int Clin Psychophramacol 1987; 2:1-19.
3. Haddad P. Newer antidepressants and the discontinuation syndrome. J Clin Psychiatry 1997; 57:17-21.
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