Author: Claudia M. Elsig, MD

Are you thinking of stopping your antidepressants?

It’s great you are feeling better, but be aware that stopping psychiatric medication isn’t as simple as it sounds. Abruptly stopping any medication without proper medical advice can be harmful. Just like any other medication, suddenly ceasing antidepressants comes with risks. 

This blog explains how antidepressants work, what happens when you stop taking them, and how to become drug-free safely.

Antidepressants: an overview

Antidepressants are medications prescribed for certain mental disorders, most commonly depression, but also for anxiety disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), social phobia, and eating disorders. They are sometimes used in the treatment of long-term chronic pain.

Antidepressants are usually the first line of treatment for moderate to severe depression¹ and are commonly used alongside talking therapies, such as cognitive behavioural therapy (CBT).

Medication isn’t usually prescribed for mild depression. However, there is concern that antidepressants are overprescribed – they are the most commonly prescribed medication in the U.S., for example.² Unfortunately, antidepressants often get prescribed easily for things like mild-to-moderate anxiety, OCD, and even bad sleep quality.

Globally, antidepressant use is on the rise.³ 

In the U.K., medical experts and politicians have called for the amount of antidepressants being prescribed to be reduced. In an open letter to the U.K. government, experts said, “Rising antidepressant prescribing is not associated with an improvement in mental health outcomes at the population level, which, according to some measures, have worsened as antidepressant prescribing has risen.”⁴

That said, antidepressants can be a lifeline for some people, and there is extensive research in this field. Many studies show they can be highly effective in treating moderate and severe depression. Meta-analyses of randomised controlled trials (RCTs) reveal that antidepressants are 20–30% more effective than placebos.⁵ 

However, research by Kirsch and Sapirstein, which led to the publication of a book The Emperor’s New Drugs: Exploding the Antidepressant Myth, set out to measure the placebo effect in the treatment of depression. Analysing data from multiple studies, they were surprised to find how small the drug effect was. 

Seventy-five percent of the improvement in the drug group also occurred when people were given dummy pills with no active ingredient in them. Different clinical trials show a small, clinically insignificant difference between drug and placebo.⁶

Commonly prescribed antidepressants

There are different types of antidepressant medications. Selective serotonin reuptake inhibitors (SSRIs) are the most common type of antidepressants, and these are usually the first choice for treating moderate to severe depression or anxiety.

Common SSRIs include fluoxetine (Prozac), citalopram (Cipramil), escitalopram (Cipralex), paroxetine (Seroxat), and sertraline (Lustral).

Other forms of antidepressants include serotonin-noradrenaline reuptake inhibitors (SNRIs) and noradrenaline and specific serotonergic antidepressants (NASSAs). 

An older form of antidepressant medication not often prescribed these days is tricyclic antidepressants (such as amitriptyline, dosulepin, and nortriptyline).

Other less commonly used antidepressants that are only usually prescribed if SSRIs don’t work are Serotonin antagonists and reuptake inhibitors (SARIs) and Monoamine oxidase inhibitors (MAOIs).

How do SSRI antidepressants work?

Understanding how antidepressant medications work helps to give a sense of how withdrawing from them might impact you.

SSRIs are said to work by increasing serotonin levels in the brain. Serotonin is a neurotransmitter produced by nerve cells in the body. It is a chemical messenger, also known as 5-hydroxytryptamine (5-HT), that influences many bodily functions, including mood, sleep, digestion, wound healing, blood clotting, learning and memory.

In normal bodily functions, after carrying a message, nerve cells reabsorb Serotonin (known as Serotonin uptake). SSRIs block the reuptake, leaving more Serotonin available.

But the link between low Serotonin and depression is complex. Some antidepressant medications, such as Tianeptine, an SSRE, a selective serotonin reuptake enhancer, works by decreasing the amount of Serotonin in the brain. If the theory that depression is caused by a deficiency of serotonin were correct, Tianeptine would be expected to make depression worse. But it doesn’t.⁷

Does low Serotonin cause depression?

For a long time, it was hypothesised that low Serotonin in the brain was the main cause of depression. The serotonin hypothesis was proposed by the late British Psychiatrist Alec Coppen over 50 years ago.⁸ 

Now, advances in neurochemistry show it to be more complex and debunk the notion that clinical depression is caused by the deficient functioning of a single neurotransmitter.⁹ 

The serotonin hypothesis is still influential, and there is reliable evidence to show abnormalities in serotonin mechanisms in depressed patients. However, more research is required to explore the diverse molecular and biological mechanisms involved and the effect of different drugs on neurochemical systems.

Recent research shows that the amino acid tryptophan is an important player in depression.¹⁰ 

A 2022 review of thousands of studies found no difference in serotonin levels between people with depression and healthy people.¹¹ 

How long should you take antidepressants?

When first prescribed antidepressants, it is typically suggested that you stay on them for at least four or five months after your symptoms of depression stop. Clinicians usually recommend staying on antidepressants for six to nine months.

More extended periods of medication can be recommended in severe cases.

In all cases, antidepressant usage and dosage should be monitored frequently.

Which antidepressants have the highest risk of withdrawal?

A recent review of published data showed Serotonin and noradrenaline reuptake inhibitors and paroxetine are associated with a higher risk of withdrawal effects compared with other antidepressants.¹² 

Why would you stop taking antidepressants?

There are many reasons you may decide to stop taking antidepressants, including:

• Your mental health is better
• The antidepressants aren’t working; you feel there has been no change
• The antidepressants are causing unpleasant side effects, such as weight gain, sexual dysfunction and nausea
• You don’t like the way the medication makes you feel
• The medication is stopping you from doing the things you want to do
• You’ve found other ways of coping
• You don’t want to take medications long-term or anymore

Whatever the reason, you should always consult your prescriber before stopping. This typically involves scheduling an appointment, discussing your reasons for wanting to stop, and considering alternative treatment options if necessary. 

Your prescriber will help you decide if stopping is right for you and how to do it safely. You will need to weigh up the advantages and disadvantages of stopping antidepressants.

What happens when you stop taking antidepressants?

There are a few things that can happen when you stop taking antidepressants. The best outcome is obviously that nothing happens at all – you feel great and can get on with life drug-free.

However, there is a chance that the original mental health symptoms may return. Abruptly stopping antidepressants can increase the risk of becoming unwell again.

There is also a risk of experiencing withdrawal symptoms. It is hazardous to stop abruptly if you have been taking antidepressants for a long time or if you are taking them alongside other medications. 

The type of antidepressant and the dosage is also significant. Higher dose levels will need to be reduced gradually.

What are the withdrawal symptoms from antidepressants?

Withdrawal symptoms vary considerably from person to person. For some, withdrawal symptoms are mild and disappear quickly without the need for intervention.

Other people have strong withdrawal symptoms. These can include:

• Anxiety, sometimes in intense surges
• A sense of inner restlessness
• Low mood or rapidly changing mood
• Anger
• Difficulty concentrating
• Difficulty sleeping
• Vivid dreams or nightmares
• Tiredness
• A sense that things are unreal, or a cotton-wool feeling in your head
• Burning, tingling or electric-shock-like sensations in the head
• Headaches
• Nausea
• Loss of coordination or dizziness
• Suicidal thoughts

Antidepressants aren’t generally thought to be addictive. However, around a third to half of people coming off antidepressants suffer withdrawal symptoms.¹³ 

Antidepressants increase brain chemicals (neurotransmitters), so the body needs time to adjust. The sudden stopping of antidepressants (SSRIs) lowers neurotransmitter levels; this sudden drop produces withdrawal symptoms.

Who gets withdrawal symptoms from antidepressants?

It is difficult to predict, and the intensity of withdrawal symptoms is different for everyone. It is generally thought that the longer the duration of use, the higher the dosage, and for certain types of antidepressants, the risk of withdrawal effects is increased as they have likely caused greater adaptation of the brain.¹⁴ 

How to withdraw from antidepressants safely

Coming off antidepressants must always be under the watchful eye of your psychiatrist or medical doctor. De-prescribing is a critical art.¹⁵ 

The process must be managed gradually and safely with expert guidance. Slowly reducing the dose of antidepressants over time is called tapering. If you haven’t been using antidepressants for very long, this can be done in a couple of simple steps. Long-term use will require more steps and a longer tapering period. 

It can be complicated to decipher withdrawal symptoms from your original condition, or in rare cases; withdrawal may be confused with an emerging and unrelated new health condition. Your medical professional is best placed to understand these complexities.

Also, a chronic disease, such as depression, can be intermittent and highly variable from person to person. There is no simple guide for everyone, and there is always the danger of reoccurrence, even after a solid recovery period and no meds, especially if the root cause hasn’t been unearthed and treated.

CALDA: safe withdrawal from antidepressants

At CALDA, we understand that depression doesn’t come from one simple cause. There is a complex interplay of factors and influences that are responsible for the development of depression. These include other physical illnesses, stress, genetics, neurobiological factors (such as hormone disturbance), trauma, and even other medications.

Depression is also often accompanied by other mental disorders, which can make it difficult for the mainstream medical route to treat. Conventionally, depression and associated mental disorders are treated with psychotherapy and the use of psychotropic drugs.

At CALDA, we do things differently. Wherever possible, we avoid the use of psychotropic drugs. We treat the causes, not the symptoms, and we help you to withdraw from antidepressants safely while supporting your body and mind to heal and restore naturally.

For a discreet, no-obligation chat with our lead psychiatrist, Dr Claudia M. Elsig, please get in touch.

References:

1. Coe A, et al. 27 Feb 2023. Self-reported reasons for reducing or stopping antidepressant medications in primary care: thematic analysis of the diamond longitudinal study. Prim Health Care Res Dev.
2. Bobo WV, et al. 23 Jan 2019. Frequency and predictors of the potential overprescribing of antidepressants in elderly residents of a geographically defined U.S. population. Pharmacol Res Perspect.
3. Mikulic M. 12 Sept 2023. Consumption of antidepressants in selected countries in 2022. Statista.
4. Thomas T. 5 Dec 2023. Experts call for fewer antidepressants to be prescribed in U.K. The Guardian.
5. Penn E, Tracy DK. Oct 2012. The drugs don’t work? antidepressants and the current and future pharmacological management of depression. Ther Adv Psychopharmacol. 2(5):179-88.
6. Kirsch I. 2014. Antidepressants and the Placebo Effect. Z Psychol. 2014;222(3):128-134. 
7. Ibid
8. Müller-Oerlinghausen B, & Abou-Saleh MT. 2 Jul 2019. Alec J. Coppen-A pioneering psychiatrist who discovered the pivotal role of Serotonin in the pathogenesis of depression as well as the antisuicidal effect of lithium. Int J Bipolar Disord.
9. Jauhar S, Cowen PJ, & Browning M. March 2023. Fifty years on: Serotonin and depression. J Psychopharmacol. 2023 Mar;37(3):237-241.
10. Correia AS, Vale N. 31 Jul 2022. Tryptophan Metabolism in Depression: A Narrative Review with a Focus on Serotonin and Kynurenine Pathways. Int J Mol Sci. 23(15):8493.
11. Moncrieff, J., Cooper, R.E., Stockmann, T. et al. 20 Jul 2022. The serotonin theory of depression: a systematic umbrella review of the evidence. Mol Psychiatry 28, 3243–3256 (2023).
12. Horowitz MA, et al. 14 Dec 2022. Estimating Risk of Antidepressant Withdrawal from a Review of Published Data. CNS Drugs. 37(2):143-157.
13. Royal College of Psychiatrists. Mar 2024. Stopping antidepressants.
14. Horowitz MA, et al. 14 Dec 2022. Estimating Risk of Antidepressant Withdrawal from a Review of Published Data. CNS Drugs. 37(2):143-157.
15. Wyelsol, G (advice by Friedman RA, MD). 7 Mar 2024. When can psychiatric drugs be stopped? Answers about ‘de-prescribing.’ The Washington Post.