Safe Deprescribing of Antidepressants

Abstract

There are numerous reasons why stopping antidepressants might be prudent, including harms (for example, emotional numbing, sexual issues, and other physical health consequences) outweighing benefits, use beyond guideline recommendations, and patient preference. Withdrawal effects arise due to adaptation to chronic use of antidepressants – often termed physical dependence, distinct from addiction. Withdrawal effects can manifest as either physical or psychological symptoms and can often be mistaken for a return of an underlying condition or onset of a new physical or mental health condition. The most severe withdrawal effects are suicidality, akathisia and protracted withdrawal syndromes which can last for months or years and can sometimes be debilitating. Careful tapering can minimise these effects. After long‐term use tapering should be gradual (months or years), and adjusted to a rate that the individual can tolerate. Dose reduction should be conducted in a hyperbolic pattern (so that decrements become smaller and smaller as the total dose gets lower) to reflect the hyperbolic relationship between dose and receptor occupancy. In order to facilitate gradual hyperbolic tapering formulations other than widely available tablets will be required, including liquid versions, compounded versions or off‐label use of existing formulations. Switching from one antidepressant to fluoxetine can be problematic. Every‐other‐day dosing for antidepressants other than fluoxetine is likely to lead to withdrawal effects.