Discontinuing abruptly vs tapering off an SSRI

[DrMetal]

I'm trying to understand when you would taper off an SSRI, vs just stopping it abruptly.

If a patient is on a SSRI and benefiting from it (even a slight benefit), and you decide to switch to something else b/c of a side effect (say sexual dysfunction), you have to add on the new med (say a NDRI) and TAPER OFF the SSRI, right? You would not want to cease the SSRI abruptly, out of concern for rebound depression.

What if the SSRI is not working at all, no benefit? All its doing is causing the side effect (sexual dysfunction). Would you be justified then in stopping the SSRI abruptly, no need to taper right? No such thing as rebound depression, if the depression was never gone in the first place, right?

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[VA Hopeful Dr]

Antidepressant Discontinuation Syndrome

Antidepressant discontinuation syndrome occurs in approximately 20 percent of patients after abrupt discontinuation of an antidepressant medication that was taken for at least six weeks. Typical symptoms of antidepressant discontinuation syndrome include flu-like symptoms, insomnia, nausea...

www.aafp.org

 

[DrMetal]

So always taper, there's never a reason to stop abruptly?

If they're on a zoloft 50 mg, with no benefit to their mood, and significant side effects (sexual dysfunction, GI upset), you wouldn't consider stopping it abruptly to stop the side effects? (sure, run the risk of anti-SSRI syndrome, but maybe better to have that risk, than the bad side effects).

 

[nexus73]

So always taper, there's never a reason to stop abruptly?

If they're on a zoloft 50 mg, with no benefit to their mood, and significant side effects (sexual dysfunction, GI upset), you wouldn't consider stopping it abruptly to stop the side effects? (sure, run the risk of anti-SSRI syndrome, but maybe better to have that risk, than the bad side effects).

50 mg sertraline is a pretty low dose many people could just stop without problems. If they were taking 200 mg a different story... and would likely start something like Wellbutrin (if appropriate) then taper off sertraline over a couple weeks. You can also add Wellbutrin and keep the SSRI and that can help sexual side effects too.

I've never heard of rebound depression from stopping an SSRI...as opposed to rebound psychosis from going cold turkey off something like clozapine.

 

[Stagg737]

So always taper, there's never a reason to stop abruptly?

If they're on a zoloft 50 mg, with no benefit to their mood, and significant side effects (sexual dysfunction, GI upset), you wouldn't consider stopping it abruptly to stop the side effects? (sure, run the risk of anti-SSRI syndrome, but maybe better to have that risk, than the bad side effects).

You can also typically just d/c Prozac since it has such a long half-life. For the more "sensitive" patients I still taper anyway to avoid any nocebo they might complain about.

 

[DrMetal]

You can also typically just d/c Prozac since it has such a long half-life. For the more "sensitive" patients I still taper anyway to avoid any nocebo they might complain about.

Well, that's where it gets confusing. How 'long' enough is a half life, how small enough is a dose, where you can consider abruptly discontinuing instead of tapering? It's hard to taper meds in the outpatient setting, much easier to tell patients to take it or not (that's why we love the prednisone 50 mg x 5 days then stop). And lets face it, if the anti-depressant is causing serious side effects, most patients will self DC it abruptly. How many then present with the anti-SSRI syndrome mentioned in the paper above? I haven't seen it much, hence my inquiry.

 

[VA Hopeful Dr]

Well, that's where it gets confusing. How 'long' enough is a half life, how small enough is a dose, where you can consider abruptly discontinuing instead of tapering? It's hard to taper meds in the outpatient setting, much easier to tell patients to take it or not (that's why we love the prednisone 50 mg x 5 days then stop). And lets face it, if the anti-depressant is causing serious side effects, most patients will self DC it abruptly. How many then present with the anti-SSRI syndrome mentioned in the paper above? I haven't seen it much, hence my inquiry.

I see it frequently. The only one I don't taper at all is Prozac (half life of over a week). The others I taper unless they are on the smallest commercially available dose (zoloft 25, celexa 10, lexapro 5, and so forth). That's likely being over cautious but I'd rather mildly inconvenience 20 patients than have 1 suffer that discontinuation syndrome.

I'm outpatient FM and its not hard to do: Zoloft 25mg, Take 2 tabs daily for 2 weeks then 1 tab daily for 2 weeks #21

 

[nexus73]

Sexual side effects are certainly unwanted, I’d say intolerable, but are they serious?

 

[Mass Effect]

Wait, why would you discontinue an SSRI that is helping because of sexual dysfunction? Just treat the sexual dysfunction. You can augment with Wellbutrin (don't have to discontinue the SSRI) or Viagara or a few other meds depending on what's going on. If the sexual dysfunction doesn't improve, then consider switching, but to switch right off the bat is premature.

 

[Mass Effect]

Well, that's where it gets confusing. How 'long' enough is a half life, how small enough is a dose, where you can consider abruptly discontinuing instead of tapering? It's hard to taper meds in the outpatient setting, much easier to tell patients to take it or not (that's why we love the prednisone 50 mg x 5 days then stop). And lets face it, if the anti-depressant is causing serious side effects, most patients will self DC it abruptly. How many then present with the anti-SSRI syndrome mentioned in the paper above? I haven't seen it much, hence my inquiry.

Tapering is easy outpatient if your patient is cognitively intact. You can write it down for them or put it in the after-visit summary. If your patient is on Zoloft 150 mg, you tell the patient what to do"

Take 100 mg daily for 5 days, then decrease to 50 mg daily for 5 days, then decrease to 25 mg daily and discontinue. I always add if you start to have discontinuation syndrome (which I define and explain), go back up to the next dose and give me a call. So if you're at 50 mg and feel like crap, go back up to 100 mg and call me. Then we go slower. Most patients tolerate a quick taper well, especially if the goal is cross-titration to another serotonergic agent.

You also likely don't need to taper 50 mg of Zoloft. Just d/c it or tell patient to cut it in half for 2 days, then d/c.

 

[DrMetal]

Wait, why would you discontinue an SSRI that is helping because of sexual dysfunction?

You could certainly treat the ED with a viagra. I was just using sexual dysfunction as an example of a side effect.

But in primary care land, conversations often go like this:

Patient: Doc, my dck doesn't get hard since you put me on that zoloft, I'm going to stop it.

Me: No wait, I can put you on a viagra.

Patient: So now you've got me on 2 medications that I don't want to take. Why don't I just stop the original med, the zoloft, that gave me this problem? I don't need it anyway, I'm not that f-ed up. [Not true, he's floridly depressed and borderline, but has no insight.]

Me: [lengthy explanation and counseling, concluding with] I think you should take the zoloft daily as prescribed, and the Viagra prn.
[Patient then goes home and takes neither medication.]

 

[Mass Effect]

You could certainly treat the ED with a viagra. I was just using sexual dysfunction as an example of a side effect.

But in primary care land, conversations often go like this:

Patient: Doc, my dck doesn't get hard since you put me on that zoloft, I'm going to stop it.

Me: No wait, I can put you on a viagra.

Patient: So now you've got me on 2 medications that I don't want to take. Why don't I just stop the original med, the zoloft, that gave me this problem? I don't need it anyway, I'm not that f-ed up. [Not true, he's floridly depressed and borderline, but has no insight.]

Me: [lengthy explanation and counseling, concluding with] I think you should take the zoloft daily as prescribed, and the Viagra prn.
[Patient then goes home and takes neither medication.]

Psych meds are unique in that they take a while to kick in and only work with daily dosing so if he's not excited about taking it, he likely won't, regardless of which med it is. You could switch him to Wellbutrin, but there's no guarantee he'll take that either. But to answer your question, the taper of an SSRI has little to do with the initiation of Wellbutrin, most SSRIs can be tapered relatively easily (Paxil takes longer to taper due to greater risk of symptoms), SNRIs take a while to taper (for the same reason as Paxil).

 

[birchswing]

Psych meds are unique in that they take a while to kick in and only work with daily dosing so if he's not excited about taking it, he likely won't, regardless of which med it is. You could switch him to Wellbutrin, but there's no guarantee he'll take that either. But to answer your question, the taper of an SSRI has little to do with the initiation of Wellbutrin, most SSRIs can be tapered relatively easily (Paxil takes longer to taper due to greater risk of symptoms), SNRIs take a while to taper (for the same reason as Paxil).

I still grouse about a CAP psychiatrist who took me off 20 mg Paxil cold turkey in 2000 and said he had never heard of the symptoms I complained about (brain zaps, vision shifting). Was hellish. I still have brain zaps from time to time and wonder if it's still residual from that, especially after a hot shower or if I have a fever. To this day I call them my Paxil shocks.

 

[splik]

. If the sexual dysfunction doesn't improve, then consider switching, but to switch right off the bat is premature.

Bad-dum Tsh tsh!