SSRI Discontinuation Syndrome
SSRI discontinuation syndrome, also known as SSRI withdrawal syndrome or SSRI cessation syndrome, is a withdrawal syndrome that can occur during or following the interruption, lowering of dose or discontinuation of regular SSRI or SNRI antidepressant drug usage. The condition often begins between 24 hours to one week after reduction in dosage or complete discontinuation, depending on the elimination half-life of the drug. The prescribing labels of SSRIs acknowledge the possibility of "intolerable" discontinuation reactions, and some patients have extreme difficulty discontinuing use from SSRI drugs.
Indicators of SSRI discontinuation syndrome
The indicators of SSRI discontinuation syndrome are the following:
Interruption, cessation, or reduction of dosage in an SSRI treatment that has lasted four or more weeks.
Symptoms interfere with normal social, occupational, or other functioning.
Symptoms are not due to another medical condition, drug use, or discontinuation.
Symptoms are not due to a relapse of the condition for which the SSRI was originally prescribed.
History of SSRI discontinuation syndrome
The first report of withdrawal symptoms occurring after SSRI discontinuation was for fluvoxamine (brand names Luvox [US], Faverin [UK]) in 1992. The Committee on Safety of Medicines in the United Kingdom reported withdrawal symptoms involving paroxetine (Paxil, Seroxat) in 1993, and the American Journal of Psychiatry revealed the same for sertraline (Zoloft, Lustral) the following year.
In 1996, Eli Lilly and Company sponsored a symposium to address the increasing number of reports of patients who had difficult symptoms after going off their antidepressants:
By then it had become clear that drug-company estimates that at most a few percent of those who took antidepressants would have a hard time getting off were far too low. Jerrold Rosenbaum and Maurizio Fava, researchers at Massachusetts General Hospital, found that among people getting off antidepressants, anywhere from 20 percent to 80 percent (depending on the drug) suffered what was being called antidepressant withdrawal (but which, after the symposium, was renamed “discontinuation syndrome”).
The World Health Organization (WHO) continues to track withdrawal syndrome, and notes:
SSRIs are an example of how a conceptual confusion over terminology can affect proper reporting, interpretation and communication of adverse drug reactions related to dependence. To avoid the association with dependence, an increasing number of researchers have used a different term, discontinuation syndrome, instead of withdrawal syndrome. The number of hits for discontinuation syndrome in searches of the international medical literature began to increase, relative to the occurrence of withdrawal syndrome, in 1997 after [the Eli Lilly] symposium on antidepressant discontinuation syndrome held in 1996. In fact, dependence syndrome has been reported to the Uppsala Monitoring Centre for all SSRIs through the same postmarketing surveillance systems, although there are significantly fewer reports of dependence syndrome than of withdrawal syndrome.
The same WHO note ranks antidepressants according to withdrawal, with paroxetine having the highest number of withdrawal syndrome reports and fluoxetine the highest number of drug dependence reports; the note concludes, "Three SSRIs are among the 30 highest-ranking drugs in the list of drugs for which drug dependence has ever been reported to the Uppsala Monitoring Centre database; a total of 269 reports had been received as of June 2002 (109 reports for fluoxetine, 91 for paroxetine and 69 for sertraline)."
"Brain zaps" and "electric shock sensations"
Symptoms described as "brain zaps", "brain shocks," "brain shivers" or "head shocks" are a withdrawal symptom experienced during discontinuation (or reduction of dose) of antidepressant drugs. The symptoms are widely variable in description and of unknown etiology; common descriptions include dizziness, electric shock-like sensations, sweating, nausea, insomnia, tremor, confusion, and vertigo. The MedDRA "preferred term" for coding these types of symptoms in adverse drug reaction reports (for use in pharmacovigilance databases such as under the Yellow Card Scheme), is paraesthesia.
In a 1997 survey, a "sizable minority" of medical professionals were not confidently aware of the existence of antidepressant withdrawal symptoms. A 2005 review of adverse event reporting showed that descriptions of "electric shocks" from patients on paroxetine had been reported more frequently than some other symptoms.
Post SSRI sexual dysfunction
Post-SSRI sexual dysfunction (PSSD) is an iatrogenic type of sexual dysfunction caused directly by the previous use of SSRIs. While apparently not uncommon, it can last for months, years, or sometimes indefinitely after the discontinuation of SSRIs; however, these extreme lengths of time are fairly uncommon. It may represent a specific subtype of SSRI discontinuation syndrome.
One or more of the following sexual symptoms persist or begin after the discontinuation of SSRIs:
Decreased or absent libido
Impotence or reduced vaginal lubrication
Difficulty initiating or maintaining an erection or becoming aroused
Persistent sexual arousal syndrome despite absence of desire
Muted, delayed, or absent orgasm (anorgasmia)
Reduced or no experience of pleasure during orgasm (ejaculatory anhedonia)
Premature ejaculation
Weakened penile or clitoral sensitivity
Genital anesthesia
Loss or decreased response to sexual stimuli
Reduced semen volume
Priapism
Definition of withdrawal
The term withdrawal has been used in the past for SSRI discontinuation syndrome; however, according to the pharmaceutical industry discontinuation symptoms and classical drug withdrawal are different. Thus, the use of proper terminology when discussing this phenomenon is still ambiguous. SSRIs are not addictive in the conventional medical use of the word (i.e. animals given free access to the drug do not actively seek it out and do not seek to increase the dose), but suddenly discontinuing their use is known to produce both somatic and psychological symptoms, as described by researchers.
Critics argue that the pharmaceutical industry has a vested interest in creating a distinction between addiction to recreational or illegal drugs and dependence on antidepressants. Arguments against the use of the term 'withdrawal' are primarily predicated on not frightening patients or alienating potential customers who may or may not need the medication. According to the consensus definition by the American Academy of Pain Medicine, withdrawal is a symptom of "Physical Dependence", not of "Addiction" and thus arguments against SSRIs being "addictive" do not clearly make the use of the term "withdrawal" inappropriate to the symptoms caused by ceasing an SSRI.
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