Skip to main content

Main menu

  • Home
  • Issues
    • Issue in progress
    • Issues by date
  • Sections
    • Editorial
    • Review
    • Research
    • Commentary
    • Psychopharmacology for the Clinician
    • Letters to the Editor
  • Topic Collections
  • Instructions for Authors
    • Overview for authors
    • Submission checklist
    • Editorial policies
    • Publication fees
    • Submit a manuscript
    • Dr. Francis Wayne Quan Memorial Prize
    • Open access
  • Alerts
    • Email alerts
    • RSS
  • About
    • General information
    • Staff
    • Editorial Board
    • Contact
  • CMAJ JOURNALS
    • CMAJ
    • CMAJ Open
    • CJS
    • JAMC

User menu

Search

  • Advanced search
JPN
  • CMAJ JOURNALS
    • CMAJ
    • CMAJ Open
    • CJS
    • JAMC
JPN

Advanced Search

  • Home
  • Issues
    • Issue in progress
    • Issues by date
  • Sections
    • Editorial
    • Review
    • Research
    • Commentary
    • Psychopharmacology for the Clinician
    • Letters to the Editor
  • Topic Collections
  • Instructions for Authors
    • Overview for authors
    • Submission checklist
    • Editorial policies
    • Publication fees
    • Submit a manuscript
    • Dr. Francis Wayne Quan Memorial Prize
    • Open access
  • Alerts
    • Email alerts
    • RSS
  • About
    • General information
    • Staff
    • Editorial Board
    • Contact
  • Subscribe to our alerts
  • RSS feeds
  • Follow JPN on Twitter
Psychopharmacology for the Clinician

What are the diagnostic criteria, therapy and prophylaxis for discontinuation symptoms due to SSRIs?

Teruhiko Higuchi
J Psychiatry Neurosci March 01, 2004 29 (2) 160;
Teruhiko Higuchi
NCNP Kohnodai Hospital Chiba, Japan
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Responses
  • Metrics
  • PDF
Loading

To date, selective serotonin reuptake inhibitors (SSRIs) have been widely prescribed as therapeutic agents for mood and anxiety disorders. With the expansion of their clinical application, increasing attention is now being paid to discontinuation symptoms. These have been defined (Oliver et al, CNS Drugs 1999;12:171–7) as a collection of signs and symptoms temporally related to the cessation or dose reduction of a drug, in which there is a predictable onset, duration and offset; there are both psychologic and bodily symptoms; and the symptoms were not previously complained of by the patient.

The most common symptoms include dizziness, nausea and vomiting, fatigue, headache, gait instability, insomnia, electric shock-like sensations, and vivid dreams or nightmares.

The symptoms that emerge after discontinuation of SSRIs are also known to occur with tricyclic antidepressants and serotonin norepinephrine reuptake inhibitors (e.g., venlafaxine).

Although no diagnostic criteria have been established for the symptoms that may emerge after discontinuation of SSRIs, Black et al (J Psychiatry Neurosci 2000;25: 255–61) have proposed the following criteria. Criterion A is discontinuation or reduction of the dose of an SSRI after at least 1 month of treatment. Criterion B is the development of 2 or more symptoms such as dizziness or shock-like sensations. Criterion C is the clinically significant nature of the symptoms. Criterion D is the inability to find any cause for the symptoms other than the discontinuation or reduction of the SSRI. Similar criteria have been reported by Haddad (J Psychopharmacology 1998;12:305–13).

The mechanism of onset of discontinuation symptoms has not been clarified. The long-term use of SSRIs is known to decrease the sensitivity of the serotonin autoreceptors or postsynaptic receptors, or to cause downregulation of these receptors. Therefore, it is generally accepted that abrupt discontinuation of SSRI treatment temporarily causes a relative depletion of serotonin in the synaptic cleft (Haddad). Cholinergic rebound theory has been implicated mainly in discontinuation symptoms with tricyclic antidepressants and paroxetine. There are no reports of discontinuation symptoms due to fluoxetine, which is an SSRI with a longer half-life. In the case of sertraline, another SSRI with a longer half-life, the incidence of discontinuation symptoms is low. It is thus thought that discontinuation symptoms do not occur unless the elimination of serotonin from the synapse occurs abruptly. SSRIs that cause discontinuation symptoms relatively easily are those with shorter half-lives, such as paroxetine and fluvoxamine.

Discontinuation symptoms that are mild in severity and bearable will disappear over several days without any treatment. If the symptoms are severe, readministration of the original treatment may be necessary.

The key points are the timing of discontinuation and the method of gradual dose reduction. If any discontinuation symptom occurs, the original treatment should be readministered, and the dose should then be reduced little by little over 1 month. If discontinuation symptoms persist with readministration of an SSRI with a short half-life, it should be replaced gradually by another SSRI with a long half-life. For prophylaxis, it is also important to reduce the dosage gradually, avoiding abrupt discontinuation of the treatment.

Footnotes

  • To submit questions for this regular feature, please send them to the Journal of Psychiatry & Neuroscience/Revue de psychiatrie & de neuroscience, Canadian Medical Association, 1867 Alta Vista Dr., Ottawa ON K1G 3Y6, Canada; fax 613 729-9545; jpn.office{at}sympatico.ca. Please include details of any relevant case and your name, address, telephone and fax numbers as well as your email address.

  • The information in this column is not intended as a definitive treatment strategy but as a suggested approach for clinicians treating patients with similar histories. Individual cases may vary and should be evaluated carefully before treatment is provided.

  • Competing interests: None declared.

PreviousNext
Back to top

In this issue

Journal of Psychiatry and Neuroscience: 29 (2)
J Psychiatry Neurosci
Vol. 29, Issue 2
1 Mar 2004
  • Table of Contents
  • Table of Contents (PDF)
  • Index by author

Article tools

Respond to this article
Print
Download PDF
Article Alerts
To sign up for email alerts or to access your current email alerts, enter your email address below:
Email Article

Thank you for your interest in spreading the word on JPN.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
What are the diagnostic criteria, therapy and prophylaxis for discontinuation symptoms due to SSRIs?
(Your Name) has sent you a message from JPN
(Your Name) thought you would like to see the JPN web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
What are the diagnostic criteria, therapy and prophylaxis for discontinuation symptoms due to SSRIs?
Teruhiko Higuchi
J Psychiatry Neurosci Mar 2004, 29 (2) 160;

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
‍ Request Permissions
Share
What are the diagnostic criteria, therapy and prophylaxis for discontinuation symptoms due to SSRIs?
Teruhiko Higuchi
J Psychiatry Neurosci Mar 2004, 29 (2) 160;
Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

Similar Articles

Content

  • Current issue
  • Past issues
  • Collections
  • Alerts
  • RSS

Authors & Reviewers

  • Overview for Authors
  • Submit a manuscript
  • Manuscript Submission Checklist

About

  • General Information
  • Staff
  • Editorial Board
  • Contact Us
  • Advertising
  • Reprints
  • Copyright and Permissions
  • Accessibility
  • CMA Civility Standards
CMAJ Group

Copyright 2023, CMA Impact Inc. or its licensors. All rights reserved. ISSN 1180-4882.

All editorial matter in JPN represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries.
To receive any of these resources in an accessible format, please contact us at CMAJ Group, 500-1410 Blair Towers Place, Ottawa ON, K1J 9B9; p: 1-888-855-2555; e: [email protected].
View CMA's Accessibility policy.

Powered by HighWire