Antidepressant withdrawal: reviewing the paper behind the headlines | Hacker News Reader

Antidepressant withdrawal: reviewing the paper behind the headlines

nationalelfservice.net

90 pointsDanBC108 comments

I recently tapered off a dosulepin, a tricyclic antidepressant.

Holy christ, I was not prepared for the 2 weeks of absolute hell that ensued - intense vomiting, headache, small visual and aural hallucinations and malaise like I've never felt before. I barely got out of bed for the first week, and ate nothing. Several times I was on the edge of going to hospital because I felt like I was dying. Honestly, possibly the worst 2 weeks of my life.

I later learned that it seems it's actually well known amongst patients that coming off of antidepressants can cause withdrawals - tricyclics, SSRIs, SNRIs, NRIs, anti-convulsants, all of them.

The thing is, out of ignorance a lot of doctors simply deny it's possible. This kind of thing infuriates me - when doing pharmaceutical trials, the manufacturers must have come across instances of patients going through withdrawals upon cessation, but somehow that information never makes it to the papers, the leaflets or the doctors.

Did you stop cold turkey? Both times I've stopped taking meds I've been instructed to do it gradually.

I tapered off over the course of 1 week, but I'd only been taking it for 4 weeks.

Taping off over 8 weeks or more is much easier. 1 week is just not enough, it's basically cold turkey.

As I said, I'd only been taking them for 4 weeks.

It was also my doctor's advice to do it over 1 week, and I'd come off other tricyclics and NRIs before over the course of 1-2 weeks, so I really had no idea what was coming.

If I ever had to come off anything like this again, I'd absolutely do it over a longer period - but I won't; these kind of drugs haven't help me, and after what I went through I will never take another again.

I agree with what you say. Your doctor didn't give you enough information; then gave you not great advice; then didn't believe you about discontinuation / withdrawal.

It's weird that people are questioning your experience here, because what you describe is sadly a common experience.

Anti-depressant medication does save life, and hopefully doctors are becoming more aware of the withdrawal / discontinuation effects.

I'm consistently amazed at how doctors aren't required - at least in Australia - to talk about side effects or withdrawal symptoms when prescribing medication. I'm capable of googling things, but it shocks me how none of this has ever been discussed with me when getting medication. Pharmacists will ask you questions to determine any contraindications, but I've never been spoken to about withdrawal or side effects. Half the time people find out about them by experiencing them.

I started taking Lexapro a few days ago. My psychiatrist and pharmacist went over all the side effects in great detail, but never once mentioned the possible withdrawal problems. I already knew something of them through a friend who's been through that with Lexapro and other similar drugs, but still—not one word from the "professionals".

(This was in the US)

Another anecdata point (also in the US): My Doctor DID go over the withdrawals with me when prescribing me Lexapro.

Pro-tip: Don't miss a day. :)

Lexapro doesn't have as severe side effects, its one of the new ones that shouldn't kick you round as much. It is still best for them to taper off the end of usage.

Yep, same in the UK - I've spoken with several GPs and consultants across specialisms about dozens of medications I've tried, and not one has ever even mentioned withdrawal symptoms.

When I spoke to my GP after this episode was finally all over, he clearly didn't even understand the mechanisms behind receptor tolerance withdrawals. I know GPs are by "definition jack of all trades", but I was still somewhat shocked.

He also seemed to think I was over-reacting when I told him I wasn't going to try any more NRI-type medications, which suggests he also doesn't even understand how severe withdrawal symptoms can be.

Hope you find a more competent doctor.

I realize I got lucky with my GP here in the States, but he did talk about things with me when I went on phentermine to help with weight loss. All the withdrawal symptoms, why I must stop taking it every three months, etc. He even went over every result in my blood work and thoroughly explained each. I think I was in that appointment for two hours, and it was amazing. I wish more physicians were like him, though I also realize they're pressed for time a lot of times and such, which doesn't help.

This isn't amazing. It is just a matter of priorities. There are many other things that need to be addressed first to ensure the patient gets onto the therapy they need. In my experience counselling people about interventions far more complex and risky than starting an anti-depressant, it is clear that 99% of people don't want a branching tree exploration of every eventuality. They get information fatigue very quickly. Ultimately, there needs to be some trust between doctor and patient for things to function in any real sense. This is why I personally loathe the word 'client' in lieu of patient - it recasts the relationship in harmful terms in my opinion, splitting the therapeutic alliance that should exist into some slightly adversarial union of compliance on the provider's part and due diligence on the client's part.

Well, information overload has never been an issue with my doctors - quite the opposite.

My doctor has no idea how the meds he prescribes me actually work. You talk of information overload, but my doctor provided no information about the meds, their effects, side effects or withdrawals. For one of the tricyclics he said "these will kill you if you take too many", but that has literally been the total information conveyed.

Regardless of information overload, doctors should at least understand the basic mechanics of how the drugs they prescribe actually work, and understand the body's mechanics of tolerance and withdrawal - and be capable of having a brief conversation about them with patients.

I started an SSRI a couple of months ago to help treat major depression and anxiety. My GP went over all of the side effects and potential health risks, timelines, as well as its severe withdrawal symptoms and that if I wanted to stop I should slowly wean off it by lowering the dosage (cutting the pills in half for a while, then quarters, etc). This was in Sydney, so some at least do it :-)

If you can find access to a psychedelic like LSD/mushrooms, it is more likely a far more effective treatment for anxiety & depression than any SSRI's available.

Microdoses can be very effective and a regimen only needs to last a handful of doses and stopping would have very little side effects. As long as authenticity of the substance can be proven, generally psychedelics are very safe, especially at microdose levels.

A little googling for psychedelic + depression will provide data. A couple of research/articles below.

https://journals.sagepub.com/doi/pdf/10.1177/026988111667551...

http://www.biblioteca.cij.gob.mx/Archivos/Materiales_de_cons...

https://www.google.com/amp/s/amp.businessinsider.com/psyched...

Please don’t pretend to be an expert in something like this. These things can be life threatening and you are suggesting using speculative treatments that may or may not work.

> These things can be life threatening

Hallucinogens aren't 'life threatening'

Suicide is, and untreated depression can lead to death by suicide.

"If you can find access to a psychedelic like LSD/mushrooms, it is more likely a far more effective treatment for anxiety & depression than any SSRI's available."

That's a horribly irresponsible thing to say.

Even though psychedelics look like a promising therapeutic regimen to some people, they should be administered in a therapeutic setting with the supervision of a psychiatrist or therapist, in the least.

Given depression patients have limited energy to do anything, the energy reserves would be far better spent in finding a good therapist rather than sourcing illegal substances.

"As long as authenticity of the substance can be proven, generally psychedelics are very safe, especially at microdose levels."

Please stop.

The most important thing a depressed person needs to do, is to find the professionals with whom they can begin the healing process. Finding a good psychiatrist and a cognitive behaviorial psychotherapist would be my first prirorities.

I'm not denying your claims. But most western societies have primary care pathways to deal with depression in a competent and effective way.

This is not a 100% guarantee, like you could give in a trivial medical matter. Mental illnesses can be really difficult - hence you will always find individuals from whom nothing works. But lot of people get help through the "official" methods - hence that should the first strategy for anyone suffering from depression.

Potential downside - the more aware you are of side-effects, the more likely you are to experience them:

> It has been shown that, due to the nocebo effect, warning patients about side effects of drugs can contribute to the causation of such effects, whether the drug is real or not. This effect has been observed in clinical trials: according to a 2013 review, the dropout rate among placebo-treated patients in a meta-analysis of 41 clinical trials of Parkinson's disease treatments was 8.8%.

https://en.wikipedia.org/wiki/Nocebo

In the UK all medication must come with a patient information leaflet, and they usually talk about the side effects that they picked up during testing or (I think) from the Yellow Card scheme.

It's really important that people fill out yellow cards when they experience side effects. I don't know if anything similar exists outside UK: https://yellowcard.mhra.gov.uk/

Thanks for pointing this out, I had no idea about this - I've got a lot of reports to submit!

Tricyclics are the absolute worst. They were the first generation and are very rarely prescribed for their on-label usage anymore because the side effects just aren't worth it. SSRI/SNRIs aren't much better though. Adult use is one thing but giving this stuff to kids is seriously messed up. I was raised on a cocktail of Prozac, Wellbutrin, Lexapro, Cerezone, Zoloft, Depakote, and Vivanse from the age of 9 years old that I am certain caused profound physiological and mental issues to this day, yet they are still pumping kids full of this stuff. We are literally giving pharmaceutical grade meth to kids just because they can't sit still. This has to be the symptom of a sick society.

> They were the first generation and are very rarely prescribed for their on-label usage anymore

Yes, I wasn't taking it for depression, but for chronic neuropathic pain (it didn't work).

I'm on Amitriptyline for pain management. Did you do a hard stop or taper off over the two weeks?

I'd only been taking it for ~4 weeks, then tapered off over 1 week.

A good book to read about this is Lost Connections. It was a really eye-opening look at other methods to treating depression (and really views the increasing rates as an over-diagnosis, such as if grief of a death lasts over a year, as well as a cultural issue). He talks about how over-prescribed anti-depressants are, especially to younger people, as well as withdrawal effects and the fact they barely beat out placebo in clinical trials.

I've been dealing with a severe case of major depression for the last five years. I've been on every class of anti-depressant under the sun, at one time being on five different medications at once. None of it was able to fully lift me out of a depressive episode. ECT (electro-convulsive therapy) was the only thing that was able to bring me back to anything resembling happiness. Lexapro was the sole medication where the benefits outweighed the side effects, so these days I'm just on that and Adderall for ADHD. Those, along with a SAD lamp to help regulate my circadian rhythm throughout the year is much more effective than any other combination I've tried.

Unfortunately, it was hell trying to convince my psychiatrist that I needed to be weaned off the other medications he had put me on. I had to do the research myself on how to safely do it, then weened myself down to just Lexapro and Adderall on my own. He was absolutely shocked when I eventually told him that I'd been on just one antidepressant for four months straight.

If I ever have another severe depressive episode (highly likely), I'm going straight to ECT. I've done two rounds of ECT over that last 3 1/2 years, and it's been two years since my last round. The medication and lifestyle changes I made (again, against doctor recommendation) seems to be working well to keep my mood relatively stable, though I still have relatively minor periods of depression each year that last a few weeks each. The medication cocktails with all of their side effects and withdrawal symptoms just aren't worth it, especially when I get depressed enough that my life is literally on the line.

I recently got put on an tricyclic (1 week in) and this worries me. I suspected withdrawals anyway, but reading this makes me think to stop taking it directly. Thank you.

"but reading this makes me think to stop taking it directly. Thank you."

If you suspect the competence of your primary caretaker to administer an effective therapeutic regimen, (a valid worry) I would find a second opionion from another doctor. But not from an internet forum...

There is a lot of value in reading (a large amount) of anecdotal experiences with withdrawal, as a distressingly large amount of doctors either doesn't remember or for whatever reason doesn't care that it is the case. That being true, it's easy to find yourself in a situation where even your second opinion says that you have nothing to worry about, when in reality you do.

Sure. But I think one of the keys in fighting depression is to find primary caretakers you trust. Healing process is really complex, and the patient-caretaker relationship - especially in mental illnesses - is a non-trivial component.

Hence, it's important you can trust the caretaker.

My advice was given in this context - it's not as important to find a withdrawals symptom expert than it is to find an expert that you can trust.

This is not to belittle withdrawal symptoms, but just to observe that in many cases they are not the most important concern of the parties in the healing process.

The first anti-depressant that worked for me was a tricyclic. When I came off of it, holy God was it bad. I've had a lot of bad withdrawals in my day -- but coming off of Pamelor was maybe the worst.

The pharma trials are a joke. There is pressure on researchers to obtain positive results. Then, pharma companies select which results they want to share. Negative results often go unpublished leaving the doctors and the public uninformed.

https://www.scientificamerican.com/article/trial-sans-error-...

I have done plenty of research on this. I have friends who are pharmacists. Doctors don't like speaking up as it can ruin them. Many of these people have really high debt and simply cannot afford not making $100k+.

This is the real problem. And the consequences are more devastating that most people think. Families and lives destroyed because they don’t understand what they are getting into, and doctors are not much help.

I think you're under estimating just how hard it is to prove that an anti-depressant works. The placebo effect is massive. The tools to measure depression are more qualitative than quantitative. That's why a number of pharma companies have abandoned neuroscience entirely.

Yes, you only need 2 positive phase 3 trials to get your drug approved. Yes, you could have done 10 others and had them fail. Yes, the FDA already knows this.

The FDA is willing to approve drugs for depression with much weaker data than say, cancer, because if they held them to the same standard, no drugs would be approved at all.

> The FDA is willing to approve drugs for depression with much weaker data than say, cancer, because if they held them to the same standard, no drugs would be approved at all.

Then maybe we don't need drugs approved?

A drug that has some evidence it works for some people is better than no drugs at all.

I don't think that's obvious at all.

It will be true some of the time, but there's lots of room for a drug to do more harm than good in that situation.

The problem isn't their effectiveness versus a placebo but patient selection. Each drug helps a small subset of all people due to natural variations in brain chemistry but does nothing or hurts everyone else. Until we have the technology to properly identify which patients qualify for a clinical trial, the option is between letting people suffer without recourse or dealing with follow on problems like overprescribing and addiction.

The FDA knows how much more complex neuroscience is to develop drugs for and has chosen the latter option as an ethical necessity.

I had to try at least a dozen antidepressants to find out that Lexapro was the only one that noticeably worked well enough to be worth the side effects. When my sister started suffering from depression as well, her doctor actually had her ask me about the medications that worked best for my depression. Lexapro ended up being effective for her as well, and she avoided the same process I went through because they were able to use the genetic clues to at least find a good starting point.

I can say with absolute certainty that I would be in a far, far worse position in life without lexapro. Others were far less effective, but it absolutely turned me around.

I'm not totally familiar with the placebo process. Are there anyways you could throw off the process like having the placebo doctors be really mean and the drug doctors be really nice? Is everything completely randomized in terms of people that are taking the drugs? IE if there was a magic formula for determining that an individual is more likely to respond positively to placebos could they pick those people?

Double blinding is supposed to prevent this. Nobody who sees the patient should know which patients are taking the placebo (person A puts either placebos or treatments in bottle X, person B gives patient X the bottle).

Yes, it seems that other people are more susceptible to placebo than others.

It is likely there are portions of the population, who have a better response to a placebo than to the actual drug - but! - the reverse is also a likely scenario. I.e. there are people who don't respond to a placebo and show a strong therapeutic response to an actual drug.

Hence, if one is capable, one should always have an active attitude to ones treatment - what works for someone else, may not work for you, and vice versa.

I hope someone can dig out the reference to this... I read this from a reputable source, but damn if I can remember from where anymore.

What fascinates me is how easy doctors are on the starting but they don't really explain in advance how subtle the ending. Apparently SSRI safe taper off is 10% decrease per period (year, semester, maybe less). That's a very long time to get off them fully. I wish they told me in advance.

If they told you that you wouldn't have taken them.

That's marketing trick, not medical advice.

> The thing is, out of ignorance a lot of doctors simply deny it's possible. This kind of thing infuriates me - when doing pharmaceutical trials, the manufacturers must have come across instances of patients going through withdrawals upon cessation, but somehow that information never makes it to the papers, the leaflets or the doctors.

My take on it: nearly everyone is hyper-focused on abuse of drugs, meaning recreational potential, and it distorts everything else in health care.

We severely overstate the side effects and negative outcomes that occur when a particular drug is used recreationally, and trivialize or ignore those very same side effects and negative outcomes when the exact same drug is used at the same dosage in a medical setting.

And we do that because side effects / negative outcomes have essentially become our way of automatically punishing and imposing a sort of moralistic judgement on people for abusing drugs. If bad things happen after you abuse them, it's your fault and you deserve it. If you weren't doing anything wrong, you don't deserve punishment and therefore those very same side effects somehow won't even happen.

We have so thoroughly conflated "recreational" with "dangerous" and "bad outcome", and especially with the concept of discontinuation symptoms or withdrawal, that the mere intent of the user is effectively being treated as the determining factor for whether something bad will happen, rather than the substance itself.

As a result, even the possibility that those kinds of problems could occur with other medications that have zero recreational potential, is routinely ignored. Those are things that happen when you abuse drugs, not when you take them for medical purposes. After all, you weren't doing anything wrong.

You can see that in action when people have a moderate injury that requires surgery and a lengthy recovery, along with several weeks or months of opioid medication, people who have no real awareness of what physiological opioid dependence is. I personally know people who developed severe withdrawal symptoms after they stopped taking their medication, who were told by their own doctor that they were addicts and must have been doing something wrong, because those symptoms occurred.

And on the flip side I couldn't even count how many people I know who have stopped taking SSRIS or SNRIs, hit an almost immediate wall of insomnia and serious psychological symptoms, and were told that they were imagining it.

Withdrawal is a really crap thing to go through, but I also want to point out that sometimes it can be a fairly non-event, too. I tapered off of Zoloft for weeks, and I really didn’t feel much of a change. Going slow and deliberate (if you have the freedom to do so) will help, as well as having lucky genetics.

I just want to underline that you shouldn’t be turned off to this possible solution because you’re nervous about the side effects or withdrawal. Definitely talk with your doc about them and see if it makes sense to go on them, and if there are ways to mitigate some of the side effects. But meds — in my case, at least — definitely have been some of the best decisions I’ve made in my life.

Exactly. The 1-2 weeks of inconvenience is nothing for some people, specially when the alternative to not taking them is death, in some cases.

It's also much less of a problem because you know the symptoms will go away. Just taper it off slowly (where "slowly" varies a lot, sorry).

Brain zaps lasted for years, we don't always all get so lucky.

Studies have shown that withdrawal and the fact that the first medication often doesn't work are reasons why people don't continue to try to get treatment for depression or anxiety or other problems. As you say, that can be the WORST thing a person can do.

I'm the same as you -- as terrible as some of my withdrawal experiences have been (and they have beent truly heinous), it's better than the alternative. Which is to literally not want to live.

I've been on SSRI for almost 20 years. It stopped working after about 6-7 years and attempted to stop talking it, not cold turkey but by gradually weaning off it. I had such a bad experience that, now I'm still on it. I asked my doctor when I could stop taking it and she recommended me a time in my life when I don't need to come in to work for a couple of good months, basically to take some time off and deal with this. The problem was that I never had that time and life got in the way, got a child now, a wife, and I project that I will postpone getting of it ad infinitum.

I'm on Paxil 20mg, and every once in a while I skip a dose I am reminded of that feeling of melting into a painful death and excruciable headaches, nausea, palpitations, sweating, very comparable with the withdrawals of an opiate addict.

Other than that, after almost 20 years on it, I feel mostly good except for a once a month dip into 1-3 days of flu like simptomps, lethargy, lack of energy that I cure with 2-3 days of sleep. It keeps on repeating around once a month.

I should find time to get off this but am afraid I can't afford at the time such luxury. I have people depending on me...

Hey friend. Sorry to hear about this. It's a real predicament and in your shoes I'd probably do what you are doing. Hope you can find that time.

ANECDOTAL: I went off of the lowest dose (37.5 mg) of Venlafaxine (effexor xr - SNRI) earlier this year. I felt like I was hungover most days, and a general vertigo feeling. It sucked ass, so I reached out to my doctor and he suggested I try to use CBD oil to help with the symptoms.

I tried it and it literally dulled the withdrawal by at least half. It made my days tolerable to the point that I could go to work and function like a human being.

I started taking Lexapro a few days ago and my psychiatrist recommended I also try a CBD vape pen to go along with it, but also mentioned to be careful about sourcing as lots of CBD sources are snake oil.

Does CBD have the same kind of high and anxiety and paranoia as marijuana?

What exactly did the psych recommend it for? Depression?

CBD is not psychoactive. So generally no. However CBD can have THC alongside it, which could have the anxiety/paranoia effects.

CBD actually is the part in the weed that relaxes you and can calm the paranoia/anxiety caused by the THC. If you take a _lot_ of it, you might experience a similar kind of heavy-body type feeling you get with drugs but I wouldn't call it being 'high'.

It's kind of an issue these days because having something that's lower in THC and has CBD in it isn't as marketable as something with higher THC even though it would likely be a more enjoyable and relaxing high for most people. I believe CBD cannibalizes the THC to some degree so generally the higher the THC percentage in the plant the lower the CBD is, and even for someone with lots of experience it will give you more anxiety/paranoia.

In legal recreational marijuana markets, at least, there are often whole sections in stores that are dedicated to stuff that's CBD-only and high-CBD combos (there's some anecdotal evidence that CBD and THC have some kind of synergy that produces better results than pure CBD).

My doctor actually transitioned me to Prozac from Effexor to help with the withdrawal symptoms. After slowly reducing the Effexor dosage to 37.5 mg, I switched to Prozac for a couple of weeks then simply stopped. I still experienced some symptoms but nothing like my previous (failed) attempts to quit.

Aside from the dizziness and head fog, the most unsettling side-effect of Effexor withdrawal was the ease with which I would become very angry... I'm NOT an angry person. At all. Also the... I hesitate to say "suicidal" thoughts because I don't think that's what it was. It was more of an indifference towards whether I lived or died.

After a few months it became clear to me that I still needed something, though nothing as strong as Effexor. Now I'm on a very low dose (10 mg) Lexapro. Combined with regular exercise I seem to have struck the right balance.

Going off Effexor was a nightmare for me. I would never take anything like it again... not worth it.

Stopping Effexor did permanent damage to my nerves. It's been years and I still have symptoms. I will never take an antidepressant again after that.

Effexor is one of the nastiest ones, even when not tapering off of it. A missed dose can mean brain shocks, and withdrawals can mean months of that, sometimes strong enough to knock you down.

I am ever surprised that they continue prescribing that one. Of the 10 I've been on that one was the harshest by far (though many others also had severe, dangerous side effects).

I agree, as I've missed a dose here and there over the years and experienced the intense paresthesia and headaches and nausea from withdrawal.

Background: I've lived my entire adult life (and most of my teens) with severe chronic depression. In my early 20's I started taking pharmaceutical treatment, and once I found the right drug (after trying many over the course of years) my life became manageable. SSRIs helped but I experienced severe nausea on most of them, or worse. It was only when I tried SNRIs like Effexor that things started to get better. YMMV, IANAPsychiatrist, etc, etc.

A few years ago I switched from Effexor to Cymbalta. Same class of drug - The Effexor simply wasn't helping as much as it used to and the switchover was done with a long taper-down and replace period. I even bought a lab-grade scale to measure out the contents of the capsules so I could cross-over smoothly.

All that said, Cymbalta has the same withdrawal effects, on about the same time scale - a single missed dose. But I wouldn't give it up unless something better comes along. I still struggle with my depression and the SNRI is just one tool in my toolbox for managing it.

I have been taking Effexor for more than 10 years. Two years ago I thought it was no longer being effective for me so I tried to taper down and stop taking the mediation. Over a period of weeks I dropped down from 150 mg to 37.5 mg. I could not drop from 37.5 mg - I experienced complete insomnia and terrible anxiety and I started to experience tinnitus. I went back to see a psychiatrist who initially didnt believe that everything I was experiencing was due to withdrawal - I had to fill one of my old scripts and prescribe myself my original dose of Effexor to get back to some semblance of normality. My anxiety and sleep levels returned to normal but although the tinnitus lessened its still there today. I worked with my doctor and eventually decided to increase the Effexor dose and it has helped greatly with my anxiety and depression. Apparently there arent many people who have reported tinnitus as an Effexor sessation side-effect. My doctor says it must just be coincidence - anyone else experience the same thing ? Just a word of caution to anyone thinking of stopping their medication - do it slowly and with the support of a doctor. I thought I knew what I was doing but I probably reduced my dosage too quickly and maybe this ringing in my ears is the price I pay.

I experienced tinnitus when I started either Celexa or Lexapro. It started on the second day. It was pretty bad and I quit it the next day. My doctor said that she had never heard of that happening.

I just quit it (as a migraine prophylactic discontinued to a very delayed onset of lethargy side effects) and had a hell of a hard time explaining to my neurologist about those brain shocks. They were horrible for the first two weeks and so disorienting, and they persisted for well over a month. And that is with severe titrating of dosage to the lowest sold (37.5mg).

I used to err on the side of double-dosing rather than miss a dose if I wasn’t sure, it is an absolute hell of a dependency.

I’ve been off Effexor for almost three years now and I still get shivers when I think about the brain zaps.

I'm on 225mg/day venlafaxine and if I miss a single day i get severe brain zaps, dissociation, exhaustion, etc.. it's hell

Once I ran out and couldn't get a doctors appointment, so ended up going to the hospital and begging them for a packet because I know the withdrawal would just wreck me.

Doctors do a really poor job explaining to patients just how hard it can be to get off of some of these drugs.

Personally it took me over a year to taper off of venlafaxine due to intense discontinuation.

While youre on it at full dose, forgetting to take it even one day is a miserable experience.

I’m currently on day five off my previous antidepressant, Zoloft. (For reference, I’m 23 and weigh ~225 lbs.) Nothing too bad, minus a panic attack last night. I certainly don’t feel “normal”, though— I feel somewhat lightheaded basically constantly, and have been experiencing a strange tingling sensation on my lips. I was taking the lowest dose recommended for adults, 50 mg.

Didn't read the underlying paper, and definitely not a medical expert, but I do wonder how they define "withdrawal?" Is there a standard definition?

If you start taking a drug that modifies how your body works, isn't it logically obvious that if you STOP taking that drug, your body will revert to it's previous state and that state change will likely be negative, therefor you're withdrawaling?

No, this is about withdrawal symptoms. When you stop taking certain pharmaceuticals, you may experience withdrawal symptoms that aren't just a return to how you felt before you started. In the case of antidepressants these symptoms sometimes include dizzyness and nausea.

Withdrawal symptoms come into play in the case of addictions as well. It can be dangerous to suddenly stop taking an addictive substance. You may have heard the phrase "cold turkey": that refers to withdrawal symptoms.

https://en.m.wikipedia.org/wiki/Cold_turkey

The body is not a state machine with trivial logical properties!

Your second paragraph is incorrect. Withdrawal is not an orderly transition to a previous physical state, it's the presence of previously unseen symptoms, typically due to biochemical adaptations to the presence of the foreign substance.

For example, if you drink a lot, some normal neural pathways are repressed by the regular presence of alcohol and your body compensates by increasing the affected neurotransmitters (GABA in this case). As a result, when you stop drinking, you have a corresponding oversupply of GABA, causing the physical symptoms of Delirium Tremens.

I was on Lexapro for 3 years. When I tapered off according to the standard protocol (already in place to avoid withdrawal issues), I experienced debilitating vertigo symptoms and had to change my process from a 2 week reduction to a 3 month process. It was intense.

>your body compensates by increasing the affected neurotransmitters (GABA

>you have a corresponding oversupply of GABA

Isn't it the other way around? I had thought that alcohol was a GABA agonist, so your body adapts to produce less of it. Then when you stop, you're _undersupplied_ which produces the DTs.

Yeah correct, alcohol is technically a positive allosteric modulator of the GABA-A receptors, which means it potentiates the effects of GABA in those receptors. Over time, the receptors downregulate to compensate for being over-stimulated. Upon withdrawal from alcohol, the GABA-A receptors are unable to respond strongly enough to the GABA which exists, so in effect you're undersupplied and that contributes to the DTs. Alcohol is actually a very messy drug that acts on a huge range of receptors but the effect on the GABAergic system is probably the most significant.

SSRI withdrawal can present new symptoms not existing before, such as the feeling of "brain zaps" and body temperature increases, so a friend has described.

The brain zaps are no joke. I was on the lowest dose of lexapro for a year.. as in my 'taper off' schedule was to just start alternating what days I took it and eventually spread it out because I couldn't even step down in dosage size I was on such a low dose.

Static electricity in the brain is a weird and painful experience. That said, it wouldn't stop me from going back on it if I had to.

The on/off taper is the dumbest idea ever, but some psychiatrists don’t know this. It basically puts you on a constant serotonin rollercoaster, thus the awful brain zaps and other side effects.

Lowering the dose one-sixth at a time every four weeks is the right approach. It gives your neurons time to get accustomed to the lowered serotonin levels by slowly increasing the number of available receptors.

This is one of the reasons that Paroxetine comes in both liquid and pill form. The pills are for maintenance and the liquid is for tapering off.

Anecdotal FYI: missing one dose of mirtazapine feels exactly like a moderate hangover the next morning. I would vaguely hypothesize depression accrues in sleep, ethanol is indeed a CNS depressant with long-term effects and missing doses of medications causes much more harm than previously thought.

Also, I had some nasty vestibular dysfunction from withdrawing from vortioxetine... eyes randomly moving around quickly in all directions on their own, limbs twitching randomly, and any horizontal eye movement causing instantaneous nausea/vertigo.

And, I once titrated off mirtazapine and had some serious nausea... recommend ginger and weed.

I'm currently on valdoxan, and have missed a dose once or twice. I was super anxious, but havn't had any withdrawl symptoms. Spoke to my psychiatrist and He said that it should have much lower withdrawl symptoms, but still recommended I taper things off when i come off it in March next year. The symptoms can be all the things the drug is trying to treat if you don't.

I'm taking SSRI:s and going to therapy due to a diagnosed major depressive disorder. I'm feeling a lot better. I have no idea would I have responded equally well with or without SSRI:s, but the most important thing for me is that my symptoms have eased considerably.

I don't really care if there is a withdrawal period at this point. I'm feeling so much better.

Yes. It's really important to remember that many people get their life back through medication and therapy.

Note: Not off-topic but not directly related to this exact article. Just sharing my personal story of withdrawal from an anti-depressant as I am in withdrawal right now. I figure it might be helpful to anyone else about to or in the process of coming off an anti-depressant. Feel free to get in touch if you want to talk outside of HN. See profile.

It has been almost three months since I stopped Sertraline (Zoloft) and it has been hard but I think harder for my wife. I have been a really moody, angry bastard. Withdrawal otherwise hasn't been too bad. Headaches and bowels for the first two weeks or so but nothing awful just unpleasant. I think I am lucky there.

I had been on Sertraline for over 9 years at 200mg/day for most of that. I decided two years ago I was ready to come off them so I spoke with my doctor (UK NHS) and we designed a reduction programme. Initially I had hoped to be off them in ~12 months but with some life events I decided not to "rock the boat" as it were which is why it is one month shy of being two years since I first start to reduce my daily dose.

I was on 25mg/every-other-day when I stopped fully. Things were a little more complicated as I moved to [redacted] in August of this year so I am not under the care of my lovely NHS doctor however we discussed this at length and she and I agreed I should continue with the plan to come off them and I am glad I did. Worst case I would start taking them again (she gave me two months supply before I moved) and make an appointment with a [redacted] doctor.

Anyway I am happy to say so far everything is excellent. I feel much more awake. I am not tired all-the-time. Honestly I hadn't realised just how tired I have felt for the past 9 years. I am not complaining as in many ways Sertraline saved my life, it is just a realisation that in order to get better part of my brain was being kept not-quite-awake-not-quite-asleep.

However the anger has been an issue. And still is an issue. Before needing anti-depressants I was pretty chilled out and on them I was much the same. But now the smallest thing can piss me off like never before. I am aware of this though so I am trying to process the anger rather than explode. Not in a violent way just as a miserable asshole. I know I am a moody bastard at the moment and my wife has been an angel. I know I am not easy to live with at the moment. But I am trying by being acutely aware of my thought patterns and emotions. It is hard to stop myself getting in a serious mood though.

However things are getting better. I don't get in a mood for the whole day because I dropped a fork when loading the dish washer (this seriously happened back in September!). I am getting better at managing when something angers me. I think part of it is a recalibration of how my brain reacts emotional to events.

My doctor did mention the anger issue but put more emphasis on things like headaches, dizzy spells, diarrhoea, etc. and obviously relapse of depression so while I was casually aware anger might be an issue it ended up being much more of an issue than I thought it would be.

As my doctor did not go into much detail over the anger related side-effect I have read up on others personal experiences and it seems it can take up to six months to be "back to normal" (for want of a better term) which is fine. I am already half way :)

I have been keeping an (almost) daily withdrawal journal that I plan to edit and send to my doctor (in the UK). Not sure if she really wants it but maybe it will offer some insight into withdrawal. Who knows but I figure it can't hurt to help. Plus it is quite helpful for me to document it all as I can track the number of "anger events" and I can see a steady downward trend which is extremely reassuring!

Thank you for sharing that. I'm curious if the anger - or what I'd more call as irritability - is in part caused by something else, however where withdrawal is perhaps amplifying it.

Have you ever been tested for food sensitivities? Do you eat wheat? And what may seem like a strange question - do you remember having ear infections as a child, were they painful at all? Likewise, have you had any surgeries or injuries in the last 10 years or prior?

And for a fun question I could ask what your astrological sign is to see if irritability is part of your natural demeanor. :P

Feel free to email me matt@engn.com

Can you explain where you were going with the ear infection question? I had a lot of them as a child, although I've been fine for years now.

Thank you for taking the time to write that up. I transitioned from Zoloft to Valdoxan earlier this year. I was taking Zoloft for a little over a year, up to a 100 mg daily dose. It took me several months to taper off from Zoloft. I remember smoking cigarettes hard and being grumpy and tired. I didn't smoke habitually before taking Zoloft, but it made the brain zaps more manageable.

I guess I never thought the grumpiness was a withdrawal side effect, I thought circumstances could just be better in my life. I was just counting down until I stopped getting brain zaps. I tapered down really slowly. I was down to taking an eighth of a tablet every other day. Trying to stop entirely before that (I.e. Stopping after a fourth of a tablet every other day) led to brain zaps that were just too tiring to deal with.

Yeah brain zaps are pretty nasty. I had them when I first started to reduce the dose. If I remember correctly it was around the 75 to 100mg/day level that I had the worst/most zaps. Felt like a lightning bolt inside my brain followed by the a very uncomfortable warmth moving around inside my head. I got pretty damn concerned about it as it almost felt like my brain was leaking inside and I thought god what if I had a stroke or something?! Very nasty things.

The reason I wrote my comment was because I wanted to mention the anger as part of the withdrawal as it isn't something discussed much by mental health professionals, at least not in my experience. They just briefly say "you might be more easily irritated" or something vague like that. However it was by far the biggest symptom of withdrawal I have experienced and the one that has had the biggest effect not just to me but those around me.

Several times my wife has commented "god you're a moody sod today can't you just keep taking the damn tablets?!" and without realising the anger is a side-effect of coming off the tablets I think it would be very easy to get into the mindset of "hmm maybe I would be better off going back on the tablets" and so they do just that.

I wanted to say that while the anger is frustrating it does get better. Like all withdrawals you need to fight through it.

Yeah I broke up with my (now) ex in that patch. It's been about a month since I took my last Zoloft, so I'm pretty sure I was experiencing that irritability as a withdrawal symptom too... and maybe I still am?

This seems like a more insidious side effect, because it didn't _feel_like a withdrawal symptom, whereas the brain zaps clearly were. I guess I won't ever know for sure if the fights with my ex were because of withdrawal or personality incompatibilities.

When I went off Effexor more than twenty years ago, it was very hard. I had a bad case of the "zaps." It was really disturbing to be walking around just doing ordinary things and, many times a day, be hit with what felt like a sudden electric shock. It lasted for over a month if I recall correctly. And at the time I don't think this effect was well-documented.

I was diagnosed with Major Depression when I was 14 (but I self-diagnosed at age 9 and probably first showed signs at age 6) and over the last ~20 years have had the distinct displeasure of trying dozens of different types of antidepressants over the years, with varrying levels of withdrawal.

I can't remember the name of the first anti-depressant I ever took -- but I do remember the migraine headache so bad it woke me from sleep and the inability to open my eyes -- and when I was able to open my eyes, the inability to see anything but black splotches because the pain was so intense.

And I remember the first real withdrawal I had, when coming off of Paxil. I was 14 and I was hot and cold at the same time, nauseated, and utterly unwell.

Most of the time, my withdrawals were staged and designed to taper off -- but that didn't make them all go away. Some drugs didn't have any withdrawal symptoms at all -- though in my teenage years as I searched for a workable medication, that was more often than not NOT that case.

There were drugs that had short half-lives (Effexor being one), where I would start to feel the symptoms of withdrawal if I took a pill even an hour or two later than expected. There were others that would sink in only after a day or two, but be truly terrible.

As a teenager and then college student, withdrawals were terrible -- but in some ways, survivable. I missed six and a half weeks of school my sophomore year of high school because of acute depresssion (which was most certainly not helped by the various withdrawals and side-effects of the drugs my various psychiatrists were trying on me) and had to take time off in college too. But at least I had that luxury.

Four years ago, I got into a depression, and stupidly stopped talking to my shrink, and let my medication prescriptions lapse. I had to go through cold-turkey Effexor withdrawal, and aside from being 21 and coming off of a tricylic, it was the worst experience of my life. But this time, I didn't have the luxury of taking time off of school. I had to go into work each day.

Last year, when I reconnected with my shrink and got back on meds, he was legitimately shocked I got through the withdrawal. In retrospect, I am too. I had a boss who was not understanding (I was told "everyone has problems") and clinicians have compared the type of withdrawal I was going through with opiates or cocaine detox.

I went back on the Effexor last year but earlier this year, decided to switch to something else. It took MONTHS to actually come off of it -- even at its lowest dose. I honestly cannot believe I did it cold-turkey last time.

The worst part? As terrible as the withdrawal is and can be -- for me, it's still better than the alternative -- which is not be on a medication that works and to suffer a debilitating depression, which is honestly, even worse.

Thank you for sharing that. I feel it's important more people share their stories. I am planning to write a book to share my experiences including the solutions I found that helped me, the problems with the healthcare system that I have encountered along the way, and my proposed solutions for that as well.

I am grateful to be able to say I survived and learned my lesson regarding medications in my early 20s (35 now), after an SSRI caused me to develop severe hyperacusis (hypersensitivity to sound) - where I could hear at -14 Dbs at different frequencies, could hear through a soundproof sound room, etc. I was in what I considered a torture state for 8 months, after which I had years of post-traumatic stress from the experience to try to deal with - which is mostly what got me into yoga.

Prior to that a different medication had given me intense burning sensation through my body, however the doctor to counter that (not believing me either) just put me on 4mg of benzodiazepine per day - which eventually the burning sensation caught up and surpassed the numbing of the benzos. I had other very negative experiences from medications. They all made everything worse - with doctors not listening, while essentially lying and continuing the medication experiment on me - until I stopped trusting doctors. There is a very real problem of indoctrination and of industrial complex influencing the healthcare system including inherently being integrated into the education system.

The first medication I was put on was at 17, it's always shocking to hear about children and young teenagers being medicated - and I know it's common that medications are the first thing tried without even much basic testing other than to do blood work to see if nutrient levels et al are within a normal range.

I have a complex history more than relating to depression. I had been diagnosed with depression - though I later learned from my own research and seeking answers/solutions - my depression was caused by a disconnect to emotion/a developmental block likely caused by painful childhood ear infections, and that was only unblocked through a sound therapy called Auditory Integration Training; at 1,000 Hz frequency if a person has an imbalance showing there then they 100% will be depressed: medication won't help them, talk therapy won't help - they're just stuck in that state. There's a book called "Hearing Equals Behaviour: Updated and Expanded" that shares the science, case studies, research on it all. The neat part is you can do a diagnostic through an audiogram and get concrete evidence of the imbalance before actually doing the sound therapy - and it's non-invasive and it will help development continue properly for at least 6 months - so you continue to get improvement.

There were also food sensitivity issues that caused some of my problems, one of those foods being wheat - where interestingly there is also an association to wheat and ear infections. Wheat fully acts like an opiate for me, where if I had even a single slice of bread made with wheat within 20 minutes I'd start to feel relaxed/almost euphoric - and then within 45 minutes I'd start going through withdrawal, irritated/irritable; imagine eating wheat (hits of an opiate) 2-3 times per day during your body-brain development, and how that could impact development of your nervous system/brain. It was in fact the audiologist who helped me with the hyperacusis who told me to stop eating wheat, and so eventually once I was healthy enough and not eating it - I could really notice the impact of when I would accidentally eat it.

My journey of pain and suffering unfortunately didn't end there though with medications. Fast forward to about 3 years ago, skipping plenty of details: as I did more and more holistic health practices I eventually stumbled into Ayahuasca ceremonies. Ayahuasca is considered a plant medicine and my overall experience is that it is healing. Many people describe a single ceremony as to being the equivalent to 100 therapy sessions - for how much emotion you process in a single night, the insights you can gain about yourself, your environment, the universe; Ayahuasca's main mechanism is breaking down the ego mind, meaning that it can breakdown layers of coping - suppressed/repressed memories - while having you in an environment and state that allows you to process those emotions/experiences that at the time of the suppression/repression the person wasn't able to process them for whatever reason. I had emotional benefit from the ceremonies - among giving me clarity on , unfortunately I wasn't only exposed to emotional pain - however I was also exposed to physical pain from a series of old injuries throughout my life - starting at the age of 5 or 6.

The past few years I have been slowly healing the pain mostly through stem cell injections. It's been a slow process for a few reasons, partly that regenerative medicine is relatively new - and because my case seems to be quite unique and how debilitating/disruptive the amount of physical pain I had severely impacted my executive function. I'm normally in Toronto and area, though currently in San Francisco to pass some time and be in a warmer climate, needing to wait another 2 months for the next stem cell treatment in Colorado; it's hard to quantify though the last treatment I had ~2 months ago reduced the pain overall by ~60%.

It looks like we already follow each other on Twitter - can't remember where we know each other - maybe through AVC or where we would have met? I remember your name though! Maybe it was at a Mashable conference many years back..

anecdotal counterpoint to the anecdotal issues: I've tapered off Prozac, Wellbutrin, and 1 other SSRI without problem.

Age, dose, length of time on it, the person's natural sensitivity level, and other factors will certainly factor into how a person responds to getting off of a medication.

I was on flux. Then i dropped it and started taking withania somniferia 500mg. I've nearly same effect.

For others reading this, you probably know this as ashwagandha.

Fascinating to see the difference between English and Chinese wikipedia content on this species.

Another really scary thing about SSRI usage is post-SSRI sexual dysfunction (PSSD). It can be permanent. Google that and read, it's a nightmare.

I suggest searching for a phage that infects this bacterium.

Reply on news.ycombinator.com