New year’s resolutions and the avoidance of cold turkey – how to stop SSRI’s in primary care.

It’s the first week of January, and for most of us, that means back to reality and back to the coal face, hopefully after a bit of festive rest and relaxation. For me, it’s also meant Janet, a middle-aged lady who has been taking sertraline for over 5 years, is now my third patient of the week wanting to stop her SSRI. This is probably unsurprising given recent increases in prescribing; nearly 20% of our patients are receiving antidepressant medications annually, with around half classed as long-term users. 

Side effects are common with these drugs, there are both human and economic costs to unnecessary antidepressant use, and NICE’s 2022 NG222 guidelines puts much greater emphasis on non-pharmacological interventions for depression . But what about our patients like Janet, already on these medications who are keen and suitable to stop? 

First up, withdrawal symptoms. Forewarned is forearmed! 

Recent qualitiative research in the BJGP has shown that patients are often unaware how common withdrawal symptoms are and want more information about them. The DTB recognises withdrawal symptoms affect large numbers of patients and can be severe and long lasting, and NICE are certainly much more explicit about them in their updated guidance. The Royal College of Psychiatry has produced a helpful table of potential withdrawal symptoms including physical, sleep and emotional symptoms, which is well worth sharing with our patients so they know what to expect. 

What do we do to get started? 

Unfortunately, there’s no one size fits all approach, but flexibility is key. Don’t suggest your patient goes ‘cold turkey’ (however festive it may sound) – abruptly stopping medication is likely to end in tears and slowly reducing the dose is much more likely to be successful. How to taper the drug will depend on how long the patient has been taking their medication, which drug they’re on, what dose, whether they get any withdrawal symptoms or have had them in the past. 

Hyperbolic tapering (no, the patients in the BJGP study didn’t understand this term either!) is the process where the drug is reduced in progressively smaller amounts, to minimise withdrawal symptoms. This reflects the fact that at lower doses, even small changes to the dose can cause a big change in serotonin receptor occupancy, and hence cause withdrawal symptoms. To avoid this, tapering by a proportion of the previous dose (e.g. 25% reduction in dose) rather than by an absolute amount (e.g. a 50mg reduction) is recommended by both NICE and the RCPsych. This should take place over months rather than weeks, and liquid preparations may be needed to enable this at lower doses. Fluoxetine has the longest half-life so is the only drug where skipping doses is an option for tapering, for other medications this just leads to fluctuations in drug levels and a higher risk of withdrawal symptoms. The RCP provides helpful tapering plans to get started, but if you’re struggling, stick with the mantra ‘go slow and be flexible’. Making sure any withdrawal effects have resolved before making another dose reduction and allowing yourself to be patient led will increase their chances of success.

How do we differentiate between withdrawal and relapse? Timing is key.

Depending on the half life of the drug, withdrawal typically begins within days of stopping, and reintroduction rapidly reduces the intensity and severity of withdrawal symptoms. By contrast, relapse tends to take longer, and core symptoms of a relapse will usually take weeks to improve if the drug is reintroduced. Identifying physical symptoms of withdrawal that are unlikely to be due to relapse (such as nausea, muscle pain or ‘electric shocks’) can also be useful, as is a patient telling you ‘this doesn’t feel like my depression…’. 

What about managing withdrawal symptoms if they do occur?

This is covered in this brilliant, primary care focussed article in the BJGP. Tapering should be slowed down with smaller reductions occurring over a longer period of time, and positive coping strategies should be discussed (such as exercise, sleep hygiene and mindfulness). Acknowledging how debilitating withdrawal symptoms can be is important, as is reassuring our patients that getting withdrawal symptoms does not mean they can't stop their antidepressant, it may just take them a bit longer to get there. Really useful information for patients can be found here. 

If you’re keen to learn more to support your patients like Janet, Siobhan covers SSRI withdrawal alongside her other fantastic ‘top tips’ for prescribing in depression as part of the Hot Topics Mental Health for Primary Care course. It’s available now on demand, or join live on 10^th February for the brand new 2024 Mental Health course.