Antidepressant Withdrawal: How Long Can It Last?

Antidepressant Withdrawal: How Long Can It Last?

Background

Antidepressants are psychotropic drugs. When you take a psychotropic drug every day, your brain, nervous system and body gradually adapt over some weeks to the constant influence of the drug (read more about this here). 

Once this adaptation is established, the body moves into a state called physical dependence. In this state a person becomes at risk for the development of withdrawal symptoms if the dosage of the drug is reduced too fast (15).

Withdrawal symptoms demonstrate that the brain, nervous system, and body have become physically dependent on the drug. Physical dependence is not the same as addiction, where the person also craves the drug(17). While antidepressants are not addictive, they do cause dependence(13). 

But what we know about the phases of withdrawal comes from addiction medicine, where psychotropic withdrawal has been more closely studied. Withdrawal is said to occur in an early acute phase starting shortly after stopping the drug, followed by a protracted (lasting for a longer period of time) phase(23).

What is acute withdrawal from antidepressants?

Early in the history of the newer antidepressants, SSRIs were presumed to be different from addictive drugs and old antidepressants in that they did not cause dependence or withdrawal. Eventually, case reports from doctors revealed that people did get withdrawal symptoms when SSRIs were stopped (20,22).

The long lists of symptoms that are the core of what doctors know about antidepressant withdrawal were derived from these clinician observations as well as adverse drug reaction databases and clinical trials. In all these instances, the antidepressant was stopped abruptly or over perhaps a week or two (8).

Once withdrawal from the newer antidepressants was recognized, it was said to be minor and over within a few weeks(24,25). There was no need to define phases of antidepressant withdrawal.

Because these symptoms arise suddenly and dramatically after cessation of the drug, we now recognize and refer to this period of initial, intense antidepressant withdrawal symptoms as acute withdrawal(3,23).

How long does acute withdrawal last?

Across psychotropic drugs, the acute withdrawal phase has been observed to last about 2-3 weeks before it changes into the protracted withdrawal phase. The difference between the two phases is the duration of the symptoms and symptom pattern(15).

Coincidentally, the entire antidepressant withdrawal syndrome was long believed to last only 2-3 weeks (14). It seems likely now that early papers were describing the symptoms of the acute phase, where symptoms sometimes completely resolve, while the protracted withdrawal syndrome that might come afterward went unrecognized (6,10).

What are acute antidepressant withdrawal symptoms?

Although there are dozens of antidepressant withdrawal symptoms, doctors are often taught to recognize only a handful with the simple mnemonic FINISH, devised in 1998 (Berber, 1998):

Flu-like symptoms

Insomnia

Nausea

Imbalance

Sensory disturbances

Hyperarousal (anxiety/agitation) 

This gives doctors a vague but narrow expectation of the  symptoms to look for when their patients go off their drugs. In contrast, a 2019 international survey of 867 patients(21) found their most frequent acute withdrawal symptoms were

• Anxiety/Panic
• Irritability
• Dizziness
• Brain Zaps
• Nightmares
• Nausea

“Brain zaps”, the electrical shock sensation in the head that is perhaps the most recognizable antidepressant withdrawal symptom, does not appear in the early journal articles, but is now known as a hallmark of acute antidepressant withdrawal (7,18).

What is the treatment for acute antidepressant withdrawal?

The only known treatment for acute antidepressant symptoms, which is the period shortly after discontinuation of the drug, is reinstatement of the drug. This should assist nervous system stabilization. After the withdrawal symptoms go away, the person might be able to taper off more gradually(2,27).

What is protracted withdrawal?

Like “acute withdrawal”, the term "protracted withdrawal" has only recently been used in connection with antidepressants, because antidepressant withdrawal has long been assumed to be "time-limited”  to a few weeks(14,24). 

Given this expectation, antidepressant withdrawal symptoms that persist past a short period are often misidentified by doctors and patients as “relapse” rather than protracted withdrawal(12).

However, it has become clear that as with addictive psychotropics, a protracted phase may follow the acute phase of antidepressant withdrawal – a previously unidentified serious risk of antidepressant use. (4,7,9,10).

There is no clear border between acute and post-acute withdrawal syndrome. One authority suggests if withdrawal symptoms last more than 6 weeks, the protracted withdrawal phase has begun(3).

What are the symptoms of protracted withdrawal?

As protracted withdrawal syndrome is essentially a continuation of acute withdrawal syndrome, it encompasses all of the symptoms that can appear in the acute phase. Withdrawal symptoms are known to change throughout both phases, with patients often being able to recognize the difference between symptoms related to withdrawal versus symptoms related to the original psychiatric complaint(3, 10).

A study of protracted antidepressant withdrawal cases reported on an Internet site found these were the most common symptoms, with about ⅔ of the cases having both physical symptoms and emotional symptoms(10):

Anxiety - 53.6%

Depression - 36.3%

Insomnia - 36.2%

Gastrointestinal - 33.3%

Decreased concentration (brain fog) - 26.1%

Brain zaps - 21.8%

Headache - 21.8%

Suicidal thoughts - 20.3%

Muscle aches - 17.3%

Visual - 15.9%

Tremor - 15.9%

Fatigue - 13%

Dizziness - 11.6%

Sweating - 5.8%

Post-antidepressant sexual dysfunction (PSSD) - 2.9%

Psychotropic drugs might differ somewhat among their acute withdrawal symptoms, but protracted withdrawal syndrome tends to have similar features across psychotropics(1,26).

How long does protracted withdrawal from antidepressants last?

Very little investigation has been done into protracted antidepressant withdrawal. One large study in patients who had been on antidepressants for more than a couple of years and then roughly tapered off found a clear increase in withdrawal symptoms a month after stopping antidepressants, with those with withdrawal symptoms continuing after 9 months mostly resolved by 12 months on average (Lewis 2022). 

Evidence extracted from patient narratives on an Internet site suggests that protracted withdrawal in these likely more severe cases tends to resolve in 2-3 years (10). This accords with what is known about protracted withdrawal from addictive drugs (15,16). 

What is the treatment for protracted antidepressant withdrawal?

Protracted withdrawal from antidepressants has only recently been recognized and is poorly understood. Doctors may prescribe many different kinds of drugs to address the wide range of symptoms, but they may or may not have a beneficial effect. Informal patient reports indicate a very low dose reinstatement of the original drug may help. Any drug treatment, though, may make protracted withdrawal syndrome worse, due to accompanying increased neurological sensitivity.  Perhaps the most reliable treatment is to be patient and allow the symptoms to naturally and gradually resolve over time(7).

How to avoid acute or protracted withdrawal syndrome?

It’s important to recognize that all that is known about acute or protracted withdrawal from antidepressants is from people who were abruptly discontinued from their drugs or tapered over only a few weeks. There is evidence that very gradual tapering over months rather than weeks reduces the incidence and severity of acute withdrawal symptoms, and thus protracted withdrawal syndrome as well(12).

Sources:

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