The use of antidepressants in the treatment of depression and a number of other medical conditions is increasingly common. Millions of people in the U.S. alone (as many as 10% of all Americans by some estimates) take antidepressants. By far the most commonly prescribed antidepressants in the general population are selective serotonin reuptake inhibitors, or SSRIs, such as Prozac, Paxil, and Zoloft.
Studies have shown that these drugs can be effective in treating symptoms of chronic fatigue syndrome (CFS) and fibromyalgia (FM), even when patients are not suffering from depression. Medications that act on multiple neurotransmitters, such as venlafaxine (marketed under the brand name Effexor in the U.S.), have been found to be especially helpful in some patients. Given the lack of effective treatments for CFS/FM, antidepressants are often the first line of defense in addressing pain, unrefreshing sleep, “brain fog,” and other symptoms.
Many patients stay on these medications (or switch between several types or brands of antidepressants) for years at a time. However, a lot of patients may consider stopping treatment after a period of time, for a number of reasons. According to Joseph Glenmullen, author of The Antidepressant Solution: A Step-by-Step Guide to Safely Overcoming Antidepressant Withdrawal, Dependence, and ‘Addiction’, “People who want to try going off today’s antidepressants are usually either feeling better and believe they no longer need the drugs, or are having significant side effects.” Others may be concerned about risks associated with long-term use of antidepressants.
While some individuals will be able to discontinue their medication without noticeable difficulty, others are caught off guard when they experience new and distressing symptoms. These symptoms can range from fatigue and irritability to sensory abnormalities and cognitive difficulties. According to a 2005 Newsweek article, as many as 50 percent of people who stop using antidepressants will experience some symptoms of withdrawal.
Antidepressant Withdrawal: An Under-Recognized Problem
Despite the number of people affected, there has been little scientific study of the problem, and many physicians are unaware that for some patients, withdrawal reactions can be severe. In fact, some doctors are baffled when patients come into their offices reporting a wide range of symptoms that run the gamut from physical to psychiatric. Some practitioners may falsely attribute symptoms to CFS/FM or depression. Others may suspect the onset of a new illness, which can lead to unnecessary and costly tests or treatment.
Over the years, antidepressant manufacturers have played down or even denied the problem of withdrawal reactions. While they acknowledge that withdrawal effects are possible, they have claimed that they are rare or that they are usually mild and short-lived if they do occur.
However, many patients tell a different story. Even a cursory search online turns up scores of stories detailing moderate to severe withdrawal reactions, reported on online discussion forums and other websites. In fact, Paxilprogress.org, a website offering advice on how to manage withdrawal from Paxil/paroxetine, receives over 3 million hits each month. In addition to patient stories, a number of articles and websites can be found written by experts who have observed frequent withdrawal problems in their patients, some of them severe. Many of the resources offer useful guidelines on how to address withdrawal reactions.
While the manufacturers of major brands of antidepressants acknowledge the possibility of withdrawal symptoms in the fine print of their product inserts, they downplay these risks. According to Thomas J. Moore, author of the book Prescription for Disaster: Hidden Dangers in Your Medicine Cabinet, the manufacturers of SSRIs assert that withdrawal has not been systematically studied. However, Moore points out, “Few drug companies are likely to volunteer to pay for an expensive study that has a good chance of revealing a new drug hazard.” As a result, patients are left to rely primarily on anecdotal evidence, and they typically do not become aware of this evidence until they go searching for information after experiencing problems themselves.
Experts on antidepressant withdrawal have expressed concern that a substantial proportion of clinicians are uninformed about antidepressant withdrawal reactions. Even doctors who are aware of the risk may not know how significant an impact such a reaction may have, and they typically don’t discuss potential withdrawal reactions with their patients before prescribing antidepressants. The withdrawal process can be so challenging for some individuals that they have difficulty “sticking it out” for the weeks or months that withdrawal symptoms last. Some patients feel they have no alternative but to go back on the drug.
The ‘Addiction’ Controversy & Other Word Games
In his book, Glenmullen describes a patient who complained about a television commercial he saw for Paxil, which depicted tense, sad, anxious people who—after being treated with the antidepressant—are then shown blissfully engaging in a variety of activities with their families. The ad explicitly states “Paxil is non-habit forming.” The patient complained bitterly to Dr. Glenmullen, “How can they get away with that?…I’m sitting there unable to get off Paxil for months watching them advertise it as non-habit forming…” Indeed, patients who know nothing about potential withdrawal symptoms before beginning an antidepressant—and then experience distressing symptoms upon discontinuing treatment—often feel misled and resentful that they were not informed of the risks.
Compounding the problem is semantic confusion about terms like addiction, habit-forming, dependence, and withdrawal. There is controversy in the literature about what constitutes “dependence” or “addiction.” Physical dependence on a drug (needing a drug in order to function) is typically not sufficient to define addiction. Many drugs, including some blood pressure medications, do cause physical dependence in that withdrawal symptoms will occur if the drug is discontinued, but this is said to be different from the classic withdrawal syndrome associated with alcohol or barbiturates. Moreover, antidepressants are not usually termed addictive because they are not linked to drug-seeking behavior and patients don’t develop tolerance—that is, they don’t need increasingly higher doses to achieve the same effect—nor do they exhibit the compulsive need or desire for the drug despite negative consequences, another defining characteristic of addiction.
To a patient trying to discontinue using an antidepressant and having difficulty doing so, however, these distinctions may seem inconsequential. A 1999 article in Drug & Therapeutics Bulletin suggested, “Debate about whether the ‘discontinuation’ syndrome is different from classical ‘withdrawal’ is probably largely a matter of semantics…From the patient’s point of view, however, discontinuation symptoms would be highly important if they resulted in any marked degree of difficulty in stopping the treatment, and might well feel tantamount to dependence.”
In fact, it may be that withdrawal symptoms have an even greater effect on CFS/FM sufferers than the general population, although no scientific study has explored this question. Since it is well-known that CFS/FM sufferers tend to be sensitive to medications, it is quite possible that they would be particularly sensitive to discontinuation as well.