Antidepressants

Authored by Dr Gurvinder Rull, 09 Aug 2017

Patient is a certified member of
The Information Standard

Reviewed by:
Dr John Cox, 09 Aug 2017

What are tricyclic antidepressants?

Tricyclic antidepressants are used to treat depression and some other conditions. They often take 2-4 weeks to work fully. A normal course of antidepressants lasts at least six months after symptoms have eased. Side-effects may occur but are often minor and may ease off. At the end of a course of treatment, you should gradually reduce the dose before stopping completely.

Tricyclic antidepressants are not just for depression

Tricyclic antidepressants are used to treat depression. They are also used to treat some other conditions such as migraine, panic disorder, obsessive-compulsive disorder, recurrent headaches, and some forms of pain. The word tricyclic refers to the chemical structure of the medicine.

How do tricyclic antidepressants work?

Tricyclic antidepressants alter the balance of some chemicals in the brain, called neurotransmitters. An imbalance of the neurotransmitters is thought to play a part in causing depression and other conditions. Tricyclic antidepressants generally block the effects of two neurotransmitters called serotonin and noradrenaline (norepinephrine). The role these chemicals have in causing, or treating, depression is unclear.

How effective are tricyclic antidepressants?

About 5-7 in 10 people with moderate or severe depression have an improvement in symptoms within a few weeks of starting treatment with an antidepressant. However, up to 3 in 10 people improve with dummy tablets (placebos), as some people would have improved in this time naturally. So, if you have depression, you are roughly twice as likely to improve with an antidepressant compared with taking no treatment. However, they do not work in everybody. As a rule, the more severe the depression, the greater the chance that an antidepressant will work well.

Note: antidepressants do not necessarily make sad people happy. The word 'depressed' is often used when people really mean sad, fed up, or unhappy. True depression is different to unhappiness and has persistent symptoms (which often include persistent sadness). 

The success rate of tricyclic antidepressants can vary when used to treat the other conditions (migraine, panic disorder, obsessive-compulsive disorder, recurrent headaches and some forms of pain).

How quickly do tricyclic antidepressants work?

Some people notice an improvement within a few days of starting treatment. However, an antidepressant often takes 2-4 weeks to build up its effect and work fully. Some people stop treatment after a week or so thinking it is not helping. It is best to wait for 3-4 weeks before deciding if an antidepressant is helping or not. If poor sleep is a symptom of the depression, it is often helped first, within a week or so.

With some types of tricyclic antidepressant, the initial dose that is started is often small and is increased gradually to a full dose. (One problem that sometimes occurs is that some people remain on the initial dose which is often too low to work fully.)

If you find that the treatment is helpful after 3-4 weeks, it is usual to continue. A normal course of antidepressants lasts at least six months after symptoms have eased. If you stop the medicine too soon, your symptoms may rapidly return. Some people with recurrent depression are advised to take longer courses of treatment (up to two years or longer).

When you are taking tricyclic antidepressants

It is important to take the medication each day at the dose prescribed. Do not stop taking it abruptly. This is because you may develop some withdrawal symptoms. The dose is usually gradually reduced before stopping completely at the end of a course of treatment. But don't do this yourself - your doctor will advise on dosage reduction when the time comes. It is best not to stop treatment or change the dose without consulting a doctor.

Are there different types of tricyclic antidepressants?

There are several different types. The ones used in the UK include imipramine, amitriptyline, doxepin, mianserintrazodone, and lofepramine. Each of these comes in different brand names.

There is no best type that suits everyone. A doctor makes a judgement as to which one would best suit, taking into account things such as:

  • Your age.
  • Other medicines that you may take.
  • Other medical problems.
  • Possible side-effects.
  • Previous use of antidepressants.

If the one chosen does not suit, it is sometimes necessary to change the dose, or change the preparation. Also, if tricyclic antidepressants do not help then another type of antidepressant may be advised.

What about side-effects and risks?

Most people have either minor, or no, side-effects. Possible side-effects vary between different preparations. The leaflet that comes in the medicine packet gives a full list of possible side-effects. You should read this before you start taking the medicine. It is beyond the scope of this leaflet to list all side-effects; however, the following highlights some of the more common or serious ones. As a rule, tell your doctor if a side-effect persists or is troublesome. Your doctor can advise on the best course of action - for example, to stop the medication, a switch to a different medicine, etc.

The most common side-effects

These include a dry mouth, constipation, sweating, slight hesitancy in passing urine and slight blurring of vision. It is worth keeping on with treatment if these side-effects are mild at first. Minor side-effects may wear off after a week or so. Frequent drinks of water will help a dry mouth. Also, some people find that sucking pineapple chunks helps with the flow of saliva and helps to ease the feeling of dry mouth.

A possible sedating effect

Tricyclic antidepressants can cause drowsiness (a sedating effect) in some people. You must be aware of this possibility, especially if you are a driver, as it may impair your ability to drive safely. Any sedating effect is likely to be greatest in the first month of starting treatment, or on increasing the dose. The Driver and Vehicle Licensing Agency (DVLA) advises that you should not drive during this time if you feel that you are drowsy or sedated at all. Also, do not operate machinery if you feel drowsy.

Small increased risk of fractures

Research studies suggest that there is a small increased risk of fractures in people taking tricyclic antidepressants. However, the reason for this increased risk is not clear.

Antidepressants and suicidal behaviour

In recent years there have been some case reports which claim a link between taking antidepressants and feeling suicidal, particularly in teenagers and young adults. This may be more of a risk in the first few weeks of starting medication or after a dose increase. It is debatable whether this possible risk is due to the medicine or to the depression. If it is due to the medication then the risk remains very small. And, overall, the most effective way to prevent suicidal thoughts and acts is to treat depression. However, because of this possible link, see your doctor promptly if you become increasingly restless, anxious or agitated, or if you have any suicidal thoughts. In particular, if these develop in the early stages of treatment or following an increase in dose.

Sexual problems

Problems with sexual function are a common symptom of depression. However, in addition to this, all antidepressants may cause some problems with sexual function. For example, decreased sex drive (libido), difficulty getting an erection, delayed orgasm, and impaired ejaculation have been reported as side-effects in some people taking tricyclic antidepressants.

Are tricyclic antidepressants addictive?

Tricyclic antidepressants are not tranquillisers and are not thought to be addictive. Most people can stop tricyclic antidepressants without any problem. At the end of a course of treatment it is usual to reduce the dose gradually over about four weeks before finally stopping. This is because some people develop withdrawal symptoms if an antidepressant is stopped abruptly. If you have withdrawal symptoms it does not mean that you are addicted to the medicine, as other features of addiction, such as cravings for the medicine, do not occur.

Withdrawal symptoms that may occur include:

  • Dizziness
  • Anxiety and agitation
  • Sleep disturbance
  • Flu-like symptoms
  • Diarrhoea
  • Tummy (abdominal) cramps
  • Pins and needles
  • Mood swings
  • Feeling sick (nauseated)
  • Low mood

These symptoms are unlikely to occur if you reduce the dose gradually. If withdrawal symptoms do occur, they will usually last less than two weeks. An option if they do occur is to restart the medicine and reduce the dose even more slowly.

What are selective serotonin reuptake inhibitor antidepressants?

Selective serotonin reuptake inhibitor (SSRI) antidepressants are used to treat depression and some other conditions. They can take 6-8 weeks to build up their effect to work fully. A normal course of antidepressants lasts at least six months after symptoms have eased. Side-effects may occur but are often minor. At the end of a course of treatment, you should gradually reduce the dose, as directed by your doctor, before stopping completely.

Are SSRI antidepressants used just for depression?

SSRIs are a group of antidepressant medicines that are used to treat depression. They are also used to treat some other conditions such as bulimia nervosa, panic disorder and obsessive-compulsive disorder.

How do SSRI antidepressants work?

Antidepressants alter the balance of some of the chemicals in the brain (neurotransmitters). SSRI antidepressants mainly affect a neurotransmitter called serotonin.

How effective are SSRI antidepressants?

About 5-7 in 10 people with moderate or severe depression have an improvement in symptoms within a few weeks of starting treatment with an antidepressant. However, up to 3 in 10 people improve with dummy tablets (placebos), as some people would have improved in this time naturally. So, if you have depression, you are roughly twice as likely to improve with an antidepressant compared with taking no treatment. But, they do not work in everybody. As a rule, the more severe the depression, the greater the chance that an antidepressant will work well.

Note: antidepressants do not necessarily make sad people happy. The word 'depressed' is often used when people really mean sad, fed-up, or unhappy. True depression is different to unhappiness and has persistent symptoms (which often include persistent sadness).

The success rate of SSRI antidepressants can vary when used to treat the other conditions listed above (bulimia, panic disorder and obsessive-compulsive disorder).

How quickly do SSRI antidepressants work?

Some people notice an improvement within a few days of starting treatment. However, an antidepressant often takes 6-8 weeks to build up its effect and work fully. Some people stop treatment after a week or so, thinking it is not helping. It is best to wait for 3-4 weeks before deciding if treatment with an SSRI is helping or not.

If you find that the treatment is helpful after 3-4 weeks, it is usual to continue. A normal course of antidepressants lasts at least six months after symptoms have eased. If you stop the medicine too soon, your symptoms may rapidly return. Some people with recurrent depression are advised to take longer courses of treatment (up to two years or longer).

When you are taking SSRI antidepressants it is important to take the medication each day at the dose prescribed. Do not stop taking an SSRI medicine abruptly. This is because you may develop some withdrawal symptoms. The dose is usually gradually reduced before being stopped completely at the end of a course of treatment. But don't do this yourself - your doctor will advise on dosage reduction when the time comes. It is best not to stop treatment or change the dose without consulting a doctor.

Are there different types of SSRI antidepressants?

There are several different types. They include citalopram, escitalopram, fluoxetine, paroxetineand sertraline. Each of these comes in different brand names. There is no best type that suits everyone. If the one chosen does not suit, it is sometimes necessary to change the dose, or change the preparation. Your doctor will advise. Also, if SSRI antidepressants do not help then another type of antidepressant may be advised.

What about side-effects and risks?

Most people have either minor, or no, side-effects. Possible side-effects vary between different preparations. The leaflet that comes in the medicine packet gives a full list of possible side-effects. You should read this before you start taking the medicine. It is beyond the scope of this leaflet to list all side-effects; however, the following highlights some of the more common or serious ones.

As a rule, tell your doctor if a side-effect persists or is troublesome. Your doctor can advise on the best course of action - for example, to stop the medication, or a switch to a different medicine, etc.

The most common side-effects

These include diarrhoea, feeling sick (nauseated), being sick (vomiting) and headaches. It is worth keeping on with treatment if these side-effects are mild at first as they may wear off after a week or so.

A possible sedating effect

SSRIs can cause drowsiness (a sedating effect) in some people. This side-effect is not common and is not as much of a problem as with some other types of antidepressants. However, you must be aware of the possibility, especially if you are a driver, as it may impair your ability to drive safely. Any sedative effect is likely to be greatest in the first month of starting treatment, or on increasing the dose. The Driver and Vehicle Licensing Agency (DVLA) advises that you should not drive during this time if you feel that you are drowsy or sedated at all.

Bleeding into the gut

Some research has suggested that SSRIs may be associated with a small increased risk of bleeding into the gut; however, the evidence is inconclusive. This is especially in older people and in people taking other medicines that have the potential to damage the lining of the gut or interfere with clotting. Therefore, ideally, SSRIs should be avoided if you take aspirin, warfarin, novel anticoagulants (apixaban, edoxaban, dabigatran and rivaroxaban) or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. If no suitable alternative to an SSRI can be found and you have an increased risk of bleeding, your doctor may advise that you take an additional medicine. This will help to protect the lining of the gut.

Small increased risk of fractures

Research studies suggest that there is a small increased risk of fractures in people taking an SSRI. However, the reason for this increased risk is not clear.

Nervous system side-effects

Dizziness, agitation, anxiety, difficulty sleeping and tremor have all been reported as possible side-effects.

Sexual problems

Problems with sexual function are a common symptom of depression. However, in addition to this, all antidepressants may cause some problems with sexual function. For example, problems getting an erection, vaginal dryness and decreased sex drive have been reported as side-effects in some people.

Antidepressants and suicidal behaviour

In recent years there have been some case reports which claim a link between taking antidepressants and feeling suicidal, particularly in teenagers and young adults. This may be more of a risk in the first few weeks of starting medication or after a dose increase. It is debatable whether this possible risk is due to the medicine or to the depression. If it is due to the medication then the risk remains very small. And, overall, the most effective way to prevent suicidal thoughts and acts is to treat depression. However, because of this possible link, see your doctor promptly if you become increasingly restless, anxious or agitated, or if you have any suicidal thoughts. In particular, you should speak with your doctor if these develop in the early stages of treatment or following an increase in dose.

Are SSRI antidepressants addictive?

SSRIs are not tranquillisers, and are not thought to be addictive. Most people can stop an SSRI without any problem. At the end of a course of treatment you should reduce the dose gradually over about four weeks before finally stopping. This is because some people develop withdrawal symptoms if the medication is stopped abruptly. If you have withdrawal symptoms it does not mean that you are addicted to the medicine, as other features of addiction such as cravings for the medicine do not occur.

Withdrawal symptoms that may occur include:

  • Dizziness
  • Anxiety and agitation
  • Sleep disturbance
  • Flu-like symptoms
  • Diarrhoea
  • Tummy (abdominal) cramps
  • Pins and needles
  • Mood swings
  • Feeling sick (nauseated)
  • Low mood

These symptoms are unlikely to occur if you reduce the dose gradually. If withdrawal symptoms do occur, they will usually last less than two weeks. An option if they do occur is to restart the drug and reduce the dose even more slowly.

Monoamine-oxidase inhibitor antidepressants

Monoamine-oxidase inhibitor (MAOI) antidepressants are a group of medicines that are used to treat depression. They can take up to three weeks to build up their effect to work fully. A normal course of antidepressants lasts at least six months after symptoms ease. You cannot drink alcohol or eat food that contains tyramine (for example, cheese, liver, yoghurt or Marmite®) while you are taking an MAOI. You cannot take some cough and cold medicines while you are taking an MAOI.

How do MAOI antidepressants work?

Antidepressants alter the balance of some of the chemicals in the brain (neurotransmitters). MAOI antidepressants prevent the breakdown of neurotransmitters such as noradrenaline (norepinephrine) and serotonin. An altered balance of serotonin and other neurotransmitters such as noradrenaline is thought to play a part in causing depression.

When are MAOI antidepressants usually prescribed?

MAOI antidepressants are usually prescribed when several of the newer types of antidepressants have been tried but have not worked so well, or caused troublesome side-effects. Some examples of newer types of antidepressant are fluoxetine, citalopram and sertraline. An MAOI may also be used if you have atypical depression. Atypical depression is a type of depression in which there are specific features not present in other types of depression. Examples of these include an improvement in mood if something good happens in your life, excessive sleepiness and a heavy feeling in the arms or legs.

MAOI antidepressants are normally prescribed or recommended by doctors who specialise in treating depression. For example, a consultant in mental health, or a GP who has a lot of experience of treating people with depression.

Most people who take antidepressants find that the newer types are easier to take because:

  • They have fewer side-effects and drug interactions.
  • You don't have to avoid certain foods or drinks that contain tyramine or cough and cold medicines.

How well do MAOI antidepressants work?

About 5-7 in 10 people with moderate or severe depression have an improvement in symptoms within a few weeks of starting treatment with an antidepressant. However, up to 3 in 10 people improve with dummy tablets (placebo), as some people would have improved in this time naturally. So, if you have depression, you are roughly twice as likely to improve with an antidepressant compared with taking no treatment. But, they do not work in everybody. As a rule, the more severe the depression, the greater the chance that an antidepressant will work well.

Note: antidepressants do not necessarily make sad people happy. The word depressed is often used when people really mean sad, fed-up, or unhappy. True depression is different to unhappiness and has persistent symptoms (which often include persistent sadness). 

How quickly do MAOI antidepressants work?

Some people notice an improvement within a few days of starting treatment. However, it may take up to three weeks or more to build up its effect and work fully. Some people stop treatment after a week or so thinking it is not helping. It is best to wait for 3-4 weeks before deciding if an antidepressant is helping or not. If poor sleep is a symptom of the depression, it is often helped first, within a week or so.

When taking MAOI antidepressants

Some important considerations are:

  • Do not eat foods or drinks that contain tyramine.
  • Do not take certain other medicines.
  • Carry a special card at all times.
  • Rules when switching to other antidepressants.

Avoid tyramine

Do not eat food or drinks that contain tyramine (including alcoholic drinks) because this can cause a very large, sudden increase in blood pressure (hypertensive crisis). This is very important if you are taking one of the older MAOI antidepressants such as phenelzine, isocarboxazid and tranylcypromine. Hypertensive crisis is less likely to happen with moclobemide, but you still cannot eat or drink large amounts of food and drinks that contain tyramine. The first sign of a hypertensive crisis may be a throbbing headache.

Tyramine is found in cheese, liver, yoghurt, Marmite®, Oxo®, Bovril®, brewer's yeast, flavoured textured vegetable protein, broad bean pods (the beans inside can be eaten), protein which has been allowed to age, or ferment (for example, hung game, pickled herrings or dry sausage such as salami or pepperoni), fermented soya bean extract and large amounts of chocolate.

Tyramine is also found in alcoholic drinks, including beer, lager or wine (especially red wine). It is best to avoid all alcoholic drinks. It is also found in non-alcoholic beer.

Only eat fresh foods and avoid food that is stale or 'going off', especially meat (including poultry meat and offal meat) and fish while taking an MAOI and for two weeks after you stop. This is because these foods may contain tyramine.

Other medicines that you may take

MAOIs sometimes react with other medicines that you may take. So, make sure your doctor knows of any other medicines that you are taking, including ones that you have bought rather than been prescribed. Always check with your pharmacist before buying any medicines from the chemist or supermarket to see if they are safe to take with an MAOI antidepressant. Some medicines that you can buy for coughs and colds can also cause a very large sudden increase in blood pressure (hypertensive crisis), or make you very excitable or depressed.

In particular, avoid medicines for coughs and colds that contain dextromethorphan, ephedrine or pseudoephedrine while you are taking an MAOI antidepressant and for two weeks after you stop it:

  • Dextromethorphan when taken with an MAOI antidepressant may make you very excitable or depressed.
  • Ephedrine, pseudoephedrine and phenylpropanolamine when taken at the same time as an MAOI antidepressant may cause very large increases in blood pressure.

Carry a card

If you are taking an MAOI antidepressant you will be given a small card that you must carry with you at all times. This card lists the different foods, drinks and over-the-counter medicines you can't take. Always make sure you show this card to anyone giving you medical treatment (for example, a doctor, a dentist, a pharmacist or a nurse).

If you change your antidepressant

If your doctor wants to change your medication from an MAOI to another antidepressant, you must leave two weeks between stopping your MAOI antidepressant before starting your new antidepressant.

What are the possible side-effects?

Phenelzine, isocarboxazid and tranylcypromine

The most common side-effect with these older MAOIs is feeling dizzy when you stand up (postural hypotension). It is more likely to happen if you are older. Less commonly, some people have drowsiness, difficulty sleeping, headache, weakness and tiredness, a dry mouth, or constipation. Very rarely these medicines can affect your liver - for example, jaundice has been reported and a few deaths from liver reactions (but these are very rare). Peripheral neuropathy (weakness, cramps, and spasms, a loss of balance or tingling, numbness, and pain) has also been reported very rarely.

Moclobemide

Common adverse effects include, sleep disturbance, and feeling sick (nausea). Less commonly, agitation and confusion have been seen in people taking moclobemide.

Note: the above is not the full list of side-effects or interactions for these medicines. Please see the leaflet that comes with your particular brand for a full list of possible side-effects and cautions.

Can I buy MAOI antidepressants?

You cannot buy MAOI antidepressants. They are only available from your chemist, with a doctor's prescription.

What is the usual length of treatment?

If you find that the treatment is helpful after 3-4 weeks, it is usual to continue. A normal course of antidepressants lasts at least six months after symptoms have eased. If you stop the medicine too soon, your symptoms may rapidly return.

Some people with recurrent depression are advised to take longer courses of treatment.

Who cannot take MAOI antidepressants?

It is normally recommended that you avoid taking MAOI antidepressants if you:

  • Have bipolar disorder and are in a manic phase.
  • Experience excitation or agitation as a major part of your depression (your doctor may prescribe a sedative medication such as a benzodiazepine for 2-3 weeks).
  • Have had a stroke or any other condition that affects the blood supply to the brain.
  • Are taking other antidepressants.
  • Have a growth on your adrenal gland (phaeochromocytoma) which can cause high blood pressure.
  • Have heart disease.
  • Are pregnant.
  • Are breast-feeding.

Are MAOI antidepressants addictive?

MAOI antidepressants are not tranquillisers and are not thought to be addictive. (This is disputed by some people and so this is a controversial issue. If addiction does occur, it is only in a minority of cases.)

Most people can stop an MAOI without any problem. At the end of a course of treatment you should reduce the dose gradually over about four weeks before finally stopping. This is because some people develop withdrawal symptoms if the medication is stopped abruptly. If you have withdrawal symptoms, it does not mean that you are addicted to the medicine, as other features of addiction such as cravings for the medicine do not occur.

Withdrawal symptoms that may occur include:

  • Drowsiness.
  • Anxiety and agitation.
  • Sleep disturbance.
  • Vivid dreams.
  • Slowed speech.
  • A lack of muscle co-ordination.

Rarely, some people may have hallucinations and delusions.

These symptoms are unlikely to occur if you reduce the dose gradually. If withdrawal symptoms do occur, they will usually last less than two weeks. An option if they do occur is to restart the medicine and reduce the dose even more slowly.

How to use the Yellow Card Scheme

If you think you have had a side-effect to one of your medicines you can report this on the Yellow Card Scheme. You can do this online at the following web address: www.mhra.gov.uk/yellowcard.

The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that medicines or any other healthcare products may have caused. If you wish to report a side-effect, you will need to provide basic information about:

  • The side-effect.
  • The name of the medicine which you think caused it.
  • The person who had the side-effect.
  • Your contact details as the reporter of the side-effect.

It is helpful if you have your medication - and/or the leaflet that came with it - with you while you fill out the report.

Why should I stop antidepressants?

You may have been advised by your doctor to stop antidepressants or you may have chosen to stop them yourself. Reasons for stopping antidepressants include:

  1. You have side-effects.
  2. You are going to try a different medication.
  3. You are pregnant or breast-feeding.
  4. You feel better and don't need them anymore.
  5. You prefer not to take medication.
  6. You haven't been helped by them.

To help you decide whether to stop an antidepressant, it might help to balance the risks versus the benefits of your decision. Your doctor can help you do this.

Risk:benefit analysis

For example, If you are planning to stop your medication because you feel better, your risk vs benefits could look like this:

  • Risk of stopping: your symptoms returning. This could have other consequences too: you might struggle to get to work; you might struggle to manage family life and relationships; you may think of harming yourself or of suicide.
  • Benefit of stopping: to be free of medication that you no longer need; no more unwanted side-effects; you feel you can move on from your illness.
  • Risk of continuing: taking a medication that you don't need anymore; possible unwanted side-effects.
  • Benefit of continuing: confidence that your distressing symptoms will not return.

Some of the risks and benefits will be personal to you; for others you will need medical advice. Ask your GP for help and guidance with this.

What if I am pregnant or breast-feeding?

If you are pregnant or planning a pregnancy, it is vital to talk to your doctor about antidepressant use so that you can make an informed decision about medication in pregnancy. Weighing up the risks and benefits of antidepressants when you are pregnant or breast-feeding can be more complicated because, as well as your health, the health of the baby needs to be considered too.

All medications are tested in drug trials to be sure that they are safe to use. None of these trials is performed on pregnant women. Because research is not performed on pregnant women, it is not possible to know for sure whether any medication is safe in pregnancy. However, because antidepressants have been around for some time, women taking them have become pregnant and had babies whilst on them.

Studies looking at these babies have shown mixed results. The family of antidepressant most commonly used in pregnancy is selective serotonin reuptake inhibitors (SSRIs). Many healthy babies have been born to mothers on SSRIs. This might suggest that the risk of taking them is quite small. Some studies of babies born to mothers on SSRIs have suggested that there may be a link to an increased rate of birth defects, particularly heart defects. Studies of attention deficit hyperactivity disorder (ADHD) and autism in babies born to mothers on SSRIs have shown mixed results. It is hard to know whether any problems seen in these babies are a result of the antidepressant, the underlying illness or other factors.

Stopping an antidepressant may cause problems for both mother and baby too. Depression and other mental illness can occur both during pregnancy and after a baby is born. It can be severe. It can make it hard for mothers to care for themselves and for their babies. This can affect how well the baby thrives and develops.

Risk:benefit analysis

Working out the risks and benefits of antidepressant use in pregnancy is complex and will need advice from a specialist but it could look something like this:

  • Risks of stopping: return of symptoms. This could have consequences for you and for the baby; it could make caring for yourself and a baby more difficult. This could affect how well your baby thrives. If you are struggling, your baby is more likely to struggle. You may begin to think about harming yourself, or even about harming your baby. You and your doctor will need to consider how severe your symptoms have been. Also, whether you have had mental health problems with any previous pregnancies. If so, you are at greater risk of having similar problems this time.
  • Benefit of stopping: the only way to be sure that the medication will not affect your baby. A fresh start for you.
  • Risk of continuing: uncertainty over the affect on the baby.
  • Benefit of continuing: to stay well which will help you and help your baby to thrive, especially if you have felt very unwell in the past. Whatever your reason for deciding to stop an antidepressant, take time to talk it through with your GP as part of your preparation to stop medication.

What should I watch out for when I'm coming off antidepressants?

Stopping antidepressants is usually straightforward but there are two things to look out for:

  • Your old symptoms returning.
  • Withdrawal symptoms.

With planning and support, it is possible to spot these issues and deal with them.

Stopping antidepressants suddenly is not dangerous but you could get withdrawal symptoms or become unwell again if you make a sudden change. If you can, stop your antidepressant when you have felt better for the last six months on medication. Plan in advance to cut down your dose gradually.

What advice can your doctor give before stopping your antidepressant?

Your doctor can help you make sure that it is the right decision for you. They can help you decide on alternative treatments. Sometimes, it is easier for other people to notice when old symptoms are returning. Your doctor can help you look out for these. Many antidepressants are easy to come off but a few can cause withdrawal symptoms. Your doctor will be able advise you about these.

Should I plan in advance?

If possible, wait until you have been feeling better for six months on your medication. You are less likely to become unwell again.

Choose a time when there are no extra stresses in your life; a time when life is settled. If work is demanding, think about taking some time off or cutting down your commitments.

Plan to change just one thing at a time. Only change one medication at a time. That way, you will know how each change affects you.

Plan a schedule. Cut down the dose gradually.

Get support around you before you stop your antidepressant. This can be from your doctor, your family and friends, support groups and counsellors - whoever you know and trust to help you as you make the change. If you can, let them know that you are stopping your treatment. Talk to them about what support you need.

Remember, some people take antidepressants for many years. There is often no rush to stop them. Take your time.

Flexibility

Once you have set aside the best time for your schedule of dose reduction and checked this out with your GP, you are ready to start. Have in mind a schedule for cutting your dose down. However, it is helpful to be flexible here. Until you start reducing your dose, you do not know how your body will respond to the change. Very often, there are no problems at all; stopping the medication proves to be straightforward. If you do run into problems, be prepared to be flexible with your plan.

If you feel that your depression might be coming back or that you are struggling with withdrawal symptoms, consider cutting down the dose even more slowly. You might even choose to stop reducing your dose altogether. Stay on the same dose for longer until your body adjusts. Whilst that might feel like a step in the wrong direction, it is better to be flexible with your plan than to risk becoming unwell.

Sometimes, you may be unsure what decision to make, particularly if you are feeling unwell or struggling with withdrawal symptoms. If you are ever uncertain, talk to your doctor and to the people supporting you. Let them help and guide your decision.

How do I avoid withdrawal symptoms?

Withdrawal symptoms can be a problem when stopping certain antidepressants. Ask your doctor whether your medication might cause them. Withdrawal symptoms are not dangerous. They usually disappear on their own within six weeks of stopping an antidepressant. You might notice:

  • Anxiety
  • Dizziness
  • Vivid dreams
  • 'Electric shock' feelings in your body
  • Stomach upsets
  • Flu-like symptoms
  • Depression
  • Headaches
  • Sleep problems

The best way to avoid these symptoms is to cut down the dose gradually. Allow plenty of time around each dose change. Take it slowly and be patient. If the symptoms get too unpleasant, try stopping the dose reduction; stay on the same dose for a while longer.

Antidepressants are not addictive; you do not need to take bigger and bigger doses as time goes by to get the same benefit. Stopping them, though, can cause withdrawal symptoms as your body adjusts to being without them. Very often, these withdrawal symptoms are just a minor inconvenience. Sometimes they can be more troublesome. Withdrawal symptoms tend to happen more frequently when stopping antidepressants which have a short half life.

What is a half life and is it important?

The half life of an antidepressant is the time it takes for the body to break down and remove half of a medication from its system. So, an antidepressant with a short half life will leave the body faster than one with a longer half life. This short half life can result in withdrawal symptoms as the level of medication in your body drops more suddenly.

Antidepressants with a short half life are more likely to cause withdrawal symptoms and include:

  • Paroxetine
  • Venlafaxine
  • Escitalopram
  • Duloxetine

Antidepressants with a longer half life include:

  • Fluoxetine
  • Mirtazapine
  • Sertraline
  • Dosulepin

These antidepressants are less likely to cause withdrawal symptoms. There are many different antidepressants, all with different half lives. If you are unsure whether your medication has a short half life and is more likely to cause withdrawal symptoms, check with your doctor.

As well as the half life of a medication, the length of time spent taking a medication can have a bearing on whether an individual gets withdrawal symptoms. The longer a person has been on a medication, the greater the chance of getting withdrawal symptoms when the medication is stopped.

Lastly, some individuals seem to be more sensitive to withdrawal effects than others and can find it difficult to tolerate them, whilst others seem to get few symptoms at all. You might not get any withdrawal symptoms, even if you have been on a medication with a shorter half life for quite some time.

There are no medications recommended to treat withdrawal symptoms. The best way to manage them is to cut the antidepressant dose down gradually, allowing your body time to adjust to each change. The longer you have taken your medication, the slower you might want to cut down.

Current recommendations for reducing the dose of an antidepressant are:

  • If treatment has lasted less than eight weeks, stop over 1-2 weeks.
  • If a treatment has lasted 6-8 months, cut down over 6-8 weeks.
  • If you have been on maintenance treatment for longer that eight months, cut down even more gradually - for example, reduce the dose by no more than 1/4 every 4-6 weeks.
Remember:
  • Withdrawal effects are not harmful.
  • They don't usually last beyond six weeks of stopping an antidepressant.
  • There are no medications recommended to treat withdrawal symptoms.
  • If you cut your dose down slowly, you are less likely to experience them.

How do I watch for old symptoms returning?

Try to remember exactly what changed when you first became ill. Spotting early warning signs requires a little time and thought. It also helps if you can share this task with someone close to you - a medical professional, a therapist or someone who knows you well. There might be some experiences that only you would spot; particular thoughts or feelings that no one else would know about. Other signs, though, are easier for those around you to spot - behaviours that people may have noticed you do last time. So, ideally, sit down with someone who knows you well and work out early warning signs together.

When thinking about experiences, it can be helpful to divide them into three different elements: thoughts, feelings and behaviours. These three elements tend to come as a package, almost like a pre-recorded message that you might have heard many times before. Sometimes, the message is so repetitive that you can barely notice that it is playing at all; you might need the people around you to notice it for you. A particular thought will be accompanied by its usual feeling. It will trigger you to act in a particular way too. For example, people who have had symptoms of obsessive-compulsive disorder (OCD) might remember feeling anxious, having obsessional thoughts and performing compulsive behaviours. It isn't only OCD which comes with packages of thoughts, feelings and behaviours. We all do this, even when life is going well. We are all creatures of habit.

These habits can be useful when it comes to spotting early warning signs of illness. Sometimes, changes in behaviours are easier to spot than changes in how you feel. Watch out for changes in your activity levels, your sleep, appetite, weight, time off work, avoiding people, keeping yourself clean and the house clean. If you think your old symptoms are coming back, tell the people who are supporting you as soon as possible.

How can I stay well?

Antidepressants are just one way to stay well. There are lots of other ways to look after yourself without needing medication. Here are some ideas:

  • Get support. As well as support from your family and friends, think about trying a talking therapy to help you understand your symptoms. There is good evidence that cognitive behavioural therapy (CBT) - which is available on the NHS and not necessarily needing a referral from your GP - and other therapies can combat depression and help you to stay well.
  • Look around for support groups in your area. MIND and other mental health charities might run groups locally.
  • Are there areas of your life which work against you? Are there issues in your work life that you can change to make your life more manageable? Are there things you wish you could change in your key relationships? Which relationships support you? If your relationships don't support you already, look around for other areas of support. Find out what is available in your area - for example, a MIND group, as above, or other mental health charity locally which could both support you and benefit from your input.

Finally, don't forget that your GP is always there to help and advise you if you run into problems. If you feel that you are taking a step back, talk with your GP as soon as you can. That way, you can get the extra support you need sooner and recover quicker.

Lifestyle factors

Do you take regular exercise? Exercise can help to prevent depression and low mood. It can also help to prevent other physical illness which in turn can affect your well-being. As well as the benefits to your physical and mental health, fitness can be a social activity and can help you to get out into the world and meet people.

Is your diet adequate? Eating a balanced diet is a vital part of a healthy lifestyle. Ask your GP or dietician about how to improve your diet to remain both physically and mentally well.

Are you getting enough sleep? Low mood and sleep problems are very closely linked. If your sleep pattern is a problem, find out how 'sleep hygiene' can help. Try cutting down on caffeine, especially later in the day, setting a regular bedtime, reducing screen use in the evenings and using your bedroom only for sleeping. If sleep remains a problem, talk to your GP about it.

Are you drinking too much alcohol? Current recommendations for alcohol consumption per week are 14 units for women and men. As well as other health risks, drinking alcohol is linked to increased rates of depression and other mental illness.

Are you using any other drugs which might affect your mental wellness? Occasionally, prescribed medications might add to your chances of becoming depressed. Check with your GP that you are on the best medication choices for you.

What if stopping doesn't go to plan?

Unless there is a medical reason why you must stop, taking antidepressants is not harmful. In fact, it is often better for your health to take medication than to struggle with depression. If stopping your antidepressant doesn't go to plan, your doctor can help you decide what to do next. They can help you work out whether to go back on medication for a while longer. Together with your doctor, you can take time to understand why stopping was difficult. That way you will know what to expect next time you try.

Further reading and references

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