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For those living with mental illness, antidepressants can be an invaluable lifeline - helping people do things we tend to take for granted, such as get up in the morning and shower. But like all medications, antidepressants can have side effects. And when you stop taking them, you may experience withdrawal symptoms.
Recently, the Royal College of Psychiatrists called for better warnings over withdrawal symptoms - and that patients should be told of potential "severe and long-lasting withdrawal symptoms" when coming off antidepressants.
What does antidepressant withdrawal mean?
It's thought that antidepressants work by increasing levels of chemicals in the brain called neurotransmitters, such as serotonin and noradrenaline, which are linked to mood and emotion. In combination with other psychological therapies, they can be very effective in treating depression, clinical anxiety and other mental health disorders.
Any psychiatric drugs change your brain and body chemistry and although they aren't classed as addictive medicines, they can cause withdrawal symptoms if they are stopped suddenly. Instead, patients are advised to gradually reduce the dose they take over time to reduce the risk.
Guidance suggests that most people should be able to withdraw from the drugs over four weeks. Now, however, psychiatrists say some patients taking the pills long-term can experience side effects that can last much longer.
"New research has revealed that up to half of all patients taking antidepressants may experience withdrawal symptoms," says Dr Omair Ahmed, consultant psychiatrist at the Priory Hospital Woodbourne. "However, the severity can vary considerably from very mild to severely disabling."
"Previously, doctors were aware of antidepressant discontinuation syndrome which can last for one to two weeks and is self-limiting. The latest guidance is suggesting that this needs to be revised as the withdrawal effects are now believed to last a lot longer than previously believed."
The change in guidelines essentially means allowing the patient to make a more informed choice, explains Ahmed.
"If patients are made aware that they may experience withdrawal symptoms for some time after stopping their treatment, it will better equip them to make a decision on whether it is right for them," he says.
What are the symptoms?
"Symptoms can vary in severity," explains Ahmed. "However the most commonly experienced withdrawal symptoms include anxiety, headaches, irritability, disturbed sleep, nausea, electric shock-like sensations and the return of depressive symptoms."
Withdrawal symptoms depend on the type of antidepressant, according to the NHS. Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants and venlafaxine can cause chills, muscle pain, excessive sweating, nausea and headache and insomnia.
SSRIs and venlafaxine can also cause dizziness or electric shock sensations. Monoamine-oxidase inhibitors (MAOIs) can cause symptoms such as irritability, agitation, sleep problems and movement disorders.
Amy Sutton, 33, has been taking citalopram, an SSRI, since early 2015 after being diagnosed with depression and general anxiety disorder.
"The first clue I had that coming off citalopram would be hard was a bank holiday weekend where I ran out. By day four I was experiencing blurred vision, immense tiredness, dizziness, a general sense of being 'out of it' and panic."
But at the start of 2019, Sutton felt ready to try to come off the medication entirely and visited her GP to discuss how to do it safely.
"The advice from my GP, and echoing the experiences of people online, was to taper down every two weeks or so, halving the tablet as I went. After about six weeks I felt ready to stop entirely. For the first few days I felt the same tiredness, blurred vision and dizziness but not as extreme."
Things changed two weeks later, however. "My mood very suddenly dropped and I would find myself crying throughout the day, suffering mild panic attacks and generally feeling worse than I have in years. It seemingly came from nowhere and was debilitating."
“When I first was prescribed SSRIs it wasn't explained to me that the side effects of coming off could be severe, and that weaning off could take months," Sutton says, adding she is now taking citalopram again.
"It was, in a way, positioned as a quick fix - which at the time it really was and did help immensely - however, I am not sure that patients realise the commitment they are making."
Bethany Lander, 29, said her main symptom of SSRI withdrawal was 'face zapping' - an electric shock-type feeling - as well as tingling and dizziness - but her symptoms were not too severe.
"My most recent drug stoppage is Prozac (fluoxetine)," she says. "It took three months after complete cessation to stop symptoms, but they were generally mild - just annoying face zaps all the time. I stopped because I got pregnant and my midwife urged me to switch to something else."
How can you avoid antidepressant withdrawal?
If you feel you are able to come off medication, the first thing to do is speak with your doctor. "The patient should speak with their healthcare provider or psychiatrist to discuss a properly planned withdrawal regime," says Ahmed.
"This ought to be done gradually so as to minimise the risk of severe withdrawal. This will also allow the clinician to monitor any problems more closely so that appropriate measures can be taken to alleviate any distress if required."
It's also important to remember that antidepressants help many people struggling with mental health problems.
Crucially, the RCP has brought the issue to light so we "re-examine the way in which antidepressants are prescribed and how someone is taken off a particular medication," says Dr Tom Pennybacker, a consultant psychiatrist and psychotherapist, and co-founder of The Chelsea Psychology Clinic in London.
"Firstly, we need to be providing people with more information about the possible discontinuation effects before they are prescribed medication," he says. "And also, that prescribers become mindful that coming off certain medications might cause some uncomfortable symptoms for a significant group of people. Tapering someone off the medication gradually rather than simply stopping it might go some way to protect against this.
"Our understanding around the physiological effects of antidepressants is still very limited. What we do know is that everyone responds to certain drugs differently," Pennybacker adds. "While for some people coming off medication immediately might be fine, you might find that others need to come off what would be considered a 'normal' dose very gradually.
"Unfortunately, this might not stop discontinuation effects from happening completely, but it goes some way to minimising the chances."