When should you stop taking antidepressants?

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.

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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.

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.