Deprescribing Antidepressants

Psychiatry is in the news again. This time, it is because RFK Jr. and the associated “Make America Healthy Again” movement have latched onto the perceived dangers of antidepressants, specifically SSRIs. There is a powerful cultural push to start discussing deprescribing these medications, if not avoiding them altogether.

As with anything in psychiatry, there is both truth and danger to be found in this movement.

The Gap in Long-Term Data

The idea of deprescribing antidepressants is nothing new. For decades, both within the field of psychiatry and from the outside, there have been calls to better study the efficacy and safety of SSRIs over longer periods of time. Most of the studies used for FDA approval look at much shorter time spans, like six or twelve months, and almost never follow up beyond that.

Thus, most of psychiatry’s experience with the long-term use of these medications has been accumulated over the past few decades observationally, rather than through randomized controlled trials.

I have written about this topic before, discussing the use of a “Prozac bridge” to help patients taper their antidepressant and ultimately stop it. Psychiatrists should always have a timeline in mind when prescribing. Too often, medical professionals simply send the prescription and then fail to adequately follow up.

Why Universal Anti-SSRI Rhetoric Fails

That said, a universal push to limit SSRI use is not the right course of action, either. There are many patients with a whole host of conditions, such as especially recurring depression, chronic anxiety disorders, and obsessive-compulsive disorder (OCD), who can and do benefit from long-term use of these medications.

Any patient who is questioning their medication regimen because of recent news headlines should reach out to their prescriber to discuss their concerns. Asking when to stop a medication is just as important as knowing when to start one. One thing we do know with certainty is that the longer someone takes an SSRI, the longer it will take them to safely come off of it. At a minimum, we should be informing our patients of this reality.

A Common Clinical Pitfall: The Story of James

Now to the actual task of deprescribing, which on the surface is not actually that complicated. The problem is that many medical professionals go about it the wrong way.

Consider James, a 43-year-old man who became depressed in his mid-20s after a difficult breakup. His doctor prescribed him Zoloft (sertraline), which he found extremely helpful. He has taken 100mg daily for twenty years. After moving across the country, each new doctor he saw simply continued the medication, without anyone ever checking in on why he started it or whether he still needs it.

James finally decided to ask his doctor about stopping it two months ago, and was given a standard, linear taper schedule:

• Week 1: 75mg daily

• Week 2: 50mg daily

• Week 3: 25mg daily

• Week 4: Stop

While James felt okay initially, after the first week he started experiencing "brain zaps" - a fuzzy, electrical sensation in his head that sometimes made him dizzy. After the second week, his sleep deteriorated. By the time he stopped it completely, James became irritable, deeply depressed, couldn’t eat, and was having frequent panic attacks.

Why Speed and Linearity Fail

That fast, linear taper is the wrong way to stop an SSRI.

Especially for someone who has taken a medication for decades, a rapid taper is almost guaranteed to cause severe discontinuation syndrome. While the initial drop to 75mg daily was likely fine, the brain requires time to adapt. In a case like James', I would have recommended staying at that 75mg dose for at least three months, maybe longer, before attempting the next decrease.

Furthermore, as the dose decreases, the increments actually need to get smaller, not remain the same. Rather than dropping down by 25mg steps, the final steps might need to be 12.5mg, 6.25mg, or even smaller. In my practice, I frequently work with compounding pharmacies to formulate these micro-dose adjustments.

It would not be surprising if a safe, well-tolerated taper took James over two years to fully complete.

Distinguishing Withdrawal from Relapse

While there are specific withdrawal effects associated with stopping an SSRI too quickly, there is also the underlying risk that the medication was actually still doing its job. Even after a perfectly managed, hyper-slow taper, it may be that the medication truly was staving off a return of James's clinical depression. If symptoms return after withdrawal has resolved, it's a sign that he may want to reconsider his plan to stop.

As you can imagine, this is a topic that quickly becomes clinically complex. My fervent recommendation is to always seek the guidance of a psychiatrist before embarking on a process of tapering an antidepressant.

If I could distill the golden rules of deprescribing, they would be:

• Go slower than you think you should: Patience is the ultimate virtue in deprescribing.

• Time taken correlates to time tapering: It will take significantly longer to safely taper someone who has taken a medication for twenty years versus someone who has taken it for one year.

• Pause if symptoms appear: When withdrawal effects show up, hold your current dose until they are completely gone before trying to step down again.

• Remain open-minded: Be prepared for the possibility that the medication is still providing a necessary therapeutic benefit.

If you are looking to discuss your antidepressant regimen, or are considering stopping one, please reach out and schedule an appointment.