The Gradual, Uphill Climb Out of Depression
At first, Zoloft seemed like “manna from heaven,” says the 53-year-old teacher from Watertown, Mass.
It was the summer of 1999 and, for reasons she still doesn’t fully understand, she had slipped into a “terrible slump.” Her doctor suggested Zoloft, America’s second-most popular antidepressant, after Prozac. And for a while, “it was great,” says the woman, who did not want her name used.
But after nearly a year on the drug, she developed a twitch in her left eyelid. It may not have been related to the Zoloft, but since she was feeling fine, she decided to stop taking the drug.
And, unlike many people who quit antidepressants, she did it the right way--very slowly, cutting the dose little by little over six weeks.
Even so, she wound up with three months of withdrawal--or “discontinuation syndrome,” the term psychiatrists prefer because “withdrawal” suggests that antidepressant drugs are addictive (like cocaine or heroin), which they are not.
Discontinuation syndrome is not a recurrence of the original depression, though that can happen too. It’s a new set of problems--in this woman’s case, bad headaches and vertigo. At one point during a walk, she says, “my body felt like it was tipping to one side. I had to keep lying down--it was terrible.”
Could a drug that was no longer in her system somehow be causing weird symptoms she’d never had before? That was “the thing that got me the most creeped out,” she says. “The drug clearly is out of your body. So what was it that lasted for three months?”
What lasted so long for this teacher, and many others who stop taking antidepressant drugs, is what scientists now think of as a prolonged period of readjustment during which the chemistry of the brain settles into a kind of new, nondepressed normal.
To be sure, many of the millions of people worldwide who take antidepressants experience no withdrawal symptoms when they stop. But some studies suggest that one in every 10 has some symptoms, and one in 20 suffers “significant distress,” says Dr. Jerrold Rosenbaum, chief of psychiatry at Massachusetts General Hospital.
Others, among them Dr. Andrew Leuchter, director of the division of adult psychiatry at UCLA Medical Center, believe the actual figures are much higher--perhaps 25% to 30% for Zoloft, more for Paxil and less for Prozac.
Yet even doctors who should be on the lookout for withdrawal symptoms such as dizziness, increased nervousness, irritability, insomnia and a dramatic increase in vivid dreams often aren’t.
In fact, a 1997 study in the Journal of Clinical Psychiatry showed that 70% of general practitioners and, surprisingly, a third of psychiatrists don’t know that significant withdrawal symptoms can occur when people stop taking antidepressants of the type called SSRIs (selective serotonin reuptake inhibitors), to which Prozac, Zoloft, Paxil, Luvox, Celexa and a similar drug, Effexor, belong. (Withdrawal syndromes can also occur with antidepressants that work differently from the SSRIs, including older drugs such as Elavil and Tofranil.)
“It’s an under-recognized problem,” says Leuchter, because when people stop taking a drug and then develop new symptoms, they can’t believe it has “anything to do with the medicine because, if they’re not taking it, how can it affect them?”
But withdrawal clearly does happen, though researchers still aren’t sure why. The basic thinking is that depression is caused by a deficiency of serotonin, a key neurotransmitter in the brain. SSRIs boost serotonin by stopping its reabsorption into brain cells, thus keeping more serotonin where it’s needed, in the synapse (or gap) between nerve cells.
Some neuroscientists think that as the brain adapts to increased levels of serotonin, the number or the sensitivity of serotonin receptors changes. Then, when SSRIs are discontinued, withdrawal symptoms may occur as the nervous system, now primed for lots of serotonin, isn’t getting enough, says Dr. Alexander Bodkin, chief of clinical psychopharmacology research at McLean Hospital in Belmont, Mass.
Researchers are sure that the severity of withdrawal symptoms from SSRIs is closely correlated with the half-life of the particular medication, meaning the length of time the drug or its active metabolic breakdown products stay in the body.
Prozac is least likely to cause withdrawal because its metabolite lingers in the body for as long as five weeks. In fact, precisely because of this, one strategy for people who have trouble getting off other SSRIs is to switch to Prozac and then taper slowly off of that.
By contrast, Paxil, Luvox and Celexa may trigger withdrawal because they are faster-clearing--they linger in the body for four to five days.
The bottom line is that if you want to wean yourself from antidepressants, do so slowly--as a rough guide, by decreasing your dose by half every one to two weeks. It may take weeks or even months to discontinue completely, but that doesn’t really matter.
Judy Foreman writes a syndicated column on health issues. She is a fellow in medical ethics at Harvard Medical School. She can be reached by e-mail at foremanj@brandeis.edu. Her column will run occasionally in Health.
