In early 2023, Liana Shatova began taking low doses of an antidepressant to relieve symptoms of premenstrual disorder, characterized by mood swings, anxiety and depression. At first the difference was startling to her.
“I felt energized and able to juggle several things at once,” said Shatova, 40, a business development manager in Greater Boston.
Then, after about 18 months of taking the medication, she began to fear that she was becoming emotionally numb.
“My best friend’s mother died unexpectedly, everyone was in shock and crying, but I couldn’t cry at all,” Shatova said. “I just didn't feel anything.”
When Shatova asked her doctor if she could stop taking sertraline, an antidepressant better known by the brand name Zoloft, she said she was reassured that she was taking the lowest dose prescribed and that it would be easy to stop.
Everything seemed fine at first, but a month later, Shatova said, she had her first attack of what would develop into chronic insomnia, followed by panic attacks. Other symptoms emerged, including night sweats, muscle and joint pain, and mood swings that prevented her from working.
She said her doctor told her the symptoms were a relapse of her premenstrual dysphoric disorder and suggested a different antidepressant. Shatova refused the new drug.
Antidepressants, primarily SSRIs or selective serotonin reuptake inhibitors, are among the most widely prescribed medications in the United States, taken by tens of millions of adults. About twice as many women as men report using antidepressants in the past 30 days. Antidepressants are most often used by women Ages 60 and older, according to the government.
Side effects are the main reason people stop taking medications, but stopping medications can also lead to withdrawal symptoms, research shows. Along with growing awareness, description of movement develops in the field of psychiatry aimed at helping patients reduce or stop taking medications when they are no longer considered necessary.
In a recent major analysis published in The Lancet In November, researchers from King's College London found that physical side effects, including rapid weight gain, a significant increase in heart rate or increased blood pressure, may be more common than previously thought, depending on the drug. The review analyzed the results of 151 clinical studies and 17 Food and Drug Administration reports involving about 30 different prescription medications used to treat depression, anxiety, bipolar and panic disorders.
Researchers looked at the effects of antidepressants on weight, blood glucose, total cholesterol, blood pressure and heart rate. They did not look at the emotional changes that patients like Shatova experience, although the study's lead author said this should be further explored in future studies.
“Not all antidepressants have the same side effects on physical health,” said Dr Toby Pillinger, an academic clinical lecturer at King's College London who led the study. “Until recently, we approached antidepressant prescribing with a one-size-fits-all policy, and I think we need to move away from that.”
Additionally, in August, mental health researchers in the UK found that serious withdrawal consequences may be more common than previously thought, especially with long-term use, although the study was small, with just 18% of participants responding to the survey. The results showed that among people exposed taking antidepressants for more than two years63% reported moderate to severe withdrawal effects, with a third describing withdrawal problems that lasted more than three months.
Symptoms ranged from insomnia to confusion, electrical sensations, muscle spasms, agitation, mood swings and derealization, or changes in the way a person perceives the world.
Dr. Mark Horowitz, a research fellow at University College London who led the withdrawal study, said another study found that about a quarter of patients experience severe symptoms when they suddenly stop taking medications, ranging from burning pain in the skin or limbs, balance problems, ongoing panic attacks, and sensitivity to sound and light.
Abruptly stopping antidepressants is not recommended, but research has shown that withdrawal symptoms can occur even when people try to reduce their dose. A review of various existing studies published last year by a group of German psychiatrists concluded that 1 in 3 antidepressant users will experience some type of withdrawal symptoms, with severe symptoms occurring in 1 in 30 users.
Dr. Joseph Goldberg, a clinical professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York, said antidepressants have long been known to cause “withdrawal symptoms,” mainly nausea and dizziness, especially when stopped abruptly.
It is not clear why some patients experience severe symptoms after stopping the medications. Some researchers concerned about reports of antidepressant withdrawal suggest that the underlying mechanisms are similar to those experienced by people suffering from alcohol and opiate withdrawal.
“Withdrawal symptoms tell you that your brain is trying to restore the balance that it was forced to change by the presence of the drug,” said David Cohen, a professor of social welfare at the University of California, Los Angeles. “I think this is the most plausible explanation for why stopping any centrally acting drug, be it antidepressants, coffee or heroin, results in some discomfort.”
The problem for psychiatrists is that medications, which are often prescribed concurrently with therapy, help a lot of peopleespecially in the short term. Dr. Jonathan Alpert, a professor of psychiatry at Albert Einstein College of Medicine, said anecdotes about extreme withdrawal do not reflect his own professional experience.
In his practice, Alpert estimates that two-thirds of his patients have been on antidepressants for more than five years, with only a small handful experiencing prolonged withdrawal symptoms lasting more than a few days.
“There's a very exaggerated idea that it's really hard to get off psychiatric medications,” Alpert said. “While I respect people's stories of their own experiences, they are very different from what we see in clinical practice and research.”
Goldberg also expressed skepticism about whether antidepressants themselves are actually responsible for the symptoms patients report.
“If someone develops frankly strange and unexpected neurological problems after years of treatment, I'm not sure how confidently we can attribute it to medicine,” he said. “Anything is possible. But I think we have to consider the more likely possibility that the thing they encounter may not be related.”
More than a year after Shatova first tried to cut back on her medication, she said she is still going through the painstaking process of tiny, gradual cuts to try to avoid worsening her symptoms.
“I'm still tapering and am now taking 0.835 mg of Zoloft, doing it very slowly and carefully,” she said. “My sleep has improved, but I still have windows and waves caused by life stresses and hormonal fluctuations.”
It's important not to dismiss people's experiences, Goldberg said, and anyone experiencing symptoms should get further testing. Former president of the American Society of Clinical Psychopharmacology, Goldberg said the organization is currently finalizing new guidelines for deprescribing. The goal is to help doctors explain what to expect when stopping psychiatric medications, so that patients do not start tapering on their own without medical supervision.
Alpert suggested analyzing different types of data stored in electronic health records to gain insight into the characteristics of patients experiencing long-term withdrawal symptoms.
“Do they have abnormal MRI findings or blood tests with markers of inflammation? By looking at larger data sets, it will be easier to identify predictors of this subgroup of people who seem to have unusually long-lasting symptoms.”
Cohen believes psychiatry needs to speed up research. However, with the 43% cut to the National Institutes of Health's annual budget proposed to Congress by the current administration (a figure equivalent to $20 billion per year), it is likely that such research will have to be conducted by either British or European researchers.
“We need large, non-industry-funded studies to look at what happens when people stop taking antidepressants, using different dose reduction strategies and a long enough follow-up period,” Cohen said. “We need dozens of these tests now.”
If you or someone you know is in crisis, call or text 988 or visit 988lifeline.orgto reach the suicide and crisis helpline. You can also call the network formerly known as the National Suicide Prevention Lifeline at: 800-273-8255or visit SpeakingOfSuicide.com/resources.
