Dizziness, Restlessness, Brain Zaps: What's Normal When Stopping Antidepressants?

"These are discontinuation symptoms, not withdrawal symptoms," Menke emphasises. The complaints are in fact not comparable to addiction, such as can occur with alcohol or certain sedatives.

Venlafaxine, an active ingredient from the group of serotonin-noradrenaline reuptake inhibitors, is particularly well known for discontinuation problems. "There are medications that cause more symptoms, for example venlafaxine. It is known that stopping it can cause greater difficulties and that the symptoms can be more pronounced. This is why it really does need to be tapered off more slowly."

Paroxetine also belongs to the antidepressants with which discontinuation symptoms occur more frequently. The British NICE guideline explicitly highlights both active ingredients.

Why the Last Few Milligrams Can Be Particularly Difficult

When tapering off an antidepressant, the dose is usually reduced in several steps. However, the assumption that each of these steps is roughly the same size for the brain is misleading.

The effect of many antidepressants on the serotonin transporters in the brain does not decrease proportionally to the dose. Halving the amount of a medication does not automatically halve its effect on these transporters. At low doses in particular, smaller reduction steps may therefore make sense.

Menke describes tapering off as a process in which the patient's response sets the pace. "It works similarly to titrating up. You start with a low dose to allow the body to get used to the medication, and increase it slowly. With tapering off, it is exactly the reverse. You reduce the dose and see what happens."

What matters is not to follow a rigid schedule. "If nothing happens, you wait a little while, for example two weeks, and then reduce further. You keep doing this until, for example, discontinuation symptoms appear. Then you proceed more slowly. So you are always working a little by sight."

How much time is needed for this cannot be stated as a blanket rule. "It depends on the patient and the medication," says Menke. Sometimes tapering off takes several months.

The duration of the previous treatment also plays a role, though not indefinitely, says Menke: "Of course it makes a difference whether someone has only taken the medication for four weeks or for longer. But whether it was one year, two years, or five years eventually becomes irrelevant."

Is the Depression Back – or Are These Discontinuation Symptoms?

The situation becomes particularly difficult when not only physical symptoms appear but mood also changes. Sleep problems or lack of drive can equally point to a recurrent depression.

Menke therefore first orients himself by how the illness presented in the individual patient. "If the same symptoms return as with the original depression, that probably points to depression rather than discontinuation symptoms. If, for example, I become sad again, suddenly have no motivation, sleep poorly, and this persists for a few days without improving, then that is more likely a relapse."

This distinction is not entirely clear-cut, however, since discontinuation symptoms can also produce psychological symptoms that resemble depression. The timeline provides a clue: discontinuation symptoms often begin a few days after a dose reduction, whereas a relapse usually develops more slowly.

When Is the Right Time to Stop?

The fact that a depression has subsided does not mean the medication should be stopped immediately. After successful treatment, an antidepressant is usually continued for several more months to reduce the risk of relapse.

Menke cites a period of at least six to twelve months and emphasises that the decision should be made together with the treating physician. "What is important first and foremost is of course freedom from symptoms and a situation in which the world around you is not currently falling apart. Everything should be settled and stable, so that a separation, a job change, job loss, or other stressful factors are not just around the corner."

Those who decide to stop need above all patience. Discontinuation symptoms are unpleasant, but in most cases temporary, and they can often be alleviated by slowing the pace or temporarily returning to the last well-tolerated dose. What matters is to take changes in well-being seriously and discuss them with the treating physician, rather than trying to interpret them alone.

If the symptoms become so severe that daily life is barely manageable, if mood deteriorates markedly over the course of days, or if thoughts of suicide arise, those affected should not wait until their next appointment but seek immediate contact with their physician or the emergency medical service.