Stopping antidepressants

Stopping antidepressants: What the data really says about withdrawal symptoms

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DESCRIPTION: Stopping antidepressants: symptoms and safe tapering. Stopping antidepressants without anxiety: how common withdrawal symptoms and withdrawal effects are when stopping, and how to successfully taper off slowly under clinical supervision.

Stopping antidepressants: What the data on withdrawal symptoms really tell us

Stopping antidepressants is a source of anxiety for many people. This article explains how common withdrawal symptoms are, how a withdrawal reaction differs from a relapse, and how to proceed carefully. It is based on the meta-analysis by Henssler and the Charité, the work of Horowitz and Bschor, and the current guidelines. An important point to note from the outset: always reduce the dose gradually under professional supervision, and never do so on your own initiative.

How common are withdrawal symptoms when stopping antidepressants?

During this phase, around a third of those being treated report symptoms. A large proportion of these is due to anticipation. Around 15 per cent – that is, roughly one in six to seven people – can be directly attributed to the active ingredient. Severe cases occur in around 3 per cent of cases.

These symptoms are real and can be distressing, but they affect a minority of people and are usually mild. Those who have taken the medication for a longer period are at a slightly higher risk, as the body becomes accustomed to regular intake. The severity of the reaction depends on the active ingredient, the dose and the duration of treatment.

What does the meta-analysis by Henssler and the Charité reveal?

The most comprehensive review to date comes from Henssler and colleagues, published in 2024 in *The Lancet Psychiatry*. In this systematic review, the team from the Charité, Department of Psychiatry and Psychotherapy, analysed 79 studies involving 21,002 participants, 72 per cent of whom were women, with an average age of 45 years.

16,532 of these people were treated with an antidepressant, whilst 4,470 received a placebo. It is this comparison that makes the results meaningful, as it distinguishes genuine effects of the active ingredient from those of the placebo. This reveals what proportion of the symptoms is actually attributable to the medication.

The interpretation of the figures is controversial. Mark Horowitz believes the true burden is underestimated, partly due to the short duration of treatment in many studies. Tom Bschor defends the validity of the review. Both sides are working with the same data but have reached different conclusions.

Withdrawal symptoms or discontinuation symptoms: what is the difference?

In technical terminology, the term ‘withdrawal symptom’ has become established, whilst in everyday language, people often refer to ‘withdrawal’. These substances do not give rise to genuine addictive behaviour. There is no craving for the substance, as is typical of addictive substances.

The debate over terminology goes deeper than it seems. The term ‘withdrawal’ associates the preparation with a drug, whilst the term ‘discontinuation symptom’ emphasises the temporary adjustment process of the nervous system. The terminology shapes how those affected experience their symptoms. In both cases, what is meant are specific withdrawal symptoms that can be managed and alleviated.

What withdrawal symptoms occur? From dizziness to ‘brain zaps’

Typical symptoms include dizziness, nausea, a flu-like feeling, sleep problems, restlessness and irritability. A characteristic feature is the so-called ‘brain zaps’ – brief sensations like electric shocks in the head. These reactions usually set in within a few days.

In most cases, they remain mild and subside after one to two weeks. Severe or prolonged courses do occur, but are the exception. Where withdrawal symptoms are more severe, the tapering-off process is slowed down; a cautious approach noticeably reduces the symptoms.

What role do the active ingredient and dose play? Paroxetine, venlafaxine, fluoxetine

Not every medication behaves in the same way. Active ingredients with a short half-life, such as paroxetine or venlafaxine, are more likely to cause symptoms because blood levels drop rapidly. Citalopram falls in the middle range, whilst fluoxetine is broken down more gradually and is usually easier to come off.

The dose level and duration of treatment also play a part. The higher the initial dose and the longer the treatment, the more gradually the dose should be reduced. An individually tailored dose-reduction plan depends on the active ingredient, the dose, and the patient’s medical history.

What is the nocebo effect?

A significant proportion of the symptoms can be attributed to the nocebo effect. People who expect problems to arise are more attuned to physical signals. Similar reactions therefore occurred in the placebo groups, even though no active ingredient had been reduced.

This is not an accusation of imagination. The symptoms are physically noticeable, but their trigger lies partly in expectation. Factual information can measurably reduce them and turn the risk factor into a starting point for treatment.

Withdrawal symptoms or relapse? How to distinguish between depressive symptoms

An important clinical question is whether new symptoms are part of the adjustment process or indicate a relapse. Adjustment reactions occur rapidly, often within days, and usually subside after two to four weeks. Physical signs such as dizziness or ‘brain zaps’ suggest this is the case.

A relapse develops more slowly and brings back the familiar depressive symptoms, such as persistent low mood and lack of motivation. This distinction is crucial. If in doubt, a discussion with the practice will clarify whether the dose should be temporarily increased again or the tapering process slowed down.

How do you safely come off antidepressants? Gradual tapering

The most important principle is: gradual tapering rather than an abrupt stop. In technical terms, this step-by-step approach is known as tapering. The dose is reduced in small increments over weeks or months, allowing the nervous system to adjust to each stage.

A step-by-step approach, becoming increasingly gradual towards the end – often down to below the minimum therapeutic dose – has proven effective. Horowitz and Taylor popularised this model because, in their experience, the final steps are the most difficult. If more severe symptoms occur, the reduction is slowed down, or the final stage is repeated. This reduces the severity of withdrawal symptoms.

What do clinical guidelines and psychiatry recommend?

The current guidelines advise regularly reviewing the use of these medicines and carefully planning the withdrawal of psychotropic drugs. Medication should not be taken for longer than necessary, and withdrawal should be planned. An experienced psychiatrist plans the individual steps on a case-by-case basis.

Psychotherapy can support this process. Those who work on triggers and relapse prevention during this phase are in a more stable position when the medication’s effects wear off. Medical supervision forms the core of a safe approach, as it combines tailored medication and realistic information with a dedicated point of contact.

A case study from clinical practice

A 38-year-old female patient had been taking venlafaxine for two years and wanted to stop taking the medication. During her first, overly rapid attempt, she experienced dizziness, nausea and ‘brain zaps’, so she resumed taking the medication for the time being.

On her second attempt, the dose was gradually reduced over several months, with particular care taken at the lower stages. Her symptoms remained mild. She also underwent psychotherapy. Patience, a tailored pace and professional support made all the difference.

Key points in brief

• When discontinuing antidepressants, around one in six to seven people experience symptoms directly attributable to the withdrawal; severe cases are rare (around 3 per cent).

• The meta-analysis by Henssler and the Charité (The Lancet Psychiatry, 2024) evaluated 79 studies involving 21,002 patients; a large proportion of the symptoms can be attributed to the nocebo effect.

• Addiction does not develop; there is no craving for the substance.

• Common withdrawal symptoms include dizziness, nausea, sleep problems and ‘brain zaps’ – brief electric shocks in the head.

• The active ingredient and dosage matter: paroxetine and venlafaxine are trickier, whilst fluoxetine is usually easier; the duration of use also plays a part.

• The safest approach is gradual tapering, with dose reductions in small increments, often to below the minimum therapeutic dose.

• Clinical guidelines and psychiatric practice recommend a planned, medically supervised withdrawal; never abrupt or undertaken without medical supervision.