In early 2023, Liana Shatova began taking low doses of an antidepressant to relieve symptoms of a premenstrual disorder characterized by mood swings, anxiety and depression. At first, the difference was noticeable to her.
“I felt energized and could juggle several things at once,” said Shatova, 40, a business development manager in the Greater Boston area.
Then, after about 18 months on the medication, he began to fear that he was becoming emotionally numb.
“My best friend’s mom died unexpectedly, everyone was in shock and sobbing, and I couldn’t cry at all,” Shatova said. “I just didn’t feel anything.”
When Shatova asked her doctor if she could stop taking the medication sertraline, an antidepressant better known by its brand name Zoloft, she said he assured her that she was taking the lowest prescribed dose and that stopping would not be difficult.
Initially everything seemed fine, but after a month, Shatova said she experienced her first attack of what would become chronic insomnia, followed by panic attacks. Other symptoms emerged, including night sweats, muscle and joint pain, and mood swings that left her unable to work.
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 medication.
Antidepressants, primarily SSRIs or selective serotonin reuptake inhibitors, are some of the most prescribed medications in the United States and are taken by tens of millions of adults. About twice as many women as men report using an antidepressant in the past 30 days, and antidepressant use is highest among women ages 60 and older, according to government data.
Side effects are a key reason people decide to stop taking their medications, but stopping them can also lead to withdrawal symptoms, research indicates. Along with growing awareness, a deprescribing movement is brewing in the field of psychiatry, which aims to help patients reduce or stop their medications when they are no longer considered necessary.
In a recent large analysis published in The Lancet in November, researchers at King’s College London found that physical side effects, including rapid weight gain, a significant increase in heart rate or elevated blood pressure, may be more common than previously thought, depending on the drug. The review analyzed the results of 151 clinical trials and 17 Food and Drug Administration reports, involving about 30 different prescription drugs used to treat depression, anxiety, and bipolar and panic disorders.
Researchers examined the effects of antidepressants on weight, blood glucose, total cholesterol, blood pressure and heart rate. They did not look at the emotional changes experienced by patients like Shatova, although the study’s lead author said they should be further examined in future studies.
“Not all antidepressants are the same when it comes to their side effects on physical health,” said Dr. Toby Pillinger, an academic clinical professor at King’s College London, who led the study. “Until recently, we have approached antidepressant prescribing with a one-size-fits-all policy, and I think we need to move away from that.”
Separately, in August, psychiatry researchers in the United Kingdom found that serious withdrawal effects may be more common than previously suspected, especially with long-term use, although the study was small: only 18% of participants responded to the survey. The results showed that among people who had been taking antidepressants for more than two years, 63% reported moderate or severe withdrawal effects, and a third described withdrawal problems that lasted more than three months.
Symptoms ranged from insomnia to confusion, electrical sensations, muscle cramps, agitation, mood swings, and derealization or alteration in the person’s perception of the world.
Dr. Mark Horowitz, a clinical researcher at University College London who led the withdrawal study, said other research has found that about a quarter of patients experience serious symptoms when they abruptly stop taking their medications, 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 found that withdrawal symptoms can occur even when people try to taper off. A review of several existing studies published last year by a group of German psychiatrists concluded that up to 1 in 3 antidepressant users will experience some type of withdrawal symptoms, and that severe symptoms will occur 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 “discontinuation symptoms,” primarily nausea and dizziness, particularly if they are stopped abruptly.
It is not clear why some patients experience severe symptoms after stopping their medications. Some researchers, concerned by reports of antidepressant withdrawal, suggest that the underlying mechanisms are similar to those faced by people suffering from alcohol and opioid withdrawal.
“Withdrawal symptoms tell you that your brain is trying to reestablish a balance that was forced to change by the presence of a drug,” said David Cohen, a professor of social well-being at the University of California, Los Angeles. “I think it’s the best accepted explanation for why stopping any centrally active drug, whether it’s antidepressants, coffee or heroin, produces some discomfort.”
The challenge for psychiatrists is that medications, which are often prescribed along with therapy, help many people, especially in the short term. Dr. Jonathan Alpert, a professor of psychiatry at Albert Einstein College of Medicine, said anecdotes of extreme withdrawal do not reflect his own professional experience.
In his practice, Alpert estimated that two-thirds of his patients have been taking antidepressants for more than five years, and only a small handful had experienced prolonged withdrawal symptoms lasting more than a few days.
“There’s been a very exaggerated idea that it’s really hard to get off psychiatric medications,” Alpert said. “While I respect people’s narratives about their own experience, it feels very different from what we see in clinical practice and research studies.”
Goldberg also expressed skepticism about whether antidepressants themselves are really responsible for the symptoms patients report.
“If someone, after years of treatment, develops some frankly peculiar and unexpected neurological problems, I’m not sure to what extent that can be attributed to the medicine,” he said. “Anything is possible. But I think we have to consider the more likely possibility that what they are finding is unrelated.”
More than a year after Shatova first tried tapering off the medication, she said she is still going through a painstaking process of small, gradual reductions to try to keep her symptoms from exacerbating.
“I’m still tapering and now taking 0.835 mg of Zoloft, doing it very slowly and carefully,” he said. “My sleep has improved, but I still have windows and waves caused by life stress and hormonal fluctuations.”
It’s important not to discount people’s experiences, Goldberg said, and anyone experiencing symptoms should undergo further testing. Goldberg, former president of the American Society of Clinical Psychopharmacology, said the organization is now completing new guidelines on deprescribing. The goal is to help doctors explain what to expect when stopping psychiatric medications so that patients do not taper without medical supervision.
Alpert suggested analyzing different types of data stored in electronic medical records to understand the characteristics of patients who have long-term withdrawal symptoms.
“Do they have MRIs or blood tests with abnormal inflammatory markers? By looking at large data sets, it will be more possible to identify predictors for this subset of people who appear to have unusually long symptoms.”
Cohen believes the field of psychiatry needs to accelerate research. However, in the wake of 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, such studies will likely need to be conducted by UK or European researchers.
“We need large, non-industry-funded trials to examine what happens when people stop taking antidepressants, using various tapering strategies and long enough follow-up,” Cohen said. “We need dozens of such trials now.”
If you or someone you know is in crisis, call or text 988, or go to 988lifeline.orgto reach Suicide & Crisis Lifeline. You can also call the network, formerly known as the National Suicide Prevention Lifeline, at 800-273-8255or visit SpeakingOfSuicide.com/resources.
