Citap.org.uk

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Helpline 0151 932 0102
SSRI WITHDRAWAL PROTOCOL

About these protocols

Selective serotonin and allied antidepressants can be very effective for moderate to severe depression,
however many people do have difficulties in coming off these medications.
With the help of Professor David Healy of Cardiff University School of Medicine, Wales, CITAp has
devised protocols for reduction and withdrawal from these drugs.
These protocols may be helpful for withdrawing from: -

If it is mutually agreed that reduction is appropriate, all these drugs may be reduced in several different
ways.
Standard reduction programme

It is vital that any reduction process is slow and gradual, probably more gradual than most people would
anticipate. Start by reducing only a small part of the dose on one day of the week. For instance from a dose
of 20mg, a reduction to a 10mg dose would take place for example on a Monday in each of the first two
weeks of the programme, with the usual 20mg being taken through the rest of the two weeks. The following
two weeks the reduced dose of 10mg would be taken on two (non-consecutive) days, and the next two
weeks on three days and so on, until the 10mg dose is being taken on every day of the week. The next
reduction step from 10mg to 5mg then commences and continues in the same way down to seven days at
5mg, and then the final stage goes from 5mg down to zero. If at any point the reduction becomes too painful,
rather than increasing the dose again, it is permissible to remain at the current level for several weeks before
reducing further.
Reduction using liquid preparations

Despite the very slow reduction achieved by the above method is can still be difficult for some people to
carry out, and especially so with some SSRIs, notably paroxetine (Seroxat). In these cases a liquid
preparation can be far more helpful, where one is pharmaceutically available. When a liquid preparation is
being taken the same method should be employed as outlined above, in this case reducing 1ml (2mg) on one
day of the week then on two days and so on. This clearly means the amount of drug reduced at any one time
is much smaller and this may work better for many people. Similar liquid versions are available for most
drugs but they are expensive and often need to be ordered specially for individual patients, which may delay
their starting their programme. If starting from a high dose of paroxetine, a mixture of tablets and liquid may
need to be used at the start.

Transferring to longer-acting preparations

It has been found that transferring over from their original antidepressant to fluoxetine (Prozac) or
citalopram (Effexor) can be very helpful for some people, as the longer acting nature of these drugs makes
them easier medications from which to withdraw. There is no need for a gap between the original
medication and new one, as these antidepressants can be directly switched to the equivalent level. Although
the first few days may be uncomfortable, it is worth persevering as in our experience this is the most
effective mode of withdrawing. Fluoxetine and citalopram are best taken early in the day, night time use can
reduce sleeping quality and quantity. Sometimes patients experience more feelings of anxiety in the few
days after transfer, because the previous antidepressant has been stopped and fluoxetine has not yet started
working. But these symptoms of anxiety should settle down and a feeling of well-being established.
Transfer can take place either at the start of the reduction programme, or there can be some reduction time
on the original drug before then transferring to the equivalent dose of fluoxetine or citalopram, if and when
further reduction on the original drug becomes too difficult or painful. Whenever transfer does take place, a
period of four weeks of stabilisation is essential before starting to reduce the fluoxetine. These four weeks
can be done with tablets but after this time it is preferable to switch to liquid. It is important to have this
period of stabilisation on the new antidepressant in order to begin a smooth reduction process thereafter.
Those switching from liquid paroxetine should preferable transfer directly to liquid fluoxetine.
Suitable drug levels at which to transfer over are: -
@ 50mgs switch to citalopram (Cipramil, but not Cipralex) @ 75mgs switch to citalopram (Cipramil, but not Cipralex) The reduction process with liquid fluoxetine is very similar to that suggested above for tablet reduction.
Fluoxetine liquid is marketed at a strength of 20mg per 5ml, and using our above protocol, reduction should
proceed by reducing in steps of 1ml (= 4mg) on a one day, two day, three days per week programme as
described above.
For those who are too anxious to tolerate the agitation that is occasionally caused by switching from
paroxetine to fluoxetine, citalopram (Cipramil - but not Cipralex) can also be used for transfer, and may be a
viable alternative antidepressant to use for slow withdrawal. Citalopram is a medium length acting SSRI
and although not as easy to use as liquid fluoxetine, does come in tablet sizes down to 10mg allowing for
small reduction steps. Whichever antidepressant is being used for reducing on or transferring to, some
withdrawal effects are inevitable. These can include anxiety, insomnia, dizziness, electric shock sensations,
skin and muscle sensations and cramps and other symptoms, but with suitably slow reduction and pauses
when withdrawal symptoms become too severe, these symptoms can usually be bearable and managed.
The formulation of some antidepressants such as Cipralex and Venlafaxine XL makes them difficult to
reduce slowly, and advice should be sought from CITAp about reducing these. A set of week by week
tables for coming off various antidepressants is available on request from the CITAp office or can be
downloaded from the CITAp website.

Transferring to St. John’s Wort
It is possible to switch to St. John’s Wort towards the end of an antidepressant withdrawal programme, as
despite this being an over-the-counter herbal product it is still a highly effective SSRI antidepressant.
St.John’s Wort is a very safe herbal remedy for depression but can occasionally have side effects such as eye
irritation or skin reactions. These are not dangerous and will disappear once you stop taking the tablets, but
it does mean that St. John’s Wort is not for you.
St. John’s Wort must not be taken whilst still taking another prescription antidepressant as this can
be dangerous. The prescription antidepressant must be stopped first and then the St.John’s Wort
commenced.
St. John’s Wort also interacts with some other prescribed medications which you may be already on
including the contraceptive pill, and it is very important that you always discuss your other medication with
the pharmacist before starting to take St. John’s Wort. If you can take it, St. John’s Wort is a very effective
way to finish off withdrawal but the changeover from your previous antidepressant may be accompanied by
some symptoms of anxiety. These will settle down quite quickly and you will then be able to taper off your
final stages of withdrawal in your own time.
St. John’s Wort may also be helpful for those who have stopped an SSRI suddenly and are experiencing
severe withdrawal symptoms as a result. It may therefore be a way of redeeming the situation and reducing
some of these withdrawal symptoms. The dosage of St. John’s Wort should be 1000mgs. There may be
some symptoms of anxiety, which again will not last and are worth putting up with for a short time, and
most people feel better once they settle on the St. John’s Wort. It may be necessary to increase the dose of
St. John’s Wort to 2000mg after three to four weeks as this higher dose seems to be more effective, and is
quite safe.
Another over-the-counter preparation that is sometimes used as part of an antidepressant withdrawal
programme is 5-HTP (5-hydroxytryptophan). This is a precursor compound which once ingested is
converted in the body to serotonin (when taken during the day) and to melatonin, the sleep hormone (when
taken at night time). It can be used like St. John’s Wort after coming off the last of an SSRI antidepressant,
and is useful also as a sleeping aid. You may take up to 3 x 50mg tablets per day but it is wise to start with
50mgs and gradually increase, whilst a 50mg dose of 5HTP taken at bedtime may aid sleep as the serotonin
converts to melatonin in the presence of darkness.
5-HTP must never be taken simultaneously with an antidepressant nor at the same time as taking St.
John’s Wort, as this can be dangerous.
Depression after SSRI Withdrawal

Whichever approach is used to reduce and come off an SSRI antidepressant it is likely that some withdrawal
symptoms will occur. These will often resemble the original depressive episode which brought about the
decision to commence antidepressants, perhaps many years ago. These are not reasons to immediately
resume the medication. Rather it is an indication that further time is necessary for the brain and body to get
back to normal after the effects of the antidepressant, as it can take several months before SSRI withdrawal
symptoms finally disappear. At this stage however it might be appropriate to consider initiating counselling
or CBT sessions in the event that the original situation causing the depression was never addressed and
resolved.
Dealing with Hypoglycaemia

Whilst taking SSRI antidepressants, and especially when on reduction programmes, the body often has
problems in maintaining blood sugar (glucose) levels, and precautions need to be taken to avoid periods of
hypoglycaemia when blood glucose falls too abruptly and too low. Many withdrawal symptoms, especially
dizziness, weakness and fainting are the result of hypoglycaemia, which most commonly occurs overnight
and is frequently apparent on waking in the morning. To avoid such episodes it is preferable to eat frequent
small meals through the day and early evening rather than large meals followed by long gaps. Increasing the
proportion of pasta, rice, fruit and vegetables in the diet and reducing the intake of refined sugars in sweets
and cakes, will also help to stabilise blood glucose, whilst having a half a banana at bedtime with the other
half kept for when waking, will further avoid hypoglycaemic episodes during the night and early morning.
Life after SSRI Withdrawal

Anxiety and insomnia are two of the longest lasting of the SSRI withdrawal symptoms to resolve, and the
distress that these can cause can undermine the sense of achievement that should come from breaking free of
antidepressant dependency. Where a benzodiazepine tranquilliser or hypnotic is being taken alongside the
SSRI no attempt must be made to reduce this simultaneously with the SSRI. Rather this should be
maintained at its current dose during SSRI reduction as it will help to minimise anxiety or insomnia arising
from the antidepressant reduction. Only when the antidepressant withdrawal programme has been
completed and full recovery from this been achieved should a start be made on reducing any benzodiazepine
or z-drug sleeping tablet. Help and guidance about dealing with anxiety and insomnia is also available from
CITAp and its National Helpline, including advice on herbal and other natural remedies, breathing
techniques to manage hyperventilation and panic attacks, and the use of therapies such as acupuncture,
relaxation, counselling, CBT and Mindfulness.

Source: http://www.citap.org.uk/SSRI-Protocol.pdf