Coming off antidepressants: tapering, withdrawal symptoms and support

Antidepressants are prescribed for depression and for several other problems, including generalised anxiety disorder, panic disorder, OCD, PTSD, nerve pain and some other conditions. After you have taken one for a while, your brain and body appear to adjust to its presence. The Royal College of Psychiatrists explains that if the medicine is stopped too quickly, the body needs time to adjust back again, and that the sudden change seems to produce withdrawal symptoms.

Because of this, the usual advice from the NHS and from psychiatrists is to taper: take smaller doses for a period and then stop completely. The College says everyone should taper, although people who have taken a medicine for only a short time may need only a couple of steps. Those who have taken one for many months or years generally need a slower reduction, often over months.

Tapering does not guarantee that you will have no symptoms, but it is meant to reduce the chance of them and to make any that do appear less severe. It also lowers the risk of becoming unwell again while the medicine is withdrawn.

People stop antidepressants for different reasons. Their mood may have improved, the medicine may not be helping, side effects may be unpleasant, or they may simply prefer not to take a daily tablet. The Royal College of Psychiatrists lists all of these as common reasons and suggests talking to your prescriber, who can help you weigh the benefits of staying on the medicine against the problems that can come with long-term use, such as increased side effects.

The NHS explains that people are usually advised to continue for at least 6 months after symptoms improve. Those with severe or recurring depression may be advised to stay on treatment for longer, as the College notes. Choosing a time when life is relatively settled, rather than during a bereavement, exams or a house move, can make the process easier to manage, though that is a practical point rather than a rule.

• Tell your prescriber if you want to stop, even if you feel well; they can check how long you have been on treatment and whether anything else, such as another medicine, affects the plan.

• If side effects are the problem, ask whether a different antidepressant or dose might help before you decide to stop altogether.

• If you have had depression more than once, ask how likely it is to return and what early warning signs to watch for.

• Ask whether talking therapy could be offered alongside the reduction; NHS inform says antidepressants are often prescribed together with a talking therapy such as CBT.

The NHS lists a wide range of withdrawal symptoms. They include headaches, aching joints and muscles, feeling sick, sweating, a racing or fluttering heart, dizziness or unsteadiness, sleep problems and strange dreams, feeling low or emotionally numb, restlessness, irritability, anxiety, tearfulness, confusion, and unusual body sensations such as electric-shock feelings in the head, often called brain zaps.

The Royal College of Psychiatrists adds that anxiety can come in intense surges, that a feeling of things not being real can occur, and that a sense of inner restlessness with an inability to stay still, called akathisia, is possible. Some people notice that turning the head to the side makes the electric-shock sensations worse.

According to the NHS, most people get some symptoms while coming off antidepressants, although some get none. The symptoms usually begin within a few days and last a few weeks. For a minority they can be severe, start weeks or months later, and last for months or longer; this is thought more likely with a longer period of use or a higher dose. The College says it is not yet possible to predict who will have the more difficult experiences.

There is no single schedule, and your prescriber should tailor it to you. The Royal College of Psychiatrists gives examples rather than rules. For someone who has taken an antidepressant for only a few weeks, it suggests a reduction of roughly a half or a quarter of the current dose every two to four weeks. For someone who has taken it for many months, who has had withdrawal before, or who takes a medicine with a higher risk of withdrawal, it suggests starting with smaller steps such as a tenth or a twentieth of the dose.

The College explains that reductions are usually calculated as a proportion of the latest dose, so the steps get smaller as the dose gets lower, and that some people need to reach a very low dose before stopping completely. It advises against skipping doses on some days, because that makes the level of medicine in the body fluctuate. Fluoxetine stays in the body for longer, and the College says alternate-day dosing may be possible, but that is something to discuss with a prescriber rather than try alone.

If uncomfortable symptoms develop, the College suggests pausing, returning to the last dose that felt comfortable, and trying again later with smaller steps. Very small doses may require liquid preparations or other formulations. The College points out that liquids come in more than one strength and that mistakes are possible, so any conversion from tablets should be checked with a pharmacist or prescriber. Tapering strips are mentioned as an option that is not licensed by the MHRA, which a prescriber may or may not choose to use.

Low mood, poor sleep and panicky feelings can occur in both situations, which is why the question causes so much worry. Rather than guessing, it helps to note when symptoms began relative to each dose change, whether any are new to you, and how they responded to changes in dose. Your prescriber can use this timeline to decide whether to hold the dose, reduce more slowly or re-assess your mental health.

If you are worried that your depression is returning, say so. The Royal College of Psychiatrists says a temporary increase in dose followed by a slower reduction may be suggested when withdrawal symptoms are troublesome. If depression has genuinely returned, the NHS advises talking to your doctor about treatment options. NHS inform lists talking therapies such as CBT, interpersonal therapy and counselling among the alternatives or additions to antidepressants.

The NHS says suicidal thoughts or an urge to self-harm are not common but can occur when starting an antidepressant, and the Royal College of Psychiatrists says that suicidal thoughts may also appear while reducing or stopping, either as a withdrawal symptom or as depression returning. Speak to your prescriber immediately if this happens. If you are in danger or do not feel you can keep yourself safe, call 999 or go to A&E.

For urgent mental health advice that is not an emergency, NHS 111 can point you to local crisis services. Tell someone you trust that you are reducing your medicine so they can notice changes you might miss.

Most people reduce antidepressants under the GP who prescribes them, sometimes with a pharmacist or a mental health practitioner involved. GP surgeries can offer review appointments during the taper, and the NHS also offers the New Medicine Service for people starting certain commonly used antidepressants. If withdrawal is difficult, your GP can refer you to NHS mental health services.

Some people choose a private psychiatrist for a longer appointment and a more detailed tapering plan, particularly after earlier attempts have been hard. A private psychiatrist can usually prescribe, but supplying liquid or special formulations still depends on what can be dispensed, and a private prescription should be coordinated with the GP so that monitoring is not duplicated or missed. Whichever route you use, ask for the plan in writing, including what to do if symptoms flare.