Talk:Antidepressant discontinuation syndrome

"Symptoms" section

The symptoms listed in this section appear to be those when actually taking the drugs. Not symptoms experienced during withdrawal. This article should be limited to discussion of stopping use of these drugs and the affects thereof. Any comments/suggestions? 68.99.208.33 09:50, 12 May 2007 (UTC)

This section is stupid and misleading it's a list of SSRI potential side effects fron takint the drugs not discontinuing them.mike (talk) 23:06, 5 February 2008 (UTC)

duloxetine (Cymbalta) Taken 2005-2009 Ok. Stopped the med symptoms dizziness, brain zaps, tremors, confusion, forgetfulness, fatigue, insomnia (both at the same time), migraine, nausea, blurry vision, visual disturbances, odd sensation in extremities, ringing of the ears, and decreased hearing. I'm going on three weeks now that I have figured out what is wrong with me I can tell the doctors. I have had CT scan and MRI all normal of course. Drs knew the med was stopped said it was out of my system and I should be fine. Glad I kept looking. And before you get too indepth with the symptoms I am a healthy 29yr/old female who until having symptoms of toxicity to cymbalta had to stop taking it. Now all I feel is what is listed above. —Preceding unsigned comment added by Mmdtemp (talk • contribs) 15:33, 4 June 2009 (UTC)

"Discontinuation of Venlafaxine" section

In the text: "Online help groups consistently mention withdrawal from Effexor as triggering dreams of a particularly distressing and hellish quality" Lots of citations... none from "online help groups", I believe. (Don't know if this matters...)

Also the word, "hellish", seems inappropriate and I doubt it is a direct quote from the legitimate looking references. It also contributes to the 'rantiness' mentioned elsewhere in this discussion.

Finally, "venlafaxine" is used everywhere else in this article instead of "Effexor" (except for the "Effexor" in parenthesis at the first use of "venlafaxine").

Dopamine Antagonists

I've removed this paragraph:

Abrupt cessation of treatment with dopamine antagonists may precipitate a florid psychosis with delusions, hallucinations, and suicidal and/or homicidal behavior. It is better to slowly taper the dose (by 10% increments of the original dose) while closely observing the patient for exacerbation of psychotic symptoms.

The above paragraph is true, but seeing as SSRIS and SNRIs are Selective Serotonin Reuptake Inhibitors and Serotonin-Norepinephrine reuptake inhibitors, they do not directly affect dopamine and are hence not dopamine antagonists. True, they may indirectly affect the dopamine system, but seeing as the SSRI discontinuation symptoms do not include any of the psychotic or hallucinatory symptoms, I felt it was misleading to include information on dopamine antagonist withdrawal.

The above comment could well apply to withdrawal from other drugs, such as Risperidone. Tom Michael - Mostly Zen (talk) 10:23, 4 December 2006 (UTC)

Comment

Posted 08-06-2008 I started taking Lexapro Sept 2006 after my mother passed away. The doctor prescribed 20mg at bedtime. It helped my symptoms (crying all the time). Dec 2006 I noticed I was dizzy and my balanced was off. I am a runner. I started noticing that I would almost fall when running. End of March and first of April I had fallen three time in one month running. I looked up the side effects of the drug Lexapro that being off balance was one of the side effects. I decided to go off of the drug. I started having the electrical shocks, brain squeeze. I could move my eyes quick and have the shocks. I called the doctor he said he didnt know what I was talking about. I thought that I was having a stoke or something. I looked to the internet. Looked up side effects of discontinuing the drug lexapro. There is was all the symptoms that I was having to deal with. So, I called the doctor again. I told him about the articles that I found on the internet. He got upset and said that just a few people have the side effects that I am one of the few. Now, the phone call before that he didnt know anything. It have been over a year and I am still having the electrical shocks and the brain squeeze. When will it end. I think the doctors should inform the patients of the side effects so they can decide if they want to take this drug. sally ky The following was added anonymously to the main article, 19:02, 10 February 2006 by 24.35.51.190

I've tried most SSRI's. In my opinion PAXIL had the most rapid onset on the SSRI dscontinuation syndrome. Every time I would try to go below 20 MG. I was reducing the dose every day by 1mg. This symptoms started as soon as I would get to 18 or 19 MG. The first symptoms included at first dizziness which escalated to vision problems, bed spins, nausea and vomiting. The vertigo was so bad that I could not move my head at all from my pillow had to sit in a dark room with no stimulation whatsoever. I called my doctor who advised me to take another 20 mg and see if it didn't help . IT did, but I was stuck taking the paxil for a year before I was able to transitioin from paxil to prozac with few problems. SSRI's really never had any effect on my depression or axiety and now come to find out since I have little to no serotonin in my body, the drug would have never worked anyway. All that suffering not to mention the 40 pound weight gain. FOR nothing. My advice is before starting any SSRI, have you serotonin levels checked to see if they will even help. Why pollute your body if they have no effect?

-- Anonymous, I doubt you'll ever see this, but it's worth mentioning that there is no test for levels of seratonin in the brain. Until technology moves on, we still have to cut a slice off a brain to test neurotransmitter levels - it's possible to test for levels of seratonin in the blood, but this is not even close to an accurate indicator of what's going on in the synapse. If more people were aware of this, then the unscientific "chemical imbalance" schtick used in SSRI advertising would look more like what it is, a crass oversimplification used as a marketing tool, and an attempt to sell these effective-but-HEAVY psychiatric medications to the general public as though they were vitamin C.

-- [Worth mentioning that this is because Serotonin doesn't cross the blood-brain barrier]

ok, cut out a piece of my brain. i'm cool with that. it would be less painful and disturbing than the constant dizziness and brain zaps and shit. (although i am so glad that "brain zaps" are a recognised side effect with a name and a definition i think i could cry). Ragnarokmephy 03:53, 6 February 2007 (UTC)

-- There's also an unrelated but similar experience called Exploding head syndrome. It's not a symptom of withdrawal (check the WP article). I've had both... brain zaps as I experience them don't usually involve much sound, if any, and almost exlusively happen when I'm half asleep (like exploding head).

Verifiability

I removed the following:

Many physicians do not get informed consent at the time of 
initial prescription that covers the difficulties of later 
withdrawal from the drug, so this syndrome can be an unexpected 
barrier to patients, especially those who tried the drug in 
response to a specific crisis, who expected an easy withdrawal 
once their emotional situation stabilized.

There was no citation for this, and for such a bold statement I think some sort of verification is needed. There were several other places in the article where I added the citation template, but this one particularly stuck out. --Clay Collier 11:01, 12 May 2006 (UTC)

Someone put it back in, so I just rephrased it to "covers the potential difficulties", which should be uncontroversial enough. It might bear mentioning that most physicians have no idea what these "heavier" discontinuation problems might be like, as the current text implies that this is intentional, which it usually isn't. It should also be mentioned that using these drugs "in response to a specific crisis" is not an approved indication, unless there is an actual depression, and that this is part of the reason why some doctors feel that SSRIs and SNRIs are inappropriate in treating light depression. Any medical treatment is a cost/benefit tradeoff. Zuiram 10:13, 14 November 2006 (UTC)

Pharmacology

The longer the drug takes to be eliminated from the body (i.e. the longer the half-life), the less discontinuation syndrome there will be, as the withdrawal is less abrupt. Prozac has the longest half-life of the SSRIs (by far, I think), and because you can essentially switch from one SSRI to another without tapering off, I think it's fairly common to switch a patient to Prozac before discontinuing so that there are less shitty effects. I'd have to find a reference though... --Galaxiaad 22:21, 30 July 2006 (UTC)

This link is a citable source, and it states that SSRIs alleviate the discontinuation syndrome. Other sources state that it is viable to use a benzodiazepine during the withdrawal period. These things generally solve the problem. Zuiram 10:16, 14 November 2006 (UTC)

I have a ref for this have to find it.

Out of interest, how does restarting SSRIs "solve the problem" of trying to discontinue SSRIs? The problem of withdrawal symptoms is one thing, but people experiencing withdrawal obviously intend to stop taking the drugs, either because they want to (because their depression has been controlled, they now have better coping mechanisms in place, and these drugs are not safe for indefinite use) or because they have to (because they have reached tolerance, often at the highest recommended dosage, or because the side effects are outweighing any benefits). That particular problem is certainly not solved by restarting an SSRI. The Prozac option sometimes works well, but rarely for long-term users of SSRIs, for whom the problem is not so much withdrawal as dependency - in other words, buffering with Prozac can minimise the shock to the system from withdrawal, but does nothing to accelerate the return to homeostasis that is necessary for complete recovery from SSRI discontinuation (and which can take a disconcertingly long time for people who have used the drugs for some years). Benzos can certainly be effective in minimising symptoms, but taking benzos daily eventually leaves the patient in the same situation - dependent on a fairly heavy drug that is very difficult to withdraw from - so they're far from ideal, and again only "solve the problem" for patients who have used the drugs short-term and whose withdrawal syndrome is brief.

Also, it's incorrect to state that "you can essentially switch from one SSRI to another without tapering off". This is often the case, but by no means is it a plain fact. While they're broadly very similar, the precise action of each SSRI is subtly different, and many patients experience severe withdrawal symptoms even when switching drugs (sometimes coupled with start-up symptoms from the new drug). With a new drug in place, these symptoms usually calm down after a while, but some people never stabilise on the new drug and have to return to the previous one. That's also another reason why the Prozac buffer method is often unsuccessful. MrBronson 23:40, 17 December 2006 (UTC)

Using one SSRI to get off another is like using methadone to stop heroin - it's just a stop-gap measure that doesn't really solve the problem.

Regarding merge from Venlafaxine

I think that the withdrawal effects of venlafaxine should be left in the venlafaxine entry, as the severity and frequency of discontinuation syndrome is notable and of interest for this drug. There is an ongoing controversy over whether the manufacturer provides sufficient warning of the risk of withdrawal effects. Jstade 05:17, 26 August 2006 (UTC)

Makes sense. The {{main}} template does the job anyway. :) --Quiddity 06:29, 26 August 2006 (UTC)

While I do not advocate to move the whole section, I think that the section should be cut down to 1-2 paragraphs. Otherwise the {{main}} template is not warranted. --Dirk Beetstra ^{T C} 08:47, 2 September 2006 (UTC)

New alteration

The second paragraph in 'persisting adverse effects' appears to have been reinstated from an earlier edit (see 'verifiability', above). While I think the point it makes would be hard to argue against, does it perhaps still need a citation? As it stands, it looks rather like POV.

More to the point, does it really belong in this section? This section is about well-documented post-SSRI effects (citations would also be useful here, incidentally), and it seems to be slightly weakened by the sudden digression. If this second paragraph is to remain, it should probably be placed elsewhere in the article. MrBronson 18:58, 24 October 2006 (UTC)

The article comes over as highly biased.

Yes, there is clearly an SSRI discontinuation syndrome. Yes, it is uncomfortable, and in rare cases unbearably so. Yes, user reports (along with some medical literature) clearly indicate that venlafaxine is worse in this regard.

No, indefinitely persisting adverse post-SSRI effects are not common.

I'm highly biased against the SSRI and SNRI drugs, at least in regards to moderate-to-severe depression, and consider my POV to be borne out by available scientific evidence. However, this article reads like a rant, and even I would not go as far as this in my criticism.

And the point about persistent memory problems seems paradoxical, as memory effects are a common side-effect of the actual use of SSRIs. This is related to their effects on the β-adrenergic system, which notably causes an imbalance in the evaluation of the "significance" of the memory, as well as altering the stored emotional context to something a bit "flatter". Withdrawal of SSRIs should not cause this, which the text implies, although it is conceivable that such a side-effect could persist after discontinuation if it existed before; this should be reversible by resensitizing the β-adrenergic system.

Zuiram 10:23, 14 November 2006 (UTC)

Zuiram -

The article doesn't suggest that indefinitely persisting adverse post-SSRI effects are "common". I don't think anyone would suggest they were "common". They certainly do occur, though, which is why they deserve a mention in an article on SSRI discontinuation syndrome. I don't think there's anything wrong with the phrasing here, and it doesn't upset the balance of the article (the bulk of it deals with the common form of discontinuation syndrome - a few weeks of head zaps, fluey symptoms, dizziness etc - and the information on persisting adverse effects is sealed away in its own section). But I do agree that there's a slight POV "edge" to this page, even though the actual information is sound. Part of the problem is that most editors who have bothered to work on this page will be people with actual experience of severe problems on (or off) SSRIs, so a slightly POV tone is probably inevitable (and most of the editors who don't fit that profile will have an overtly pro-SSRI agenda, either because they're currently taking them and doing well, or because they have been wound up by some of the, er, "less scientific" criticism of SSRIs that does the rounds). This is one of those subjects where it's hard to get a balance, because the only people interested are likely to have a strong opinion one way or another.

Regarding the memory problems: you're correct that the problem originates during SSRI use, and most people who complain of poor memory post-SSRI had poor memory while taking the drug. But the problem will often get much worse once the drug is discontinued (this goes for most of the "persistent" symptoms). This isn't that strange really - you can see exactly the same pattern with many cases of tardive dyskinesia in patients who have been taking antipsychotics. Slight tics emerge on the drug, and can escalate into full-blown movement disorder once the drug is withdrawn. I'm sure you'll agree that neurological symptoms worsening after the withdrawal of the psychiatric drug that caused them is hardly a new phenomenon. Incidentally, maybe I should know this, but how exactly would one "resensitize the β-adrenergic system"? With antihypertensives? Do you know of this working on anyone who has experienced post-SSRI memory issues? If what you're suggesting actually works, a lot of people would be extremely interested.

Also, to answer what you posted higher up the page:

It might bear mentioning that most physicians have no idea what these "heavier" discontinuation problems might be like, as the current text implies that this is intentional, which it usually isn't. It should also be mentioned that using these drugs "in response to a specific crisis" is not an approved indication, unless there is an actual depression, and that this is part of the reason why some doctors feel that SSRIs and SNRIs are inappropriate in treating light depression. Any medical treatment is a cost/benefit tradeoff.

Of course, the reason why the mass prescription of SSRIs does not involve truly informed consent is that the drug companies fail to pass on the "uncomfortable" information (and in some cases have suppressed trial data, etc), so most docs are just unaware of how powerful and potentially problematic these drugs are. This is why SSRIs are overprescribed, often inappropriately, and why patients who experience serious problems on discontinuation can have problems finding a doctor (even a psych) who has any idea about what's happening. So doctors get a bit of unfair stick on this - but I think it's fairly obvious that the blame really lies with the drug firms, who have generally behaved appallingly when it comes to SSRIs, and continue to do so. Obviously, a bald statement like that is way too POV for Wikipedia, but there's no other context in which to explain this ongoing problem of doctors not being sufficiently knowledgable about these drugs to provide the necessary information to their patients, or even to correctly judge the risk/benefit ratio - and that is a BIG problem. I'm not sure there's any way to state the facts here, without it looking like some kind of anti-pharma rant (something discreet like "many doctors are unaware of severe withdrawal symptoms" sort-of reads as "many doctors are incompetent", which is obviously not the case... but that's what I've changed it to for now, anyway). MrBronson 06:26, 16 November 2006 (UTC)

One other point - the PANES entry was removed from Wikipedia on the grounds that a.) the term "PANES" is not used in science/medicine, even by those who have studied severe post-SSRI issues - it's a term made up by one person, who maintains a "PANES" website which only contains a couple of case histories, and was last updated four years ago, and b.) all the relevant information in that page has now been moved to this page and placed in the "Persisting adverse effects" section. So I'm deleting the bit about "PANES", along with a few other very slight changes. MrBronson 06:30, 16 November 2006 (UTC)

After being a recipient of discontinuation syndrome from SSRI medication i can verify that the myriad of symptoms do last an awful long time. The longest lasting symptom for me is moderate to severe left sided morning headache and dizziness and /or head pressure when bending over. it is now three months since coming off SSRI'S over a six week period in which symptoms still occured. Prior to taking SSRI's i was not a headache sufferer. Does your research or can it in the future look at the incidence of neckpain and headache post SSRI use/ withdrawal, as sometimes this may be lost in the data.( Darryl Coulstock. Bach Health. 1000hrs ^ Aug 2008) —Preceding unsigned comment added by 203.145.107.130 (talk) 00:09, 6 August 2008 (UTC)

duplication of SSRI info

Does the list of symptoms of SSRIs (as well as the list of SSRIs themselves) need to be here? It appears to be mostly duplicated from the SSRI article, and occupies a fair portion of space. I think it's somewhat distracting, and am inclined to delete it - but I figured I should ask here first. --moof 07:15, 5 January 2007 (UTC)

Response - Symptoms of withdrawal and symptoms of SSRI overlap, due to change in neurotransmitters, but are not exactly the same. I think the symptoms and list of medications are important for the reader only glancing at the article and looking for something they identify with. (67.82.232.151)

Terminology

Although there are those who would like to block the use of the term 'withdrawal' from this class of effects, it is an argument mostly based on social engineering, not on technical accuracy. The AAPM, APS, and ASAM have consensus definitions for Addiction, Physical Dependence, and Tolerance which are widely accepted as reasonable. Although SSRIs generally do not qualify as "addictive" (the term for the psycho-social-behavioral issue of using a drug or engaging in an activity in the face of harm), they do qualify as causing physical dependence. Simply, physical dependence is defined by withdrawal symptoms. The distinction between Addiction and Physical Dependence was created to be able to talk about the two separately. It is unnecessary to come up with some ill-defined "syndrome" to describe SSRI withdrawal effects. Not everyone experiences withdrawal from all dependence-inducing drugs, just as not everyone who uses an SSRI experiences the withdrawal effects. The arguments, such as those made by Dr Richard C. Shelton in his 2006 overview (J Clin Psychiatry 2006:67 suppl 4), are based on the idea that it is too scary to use the term 'withdrawal' in the general public because it brings up the spectres of addiction for patients. The reason this argument fails to take the day is that the symptoms of withdrawal do not require addiction and creating new technical medical terms for the explicit purpose of confusing the general public into misunderstanding the nature of the problem they may face is clearly unacceptable as a general practice. The only argument that seems positive is that SSRI Discontinuation Syndrome might yield more unique search results than SSRI withdrawal might. But, please, this is an explicit attempt to downplay the seriousness of the problem, not to actually create a useful distinction. People experience withdrawal from these drugs.

On Jan 10, a change I made was removed: "user 67.82.232.151 (→Definition of Withdrawal - removed 78% of patients comment, citation did not provide statistic." This is certainly untrue. If you mean the /abstract/ does not provide the statistic, then that's true, but the full article certainly does. They are not the primary source, but the sentence was cited to that article because there are several points that are summarized out of the Shelton article. He gives the source of the statistic as: Priest RG, Vize C et al. "Lay people's attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch." BMJ 1996; 313:858-859. The Priest 1996 survey and a couple others like it are used to support the argument that the general public believe anti-depressants to be "addictive" and are wary of starting to take them. This is an important problem with effective treatment in many medical fields from pain management to severe mental illness to more mild mental health issues.

Response - I only removed the statistic because there was no citation. I was only able to read the abstract of Shelton's article and could not access the full text. I moved the withdrawal terminology "argument" to its own section as well since it seems worthy of being its own internal discussion of the broader context. (67.82.232.151)

I feel like the "persisting adverse effects" section should be removed entirely--I don't see any citations for anything other than the four cases of sexual dysfunction. If someone can find something--ANYTHING--then go for it.

- In answer to the above, there's some relatively recent stuff here:

"Persistent tardive rebound panic disorder, rebound anxiety and insomnia following paroxetine withdrawal: a review of rebound-withdrawal phenomena" (Can J Clin Pharmacol. 2006 Winter;13(1):e69-74. Epub 2006 Jan 23.) viewable here - http://www.cjcp.ca/pdf/CJCP_04-032_e69.pdf

"Effects of gradual discontinuation of selective serotonin reuptake inhibitors in panic disorder with agoraphobia" (Int J Neuropsychopharmacol. 2007 Jan 16) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17224089&query_hl=27&itool=pubmed_docsum

"Genital anaesthesia persisting six years after sertraline discontinuation" ( J Sex Marital Ther. 2006 Jul-Sep) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16709553&query_hl=9&itool=pubmed_docsum

"Neurobiology of antidepressant withdrawal: implications for the longitudinal outcome of depression" ( Biol Psychiatry. 2003 Nov 15) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=14625154&query_hl=3&itool=pubmed_docsum

"Persistent sexual side effects after SSRI discontinuation" ( Psychother Psychosom. 2006) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16636635&query_hl=9&itool=pubmed_docsum

"Newer antidepressants and the discontinuation syndrome" (J Clin Psychiatry. 1997) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=9219489&query_hl=17&itool=pubmed_docsum (quote: "Although generally mild and short-lived, discontinuation symptoms can be severe and chronic")

This is in addition to an absolute mountain of anecdotal evidence, which is obviously not much use for Wikipedia in itself - but adverse neurological effects from chronic use of psychiatric medications is hardly an novel concept. The relative lack of research done in this area is unsurprising, considering obvious problems such as inability to measure brain NT levels, difficulty in establishing any kind of control group, etc. There are, however, plenty of case histories - this isn't something someone's made up, it's a very real phenomenon, even if the exact mechanism is not yet understood. MrBronson 05:01, 1 April 2007 (UTC)

I looked through all this stuff, and I still see no citations for much of the "persisting adverse" section. According to this section, patients can experience poor short-term memory, poor concentration, tinnitus, akathisia, tachycardia, and depersonalization for an indefinite period of time *after* ceasing SSRI use. I'm removing this until somebody can find *any* citation whatsoever for the effects listed. Furthermore, please provide some kind of reference for "PAWS." 67.171.78.5 01:23, 5 April 2007 (UTC)

More specifically--I see articles cited for continuing sexual dysfunction and panic attacks, but I found nothing discussing any of the above listed effects (poor memory, akathisia, etc.) 67.171.78.5 01:26, 5 April 2007 (UTC)

OK, there's now a properly-cited reference to long-term discontinuation problems. The symptoms noted are referenced in the full text of the article cited. This section of the paper was recently quoted in the New York Times, incidentally. Let this be the end of the argument, if possible. MrBronson 14:54, 6 May 2007 (UTC)

I'm not trying to "argue," really. These just seem like very strong claims to make with little solid citations. The "long-term discontinuation" link you provided does not make any reference to symptoms continuing for "years"--it clearly says "months," and as such, I'm removing the "years" from the wikipedia article. Furthermore, the link seems only to provide an abstract of the article. Is there a way to make the full text accessible for all readers? 67.171.78.5 05:38, 12 May 2007 (UTC)

The PAWS section is taken almost word-for-word from this site http://www.interventionctr.com/paws.htm Also, this syndrome seems to apply to those withdrawing from alcohol or hard drugs...I'm not sure this is applicable to SSRIs. 67.171.78.5 00:46, 3 May 2007 (UTC)

Another note on use of the word addiction: Older theories of addiction defined it in terms of dependence (both physical and psychological) and withdrawal. It is now understood that physical dependence and withdrawal are neither necessary nor sufficient to result in addiction. Modern theories of addiction define it in terms of persistent and compulsive use of a substance. This is an important distinction, because one of the notable characteristics of addiction is a strong, enduring tendency towards compulsive use that outlasts any physical withdrawal symptoms. For example, a person who has ceased using heroin and outlasted the effects of withdrawal is still at high risk for relapse months and even years later. This effect is very much absent in the case of SSRIs. While they may result in physical dependence (in the sense that use of the drug is encouraged by negative symptoms during discontinuation), they do not encourage persistent or compulsive use--either in humans or in animal models. The use of the word addiction is scientifically inaccurate, and therefore inappropriate for the article.

The above distinction is discussed in a semireasonable fashion in the "Definition of withdrawal" section. However, I still see the word addiction appearing throughout the article (eg, in the "Discontinuaton of Duloxetine" section). With or without qualifiers, the word addiction gives the wrong impression about the physiological mechanisms underlying discontinuation syndrome, which are very much distinct from those involved in drug addiction.

I understand the strong feelings among many of those contributing to this article. I've been through SNRI withdrawal several times and it's not fun. But I'm also a scientist who specializes in neuropharmacology and addiction, and I find the frequent reference to "addiction" and "physical addiction" (as opposed to physical dependence) to be troublesome.

Original Research

As this article is generally well referenced, I believe placing OR tags (or fact tags) in places there are specific problems would be more useful in improving this article than putting the tag at the top. Neitherday (talk) 17:27, 16 July 2008 (UTC)

"Mechanism" section

The writing in this section is simply appalling. It is written like the rough draft of a student dissertation with a mesmerizing degree of stylistic incompetence, i.e., like gobbly-gook. Can we please find someone to translate this into language more suitable for an encyclopedia and less like a medical monograph? Sadly I seem to be as busy as the person or people who contributed that section, but someone needs to rework this rubbish. As a professor well used to marking medical essays and research papers, the writing here is a perfect example of what not to do when learning to communicate as a scientist. Budding doctors, note this! —Preceding unsigned comment added by 86.147.216.35 (talk) 08:12, 31 August 2008 (UTC)

Brain zaps

I wanted to express my discontent with the decision to move the article on "Brain zaps" here. Most of the information has been edited out, leaving only a vague aberration of what the article once was. Moreover, brain zaps are not exclusive to antidepressant withdrawal. They are also found in benzodiazepine withdrawal and as side effects of other medications such as Buspirone. Additionally, brain zaps are not the same thing as paraesthesia, but that's arguable (and should be argued in a controversy section in a dedicated article). Overall, the choice to downsize and relocate the brain zaps article has made it less accessible and less accurate, which is counter to the spirit of Wikipedia. Svadhisthana (talk) 22:11, 2 August 2008 (UTC)

The reason I boldly performed the merge was simple: there are parctically no reliable sources that discuss the issue. Please see my comments there, and indeed my work initially trimming the article of rampant original research prior to concluding that there was nothing to basically salvage. This is what was left after I cleared all the OR and unverified content. If you can provide further sources that discuss the subject, please do so, here or at Talk:Brain zaps. — Scientizzle 01:52, 3 August 2008 (UTC)

Thank you for your response and clarification. I'm presently looking into finding credible sources in order to revive the article. Having experienced the phenomenon personally, you see, I have plenty of reason to want to see the article restored. svadhisthana (talk) 17:35, 13 August 2008 (UTC)

Electric shock sensations

My preliminary research has turned up the following:

• Of the terms "brain zaps," "brain shivers," and "electric shock sensations," the last is found most frequently in credible sources.
• Electric shock sensations are often referred to in medical literature as co-occurring with, or a type of paresthesia.
• Electric shock sensations have been described as being symptoms of the following conditions: multiple sclerosis; neuropathic pain; epileptic seizures; spinal disc herniation; rheumatoid cervical myelopathy; spinal epidural abscess; alveolar, lingual or mental nerve blocks; reflex-sensitive spinal segmental myoclonus; and, of course, SSRI discontinuation syndrome.
• Electric shock sensations have also been described as being caused by the following procedures: electroporation therapy, occipital nerve stimulation, and cervical spine surgery. (Some of these procedures may actually cause real electrical shocks, not just neurological sensations. I'll be sure to read into them carefully.)

It appears that my research is pointing me toward creating an article for electric shock sensations. Since brain zaps and brain shivers are found as alternative descriptions for the term, I'll likely redirect them there after the article is created. svadhisthana (talk) 07:02, 16 August 2008 (UTC)

Further updates will be here. svadhisthana (talk) 20:39, 16 August 2008 (UTC)

Any model for the mechanism behind these things? My experience include split instant loss of vision and/or hearing. It was like a tinnitus burst. 71.86.152.127 (talk) 04:30, 28 September 2009 (UTC)

Fluoxetine as intervention in SSRI Discontinuation Syndrome

Shouldn't this section be placed as a sub-section of the "Prevention and treatment"? Xargque (talk) 23:57, 4 March 2009 (UTC)

Non-existent reference

Under the Fluoxetine intervention section, the reference:

• Intractable withdrawal from venlafaxine treated with fluoxetine was reported by WJ Giakas, JM Davis - Psychiatric Ann, 1997.

Does not appear on a search on PubMed:

http://www.ncbi.nlm.nih.gov/sites/entrez

Specifically, the search "Giakas[au] Davis[au]" returns no results whatsoever; my other attempts to find the article also were fruitless. I have labeled this as needing citation, but recommend the removal of this apparently nonexistent reference, unless the reference can be found.

Xargque (talk) 00:06, 5 March 2009 (UTC)

I went to pharmacy school and although I do not practice, the PI sheet tells me that the difficult venlafaxine's withdrawal is due to the following: the patient is withdrawing from two major metabolites: venlafaxine and O-desmethylvenlafaxine. The combined half-life is anywhere from 12-20 hours. It takes anywhere from two to five days to clear out of your system. While you clean out of one metabolite, you still have another one in your system. No other popular SSRI or SNRI does a double metabolite withdrawal. —Preceding unsigned comment added by Julcal (talk • contribs) 15:29, 6 April 2009 (UTC)

That is not correct. Active metabolites if anything help as it gives your body a chance to adapte. The quicker a drug and its active metabolites leaves the body, the more intense the withdrawal syndrome. Anyway 12 - 20 hours is rather a short time. Drugs like fluoxetine can take weeks to leave the system so even with abrupt withdrawal there is a chance for the body to adjust before all the drug leaves the body. Fluoxetine has an active metabolite, norfluoxetine so you are incorrect in saying that only venlafaxine has active metabolites.--Literaturegeek | T@1k? 19:39, 6 April 2009 (UTC)

Active metabolites do not help when you are withdrawing from both of them. It would be like withdrawing from two separate medications at one time - no doctor would ever suggest such a thing. ADDING another AD would help the body adapt, eg. Prozac. 12-20 is an abrupt withdrawal, as you say, which makes the withdrawal even worse. Fluoxetine has an active metabolite but it has an incredibly long half life. It essentially withdraws itself. I stand by my statement. --Julcal (talk) 22:09, 6 April 2009 (UTC)julcal

Mwalla, it is not like withdrawing from two different drugs if the active metabolite shares the same pharmacodynamic/mechanism of action. If the body metabolised it into an opiod agonist or GABAergic drug or something then yes but this is not the case here so you are mistaken.--Literaturegeek | T@1k? 22:25, 6 April 2009 (UTC)

Um... venlafaxine is not an active metabolite of itself. It makes no sense. I quote from the PI: "Venlafaxine is well absorbed and extensively metabolized in the liver. O-desmethylvenlafaxine (ODV) is the only major active metabolite." To suggest that venlafaxine turns itself into itself is a bit... peculiar. I second LG's thoughts regarding an active metabolite possibly (not definitely) helping with withdrawal - if a compund (eg., venlafaxine) turns itself into an active metabolite (eg., ODV), then it would be logical for it to sort of "taper itself out" - that is, when the original compund's concentration in the blood diminishes, a (potentially weaker or stronger) active metabolite is formed (perhaps not as the single metabolite), leading to a prolonged effect similar to the original substance, most often weaker than the original compund's effect but of a longer duration (the combined half-life of both compounds is usually longer than that of only the first compound). Then again, there are substances (terfenadine comes to mind) where the metabolite actually is the active principle (as in fexofenadine, terfenadine's metabolite), or where the metabolite has different properties (eg., hydroxyzine enters the brain and acts as a mild sedative, while its metabolite cetirizine less readily crosses the blood-brain barrier and thus is less calming). WnC? 23:18, 6 April 2009 (UTC)

The ref says it has an active metabolite, but not that this makes wd harder. This is synthesis WP:SYN and original research WP:OR, even if allegedly "everybody knows" and "no doctor would" and it "is plausible". It is just wrong and the ref does not say that. This is not admissible as evidence to WP, the reference has to LITERALLY SAY what you claim, that is how citations work. Trust me. 70.137.165.53 (talk) 11:36, 7 April 2009 (UTC) 70.137.165.53 (talk) 11:36, 7 April 2009 (UTC)

First, is Julcal's pharmacy sheet an acceptable source, can that be cited? Second, until someone can help find the reference that I asked about in this thread, I will remove the offending statement in the article that prompted this whole discussion. Xargque (talk) 16:38, 8 April 2009 (UTC)

SSRIs and SNRIs

Aren't SSRIs and SNRIs two completely different medication classes? Venlafaxine for example is an SNRI, but is listed as an SSRI in this article, then confusingly is noted as an SNRI just below the list.

Perhaps venlafaxine and duloxetine should just be taken off the list of SSRIs, but the paragraph below the list highlighting their difference remain (and something mentioning the similarity of discontinuation symptoms to SSRIs be put it, but only if this is true and reliable sources can be found).

But also, if SSRIs and SNRIs are different, shouldn't the section on 'Discontinuation of SNRIs' be split into a different article totally? A separate article called 'Serotonin norepinephrine reuptake inhibitor discontinuation syndrome'?

—Preceding unsigned comment added by 190.213.57.220 (talk) 18:53, 14 August 2009 (UTC)

Maybe make a second list while explaining that they are in a different class?... With the qualification, "although the withdrawal symptoms are {identical and/or similar}" —Preceding unsigned comment added by 121.210.170.141 (talk) 14:16, 2 September 2009 (UTC)

tags

The article currently has two tags applied to the entire text. The "original research" tag has been there more than a year. The "expert" tag has been there for months. However, there seems to be no current discussion as to what the tags refer to or are trying to resolve? Does anyone object if I remove the tags?TVC 15 (talk) 02:34, 13 September 2009 (UTC)

Sections of the article remain unreferenced and, in the absence of verification, constitute original research. Please leave the tags until this is resolved. For example, the following sentences and sections need references:

• "The condition often begins between 24 hours to one week after reduction in dosage or complete discontinuation, depending on the elimination half-life of the drug."
• "The prescribing labels of SSRIs acknowledge the possibility of "intolerable" discontinuation reactions, and some patients have extreme difficulty discontinuing use from SSRI drugs."
• The entire "Indicators" section.
• "Several pharmacokinetic and pharmacodynamic factors influence the frequency and onset of these symptoms. When allowed to run its course, the syndrome duration is variable (usually one to several weeks) and ranges from mild-moderate intensity in most patients, to extremely distressing in a smaller number of patients who may have side effects for months."
• "Due to a lack of peer reviewed diagnostic criteria many physicians, unaware of the potential severity of discontinuation syndrome, do not get informed consent at the time of initial prescription from the patient (though patients in clinical trials do), so this syndrome can be an unexpected barrier to patients attempting to discontinue the drug. In addition, warnings to patients not to stop taking the drug without doctor's approval, while indicated, may lead to a reluctance to discontinue SSRI therapy in patients who need not take the drugs long-term."
• "Critics argue that the pharmaceutical industry has a vested interest in creating a distinction between addiction to recreational or illegal drugs and dependence on antidepressants."
• The first two paragraphs of the "Mechanism" section.
• "The condition may be avoided by either recommencing the original, and/or lesser dose of the SSRI (or a similar SSRI), or slowly reducing the dosage over several weeks or months. While slowly reducing the dosage does not guarantee that a patient will not experience the discontinuation syndrome, it is considered a safer method than abrupt discontinuation. Gradual discontinuation, or tapering, or titration, can be accomplished by breaking pills into parts or using a graduated oral syringe with the liquid form. Alternatively, a compounding pharmacy may take one's prescription and divide it into smaller graduated doses. For example, a 20mg prescription of Cymbalta which comes in gel capsules containing tiny sphere-shaped pellets, may be divided into 20, 15, 10, 5 and 2.5mg doses."
• "Discontinuation of Duloxetine" is almost entirely unreferenced, and only cites the manufacturer's prescribing info.
• "Neonatal withdrawal" contains several unreferenced statements at the beginning.
• The last three paragraphs of "Controversy" have no references.

I'm sure you can find citations for most, if not all of these. Many can be copied over from paroxetine, I bet. Until then, the tags need to stay. Skinwalker (talk) 00:03, 16 September 2009 (UTC)

cold-turkey and sexual desire

Personally and several other anecdotes found on support forums describe returning sexual desire with a vengeance upon sudden discontinuation of SSRI's. I've searched for the last hour but can not find reputable sources. My experience was with clomipramine and it like reentering adolescence. It was the sole psychoactive drug in my system and the new found desire was accompanied by the electric shocks as the clomipramine 1/2 lives passed. I had seen Scientific American article on human love where low serotonin/ high dopamine levels were involved. I found this poor source upon quick search but I believe there is better. SSRI withdrawal results in lowered serotonin, and in some people whose dopamine levels were unaffected by their depression, then perhaps their mind is put into the passionate love state looking for a partner to attach to. Anyone have supporting sources? 71.86.152.127 (talk) 06:41, 22 September 2009 (UTC)