A Functional Medicine Approach to Antidepressant Withdrawal

Second generation antidepressant medications, including fluoxetine (Prozac), citalopram (Celexa), paroxetine (Paxil), sertraline (Zoloft) and venlafaxine (Effexor)  are widely used for numerous indications, including depression, anxiety, obsessive-compulsive disorder and others. While they were initially praised for their safety, one of the biggest concerns with these medications is often overlooked: withdrawal. And unfortunately, standard guidelines have long underestimated the duration and severity of antidepressant withdrawal symptoms from extended use of antidepressants (Sørensen 2022).

As a phenomena, antidepressant withdrawal is commonly confused with other conditions, even misdiagnosed as a relapse of the original mental health concerns (Horowitz 2022). This often leads to an inappropriate reinstatement of the medication causing the withdrawal. Yet from the latest published data, we know that antidepressant withdrawal is common, even debilitating in some cases.

Incidence and Symptoms

A systematic review of antidepressant withdrawal studies found that withdrawal occurs in around 56% of individuals when they stop antidepressants. Of patients that have withdrawal, almost half describe their symptoms as severe (Davies 2019).

Symptoms of antidepressant withdrawal can affect numerous organ systems and physiological processes (Henssler 2019), including:

• Systemic: flu-like symptoms, dizziness, drowsiness, impaired balance, fatigue, weakness
• Cardiopulmonary: rapid heartbeat, shortness of breath
• Sensory: electric shock sensations, tingling or numbness, itch, tinnitus, blurred vision, altered taste
• Neuromuscular: muscle tension, muscle pain, nerve pain, tremor, poor coordination
• Vasomotor: sweating, flushing, chills, poor temperature regulation
• Gastrointestinal: diarrhea, abdominal pain, poor appetite, nausea, vomiting
• Sexual: premature ejaculation, genital hypersensitivity
• Sleep-related: insomnia, nightmares, vivid dreams, excessive sleep
• Mental: Confusion, disorientation, amnesia, poor concentration
• Emotional: irritability, anxiety, agitation, tension, panic, depressive mood, impulsivity, sudden crying, outbursts of anger, mania, increased drive, mood swings, suicidal thoughts, derealization, depersonalization
• Psychotic: visual and auditory hallucinations

The duration of withdrawal from antidepressants is not well characterized. However, the research that is available suggests that an extended duration of withdrawal is not unusual. In one study, symptoms remained for up to six weeks in 40% of individuals, while a separate study found that at 12 weeks, 25% were still symptomatic (Zajecka 1998, Davies 2019). Cases where individuals were still struggling with significant withdrawal for over a year have also been reported (Stockmann 2018).

Antidepressant Withdrawal Versus Relapse

Differentiating withdrawal symptoms from relapse can be a challenge since antidepressant medication withdrawal can include numerous mental and emotional symptoms. However, withdrawal can usually be identified by careful evaluation.

When differentiating withdrawal from relapse, consider (Horowitz 2022):

• Symptom onset in relation to any recent dose reduction
• Associations between mental-emotional and physical symptoms
• Symptom response to dose reinstatement
• Symptom wave patterns including onset, peak and resolution over time

Treating and Preventing Antidepressant Withdrawal

When antidepressants are tapered, it should typically be slow, with each step considered carefully by both the patient and practitioner to minimize symptoms. Recent data suggests that “hyperbolic” tapering may help to reduce withdrawal effects (van Os 2023). Hyperbolic tapering is based around a percentage decrease, so that the decrease in milligrams of medication with each reduction is smaller every time the dose is reduced. It typically requires compounding or other means for effective dose reduction. Regardless of what any treatment algorithm recommends, if a patient is struggling, the pace of any taper can be slowed.

My own clinical experience with thousands of patients has shown me that the same underlying imbalances that contribute to depression can also contribute to withdrawal symptoms. Evaluating for deficiencies in vitamin B12, folate, magnesium, omega-3 fatty acids, vitamin D and amino acids is often critical for reducing withdrawal symptoms. Supporting neurotransmitter and brain-derived neurotrophic factor (BDNF) production can also be helpful in challenging cases. Normally, symptomatic patients need a few months of treatment to stabilize before attempting a withdrawal. The approach is outlined in my book, Functional Medicine for Antidepressant Withdrawal, available on Amazon.

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