Like jumping off cliff after steep downhill

Quitting antidepressants can be tricky, leading many to a quagmire of drug dependence

The first time Tara (last name withheld) went off antidepressants in the early ’90s, she barely thought about it.

“I started taking Paxil when I was 23, when it first came on the market in Canada,” said Tara, who started using antidepressants to combat “an anxiety slump.” After a few months, she started to “feel normal” and stopped taking the drug.

At first, Tara felt like her old self. But on day four, Tara had terrible headaches and was dizzy, sleepy and nauseous. “The only way to describe it is that I felt terribly hungover,” Tara said. Her symptoms lasted a week. When she went to the doctor, he told her she was likely experiencing “antidepressant withdrawal syndrome,” a term that her doctor had never brought up during Tara’s initial prescription appointment.

“My doctor said that (medical professionals) were starting to hear that withdrawal was a challenge for people who stopped taking SSRIs” — selective serotonin reuptake inhibitors, the most commonly prescribed antidepressants. He advised her to go back on her meds.

Thirty years later, Tara is still on — and off — them.

Tara’s experience with antidepressants is depressingly common: get a prescription for a short-term mental health issue, then find yourself still on the drugs years, even decades, later.

Precise numbers are lacking in Canada, but SSRI consumption has doubled over the past 20 years in most developed countries. In 2021 (the most recent year for which data is available), Statistics Canada reported that 14 per cent of women and seven per cent of men took prescription medication for mood disorders between 2016 and 2019. In addition to depression,

SSRIs are prescribed for anxiety disorders, panic attacks, post-traumatic stress disorder and panic attacks.

While antidepressants can help many of the people who take them, many Canadians remain unaware of how to safely get off them. What should, for most people, be a shortterm prescription often turns into a quagmire of drug dependence, as they deal with the hamster wheel of withdrawal.

“Every time I went on the medication, I hated it because I knew that I was going to have to go through withdrawal,” said Laura (last name withheld), a Toronto entrepreneur and educator who has been on and off antidepressants for 25 years, since she was a teenager.

Like Tara, Laura’s symptoms have included feeling like she had the flu, a throbbing sensation in her face, nausea and “brain zaps,” which feel like electric shock sensations in the head. According to Surviving Antidepressants, a peer-to-peer support platform, other common symptoms discussed include everything from vertigo to suicidal ideation and occasionally homicidal thoughts.

“Unfortunately, many patients, without the doctor’s advice, stop the medications themselves once they feel better and then have withdrawal syndrome,” explained Dr. Mark Berber, a professor of psychiatry at the University of Toronto’s Temerty Faculty of Medicine. “Then the patient says, ‘Holy moly, my depression or anxiety is back.’ They think they’re sick again, so they go back on the drug.

“It’s very important when we prescribe these medications — and they’re hugely prescribed — that we explain to the patient that they cannot be suddenly discontinued, that they must be tapered off slowly.”

The conventional way to get off antidepressants is called “linear tapering,” gradually reducing your dose. Regular protocol is to cut it in half for a week and then in half again.

After years of experiencing the roller-coaster of the SSRI vicious circle, Laura decided linear tapering wasn’t working for her. “I’m really sensitive to medication,” she said. “I needed to take smaller steps over a longer period of time in order to not be in agony.”

Instead, on her doctor’s advice, Laura consulted a compound pharmacist, who supported her need for smaller steps with more precise dosing than she could do herself. Compound pharmacists can dispense micro-doses in tiny increments to scale down from, say, 1.5 mg to 1.4 mg, whereas the smallest tablet dose is usually 10 mg.

Laura said that it was an expensive route — about double the regular cost of antidepressants — which might make it inaccessible to some. But within six months, she was able to wean off SSRIs. Laura has now been off antidepressants for three years.

A growing number of people are choosing a similar antidepressant exit route. It’s known as a “hyperbolic tapering” protocol, a new way of thinking about SSRI de-prescribing, which takes into consideration serotonin transporter occupancy”: essentially, how the drug actually works in the brain.

One of the most ardent champions of hyperbolic tapering is Dr. Mark Horowitz, a training psychiatrist and clinical research fellow in psychiatry at North East London NHS Foundation Trust, who studies the neurobiology of depression and how antidepressants work.

“The key thing is that doubling the dose doesn’t double the effect,” said Horowitz, while pointing to a graph with a hyperbolic (sharp) curve that shows how the brain reacts to an increased dosage of an SSRI. “It goes up very steeply at low doses and it flattens out at higher doses.”

Horowitz explained, “When there’s not much drug around, every extra milligram has a big effect because all of the receptors are open.”

Since increased doses don’t have a linear effect, it makes sense that decreased doses don’t either. Horowitz said that a two-milligram dose can have half the effect of a 40-mg dose, as opposed to the one-20th you might expect.

“If you step down from 20 to 10 milligrams, which is half the dose, there’s a small effect on the brain that people can usually handle,” said Horowitz. “Going from 10 to five is a bigger effect and people often find a bit of trouble with it. But when they go from five milligrams to zero, it’s like jumping off a cliff after walking down a steep hill.”

Horowitz runs a psychotropic drug de-prescribing clinic in the U.K. He said that his email inbox was full of messages from people in North America asking him for help in designing a hyperbolic tapering protocol, since the guidelines here are still largely linear.

So when entrepreneur Tyler Dyck and scientific researcher Brandon Goode contacted him about starting Outro Health, a virtual medical SSRI de-prescribing service for Canadians, Horowitz was eager to sign on. The service launched last November.

Dyck and Horowitz said they are passionate about antidepressants in part because they’ve both been on SSRIs and understand how hard it can be to get off them.

Dyck said he was given a prescription for Lexapro in 2016, when he went to a doctor about insomnia and stress.

“I was working 75 hours a week in a pretty unfulfilling job and not eating well or exercising,” said Dyck. “My family doctor said that based on the fact that my mom, my aunt, my sister and my cousin were all on antidepressants, I must have a chemical imbalance and medication was really the only option.”

Of the multiple side effects he experienced, sexual dysfunction was the most difficult: “My wife and I were trying to have baby and I couldn’t even think about sex.”

Genital numbing, erectile dysfunction and the inability to orgasm are common antidepressant side effects which, according to Berber, about 40 to 50 per cent of patients experience while on the medication. Worse still, not everyone gets their libido back after they get off the drugs.

In 2006, researchers dealt with so many reports of dysfunction aftereffects — for decades — they classified Post-SSRI Sexual Dysfunction, which may include emotional blunting and apathy, as a separate syndrome.

Both Dyck and Horowitz said getting the word out about withdrawal is an important first step in helping people successfully get off antidepressants.

“We need to be informed about how safe and how effective these drugs are and how to stop them before we start taking them,” said Horowitz, who took SSRIs for 15 years like a “good patient” and is still on a minuscule dose after a very long taper. “I would argue that almost nobody is given a chance to give proper informed consent for antidepressants, since very few doctors know all these things.”

Dr. Dee Mangin, a McMaster professor of family medicine, said that awareness of withdrawal syndrome is on the rise both with doctors and individuals.

“The weight and volume of patient reports and patient advocacy raising awareness have been key, as well as the support of clinicians who also observe this both in patients and, in many cases, in themselves and family members,” she said. “This combined voice has become loud enough to be heard.”

She added, “When most of the information on drugs today comes from commercially driven trials, we need to put a lot of weight on these independent voices and experiences of patients.”

Horowitz said this would be a welcome change. “I feel like I was misled. I don’t want other people to fall into that same trap I did.”