Brief report
Antidepressant withdrawal symptoms—Telephone calls to a national medication helpline

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Abstract

Aims and method

Withdrawal symptoms are associated with cessation of all antidepressants but particularly paroxetine and venlafaxine. We aimed to examine rates of withdrawal symptoms reported to a national medication helpline over seven and a half year period. All calls reporting symptoms of antidepressant withdrawal were noted from a retrospective examination of contemporaneous handwritten records.

Results

Between October 1997 and March 2005, the national medication helpline received 22,422 calls of which 1753 (7.8%) concerned antidepressant discontinuation symptoms. Of these, 690 calls (39.36%) related to paroxetine and 252 (14.38%) to venlafaxine. Calls regarding paroxetine increased ten-fold in the month following a BBC ‘Panorama’ programme centring on problems associated with its use. Comparing number of calls with the number of prescriptions written over the same period revealed that MAOIs have the highest rate of reported reactions.

Clinical implications

Withdrawal symptoms were reported with nearly all antidepressants but most commonly with paroxetine and venlafaxine. Television programmes reporting adverse consequences of drug therapy can greatly increase reporting of discontinuation reactions. The highest rate of reporting adverse discontinuation symptoms was for MAOIs.

Introduction

Withdrawal or discontinuation symptoms have been reported with tricyclic antidepressants (Dilsaver and Greden-Snider, 1987, Garner et al., 1993), monoamine oxidase inhibitors (MAOIs) (Dilsaver, 1994, Lejoyeux and Adés, 1997) and selective serotonin reuptake inhibitors (SSRIs) (Therrien and Markowitz, 1997, Haddad, 1998), including venlafaxine (strictly speaking, a serotonin-noradrenaline reuptake inhibitor (SNRI)). Withdrawal reactions seem to be most commonly associated with paroxetine in particular but also with venlafaxine (Piednoir et al., 2002). Frequency of withdrawal reactions may not relate directly to mode of action since drugs with similar pharmacological actions have different propensities for discontinuation reactions. For example, withdrawal reactions are more common with paroxetine than with escitalopram in both depression and anxiety (Baldwin et al., 2005). There may also be minor differences in the rate and severity of reactions reported for the two available SNRIs, although as with venlafaxine, the frequency of reactions with duloxetine is rather high (more than half experience at least one symptom) (Perahia et al., 2005). Frequency of effects may be partly dependent on pharmacokinetic properties such as plasma half-life and clearance rate on cessation, as well as pharmacodynamic factors such as molar potency for reuptake inhibition (Schatzberg et al., 1997).

The Maudsley hospital pharmacy department runs a national medication helpline for patients and carers, which is funded by the National Institute of Mental Health in England. This is a weekday service staffed by experienced, specialist pharmacists and which receives direct calls from the public and referred calls from mental health charities and NHS Direct. Throughout the time of operation, staff had noticed trends and anomalies in the reporting of discontinuation reactions related to antidepressants. The most striking of these was an apparent increase in calls related to paroxetine following a BBC Panorama programme. We utilised our database of call details to investigate the frequency and pattern of calls relating to antidepressant discontinuation.

Section snippets

Method

The Maudsley medication helpline is a single telephone line which operates for 5 h each weekday. Calls are received from patients and carers all over the UK. The majority of the callers have been made aware of the service by mental health charities or by NHS Direct. The helpline is staffed by senior pharmacists with wide experience of psychiatry.

We hand-record details of all calls received and the replies we make to them. Caller names are not recorded without prior permission and most callers

Results

The helpline held records for 22,422 telephone calls received between October 1997 and March 2005. Of this total 1753 calls (7.8%) were from people suffering discontinuation symptoms at the time of the call.

Almost all marketed antidepressants were reported by callers to be the cause of discontinuation reactions but the largest number of calls related to paroxetine (690 calls, 39.36% of antidepressant total) and venlafaxine (252 calls, 14.38%). No other single antidepressant accounted for more

Discussion

This analysis of calls received by a specialist helpline over a seven year period has confirmed the relatively high prevalence of discontinuation symptoms with paroxetine and venlafaxine. It is also clear that a television programme on a national channel had a significant effect on the numbers of calls relating to paroxetine. Somewhat unexpectedly, we found that calls regarding discontinuation symptoms had been received for nearly all antidepressants marketed in the UK during the study period.

Acknowledgement

This study was funded by an unrestricted grant from Lundbeck Plc.

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