Talk:Antidepressant discontinuation syndrome/Archive 1

"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)


 * There is a whole section on "Post-SSRI sexual dysfunction" which is actually a very minor & unimportant withdrawal symptom compared to others which are a lot more disabling and often life threatening! Nowhere is it elaborated the more serious symptoms like Panic and Anxiety Attacks, Tachycardia, Melancholy and mild to severe hypertension often resulting in a hypertensive crisis, landing the patient in the ER, when more than one of the above symptoms manifest together at once. Also, it is mentioned multiple number of times that Fluoxetine is the drug of choice for SSRI Discontinuation Syndrome due to its longer half life. Maybe several people are fond of Fluoetine. But actually Fluoxetine Discontinuation Syndrome is often a lot more delayed and a lot more long lasting than Escitalopram and others with a shorter half life. Arent there any middle aged doctors with practical experiences, who edit Wikipedia?Sub40Hz (talk) 13:27, 19 September 2010 (UTC)

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)

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)

---

Given the proliferation of web sites dedicated to people who are still having 'withdrawal' symptoms years after discontinuing these drugs, some of whom find themselves permanently crippled with severe neuropathic pain, cardio-respiratory exhaustion, and digestive torture nearly a decade later (like me), I find the above 'moderate' coffee-table like discussion of my eternal misery as 'rare' both hysterically funny and tragic. See the above section entitled 'Comments' for details.

The only thing 'rare' about it is the paucity of doctors, corporate executives, and bought-and-paid-for 'clinical researchers' who are willing to openly accept liability for the damage they have done. Well, think about it. Would you?

The remark about 'recharging' the nervous system with some other powerful drug after it has been damaged once already just smacks of recidivism to me. Keep in mind that nearly a third of the human race is at least genetically classified as relatively poor metabolizers due to normal genetic variation, and at least 10% are known in fact to be very poor metabolizers. Do we really want to stop up the serotonin bathtub in such individuals?

NPOV! NPOV! sorry, I cannot create research papers that prove what everyone who has been damaged already knows. I leave that up to your own conscience, but from where I sit, the official discourse is so slanted it falls right off my monitor. Please add more cautionary notes. We are just now finding out about the risk of suicide that the pharma companies concealed. How many more have to find out about the brain damage the hard way? —Preceding unsigned comment added by 75.79.69.67 (talk) 05:36, 30 December 2009 (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. &mdash; 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)

Autoreceptor downregulation
It is my understanding that some people experience these zap-like symptoms not only when they are coming off of the medication, but sometimes when they are ramping up on the medication, such as Lexapro or Zoloft. I believe there is data in the literature about an auto-receptor down-regulation phenomenon which takes place when the medication is first administered. In the presence of these new high levels of serotonin, the dorsal raphe nuclei (or other hindbrain nuclei) may decrease their release of 5HT -- that is, until the dosage is continued to be increased. Can someone look this up and include this in the article? This autoreceptor downregulation phenomenon may be something to mention, not just in the brain-zaps section, but at large, since this would apply to other withdrawal-like symptoms that people may experience when first going ON these drugs. --1000Faces (talk) 04:10, 2 December 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.-- Literature geek |  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.-- Literature geek |  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). W n C? 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)

Spelled out name
Is there a reason we recently spelled out SSRI? Is there a policy about never using abreviations in titles? Because I know there is one saying that we need to use the most common name. This syndrome is rarely if ever spelled out. It's always SSRI discontinuation syndrome or SSRI withdrawal syndrome. In fact, I think I'll be BOLD and move it back, unless there's a good explanation in the history.— trlkly 19:25, 30 September 2009 (UTC)
 * Nope, you need more than "per main." WP:MAIN is just the front page. There is no other reason given. I give WP:COMMONNAME. — trlkly


 * Just replying to the edit summaries for the comments above: as explained in the History section of the article, "discontinuation" and "withdrawal" are used interchangeably. The manufacturers understated the likelihood of withdrawal symptoms, and chose the term discontinuation to avoid the association with addiction.  However, withdrawal is the more accurate term, because the widely reported withdrawal symptoms are novel to the patients (i.e., not just relapse to prior symptoms) and thus establish physical dependence.TVC 15 (talk) 03:36, 1 October 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)
 * I found this for you: increase of libido upon treatment emergence is 1% or less for Cipramil Alatari (talk) 16:03, 21 October 2009 (UTC)

5-htp
5-htp also has the SSRI discontinuation syndrome. I think it's because of the tolerance of the serotonin receptors so anything that rises the serotonin levels daily, will produce tolerance low slowly. — Preceding unsigned comment added by 134.147.35.48 (talk) 17:43, 1 September 2011 (UTC)

that sounds really bullish. If anything you might be justified in saying that because the body tightly regulates 5HT, excess tryptophan activates repressor proteins as part of the natural regulatory systems. Tryptophan itself acts as a growth signal throughout the body, and prolonged excess has been associated with inhibition of this growth, ie reduced bone density correlate with high levels of tryptophan, higher bone density correlate with "low"(or is simply just lowER) levels of tryptophan.

BUT 5htp has _never_ been linked to BRAIN ZAPS, or EXPLODING HEAD SYNDROME. These truly are no joke. I know they sound like a joke but they are the perfect description, and are clearly experienced by many people because of the adoption of the terms by the public, despite the reluctance of the "Mainstream medical community" to even accept the application of the word "withdrawal".

i've experienced both of these withdrawal effects and most of the other people ive known who have taken SSRIs have also experienced BRAINZAPS. in one case she was unable to stop taking it because they were so severe, and prolonged after withdrawal, and she became dependent on it (so far for life) despite wanting to discontinue and attempting many times.

the only credible risk of actual 5htp (not some impurity) is nausea. what do you know serotonin is going to agonise the receptors in the brain stem involved with nausea too! its a sign that its getting through. perhaps adjust or divide the dose rather than filling the shopping cart with more dangerous antiemetics, unless you would risk your kidneys or EPS just to avoid what is typically a minor inconvenience. seriously ive never seen significant nausea with less than 200mg of 5htp which is a large dose, and the only indications for more are in regimes likehttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3068871/ which is 20years ahead of the "Main stream" who are so simple minded they want to use a single nutrient L-Dopa (L-dopa and 5htp are not a drugs, despite the fact that bigpharma cannot deny they are essential for pd and so want to control and own them. suddenly they go from risky unknown 'herbs' to "drug" ie something Bigpharma owns, controls and has authority over ) used alone without considering that it could imbalance other related aminoacids, and that this is the reason for the "side effects".

its astounding that there are so few studies with Control group, 5htp group and, Drug group (ie SSRI/SNRI/MAOI, Direct agonist, etc). I personally think it is because they would show just how ineffective antidepressants are at restoring levels of neurotransmitters when the diet is depleted. its just like whipping a dehydrated horse harder instead of giving it water.

And to those that will endlessly parrot the assertion that not a single american is deficient in tryptophan, cysteine, methionine, or other precursors for the fundamental neurotransmitters, ITS THE RATIOs dummies. Tryptophan absorption is also impaired by FRUCTOSE. rofl. Low Serotonin stimulates insulin and craving for carbos, because this is the bodies natural way to increase bioavailablity of tryptophan. some sugars bind aminoacids other than Tryptophan allowing the Tryptophan access to the transporter. Tryptophan has to compete for a single transporter system to cross the bbb and is out competed by all other aminoacids because its a larger molecule. Increase the ratio of aa's like glutamic acid (pass the msg), and you will induce depletion of serotonin. Counter intuitively eating more "protein" can _cause_ or make your _deficiency_ _worse_.

All the soy, and corn causes excess glutamic acid by ratio, and is causing serotonin depletion, and diabetes, depression etc, by now it has to be intentional. this has been known for decades. — Preceding unsigned comment added by 220.101.100.14 (talk) 06:04, 14 May 2012 (UTC)

Reference 13
Reference 13 regarding Post SSRI Sexual Dysfunction is not linking to a valid source. I apologize if this is not the correct area or manner to report this - I'm new here. Ethteck (talk) 00:40, 31 July 2013 (UTC)
 * Hi Ethteck, a belated welcome to Wikipedia and thank you for your comment! You did everything right so no need for apologies. I fixed the link.  Lova Falk     talk   08:53, 17 November 2013 (UTC)

Suicide
Not a single mention of suicide outside the references?

Remove the pharma shills that control this article complex from Wikipedia at once. — Preceding unsigned comment added by 77.56.139.11 (talk) 18:00, 24 May 2014 (UTC)

Edits of July 31
Comments moved here that were left on my Talk page: "Per MEDRS the popular press is discouraged as the "''sole source for a medical fact or figure. Editors are encouraged to seek out the scholarly research behind the news story.''" which has been done. Therefore the NY Times quote is acceptable to place in the article as a representation of the WP:notable level of the syndrome.  We are not solely relying on that popular source (and others) to build the article.

I kept your new source but your edit summary made it seem like you replaced the original source with a secondary that cites the primary. This I find is not the case. That source is not mentioned at all within the overview on 2nd gen anti-depressants. Also, the name of the reference then made no sense and the citation was missing information and lastly using the word 'most' might technically be correct but in fact it is only one of many drugs that has nearly 0 chance of discontinuation syndrome. Alatari (talk) 23:42, 31 July 2014 (UTC)"


 * Your own primary research citation that you added back in states " fluoxetine was not associated with any significant increase in symptomatology". The AHRQ review states that a clinical trial showed no difference between fluoxetine and placebo. I added two additional secondary references stating that discontinuation syndromes with fluoxetine were "mild or non-existent".  If you want to generalize this to fluoxetine, you need to come up with references better than these that state that it causes these symptoms.  Thanks Formerly 98 (talk) 00:37, 1 August 2014 (UTC)
 * You are mis-attributing the work I did. First, this is our article and I didn't add that source but returned it when you replaced it with what was supposed to be a secondary source quoting the primary.  Your edit summary was incorrect and you failed to cite it properly. You next edit summary accused me of badly sourcing the next statement when I was reading from a source you provided then properly cited. Did you forget you provided that source? Alatari (talk) 02:56, 1 August 2014 (UTC)
 * I apologize if I accused you of anything, particularly so if inappropriately. But my edit summary said nothing about the secondary ref quoting the origninal primary one.  It says I replaced it. Formerly 98 (talk) 13:44, 1 August 2014 (UTC)
 * Then why did you keep the same ref name=""? That implies that it was just a move to secondary citing or alternate weblink. Alatari (talk) 08:52, 3 August 2014 (UTC)
 * I also removed the NYTimes quote again. The problem is that you are not using it to establish "notablity" at all, but to make a statement about how frequent the disorder is. Furthermore, this estimate of the frequency, which is well above the average found in good secondary sources, has been placed in a box to emphasize it.  MEDRS explicitly states "primary sources must not be used to "debunk" secondary sources.  The AHRQ review gives much lower rates and is a secondary source. It quotes this excellent summary http://www.mhra.gov.uk/home/groups/pl-p/documents/drugsafetymessage/con019472.pdf which found that for most placebo controlled trials, the discontinuation syndrome rate differed only by 10-20% from the rate in those discontinuing placebo.
 * That section is about the history of syndrome and it's reflection in the news of the time. I wrote a section from the CSM Expert report backing up the NY Times quote and clarifying it then extending a few years past. Alatari (talk) 06:32, 1 August 2014 (UTC)
 * The source you provided has this to say: "'While withdrawal reactions on discontinuation of SSRIs and related drugs are well recognised, there has been increasing public concern about the potential of SSRIs to produce drug dependence or abuse.'"
 * Which recognizes and sources a concern by the pubic who thought that discontinuation syndrome is part of withdrawals from a classic addiction model. Alatari (talk) 03:22, 1 August 2014 (UTC)
 * It also states "'A review of the available published and unpublished data revealed no evidence that these drugs were associated with dependence, and the results of clinical and pre-clinical studies indicate that dependence, and the abuse potential of these drugs, is low.'" I'm not quite sure how a public concern about SSRI addiction from a decade ago that wasn't substantiated is all that notable that it needs a big boxed quote like that. It seems to me excess weight. Formerly 98 (talk) 16:44, 1 August 2014 (UTC)


 * Happy to take this over to the reliable sources board if you disagree. Formerly 98 (talk) 00:52, 1 August 2014 (UTC)
 * There is no need. The source you provided confirms the NY Times story with a chart of the 1990's studies showing 14 to 86% withdrawal chances on their 10 to 100 patient sample size studies (page 126). "'A search of the literature identified a number of studies which specifically assessed the risk of withdrawal reactions with the SSRIs and related antidepressants. The incidence of withdrawal reactions on discontinuation found in these studies ranged from 0% to 86% of patients. Wide variations were found between studies measuring the incidence of withdrawal reactions with a particular drug. This may be due to a number of factors, including study design, the patient population and the definition of withdrawal reactions employed.'"Alatari (talk) 04:59, 1 August 2014 (UTC)


 * We really need to be clear that the later figures from the chart of studies larger than 1000 patients include a tapered off ending to the medication and not an abrupt end Abruptly ending the medication has a very high chance of withdrawel symptoms.  Alatari (talk) 04:59, 1 August 2014 (UTC)


 * Yes and no. The problem here is that 1) most of these studies contain no arm testing withdrawal from placebo.  In those that do, the difference between the rate of experiencing withdrawal in the SSRI and placebo arms is generally about 20%.  In some cases higher rates of "withdrawal" were seen in the placebo arm compared to the SSRI arm.


 * And you are correct that the lower rates of withdrawal syndrome are in studies with tapered withdrawal. However, tapered withdrawal is the standard of care recommended on the package insert of all of these drugs.  Its like putting in the AE rate for people who overdose.  Its relevant, but almost completely avoidable. I think the focus of the discussion should be on the AE rate among those who use the drug in the recommended manner, not the rate in those who deliberately overdose, don't follow dosage instructions, etc.  Its ok to put that other stuff in, but it shouldn't be weighted in a way that is excessive.


 * You continue to add and add back what I considered to be MEDRS non-compliant references. I've posted a note to the Medicine Project Talk page requesting that folks from there help us resolve our disagreement. Formerly 98 (talk) 13:24, 1 August 2014 (UTC)
 * I'll repeat for the 5th time or so. This is about the history of the 1990's, media attention, public concern and the formation of the CSM Expert committee to address the issue.  We do not sanitize the history of the article just because it makes you uncomfortable.  Alatari (talk) 08:56, 3 August 2014 (UTC)

The points of contention from the POV of Formerly_98

1) There is a disagreement regarding the appropriateness of some references. I've heard of these symptoms, but don't think these are the best references to support the idea that all of these are "common". Some are primary research, others seem to just be letters to the editor.


 * "Common symptoms include diarrhea, nausea, vomiting, fatigue, headaches, sweating, dry mouth, dysphoria, fasciculation, insomnia, nightmares, somnolence, tremor, hyperarousal, loss of balance (vertigo, dizziness), agitation, anxiety, confusion, and sensory disturbances. [7] [8]. [9] [10] One electric shock-like sensation is distinctive and given the name "brain shivers" or "bottled lightning" and has been described as "a constant electric “whirr” inside of it (the head) that won’t stop" or "electric shocks pulsing rapidly through your brain every 2-5 seconds".[9] [10]""


 * To be clear. Sources 8,9 and 10 were already in the article and Formerly 98 was using them before I made my changes. Alatari (talk) 08:52, 3 August 2014 (UTC)
 * Reference 7 strikes me as a series of case reports
 * Formerly 98 you linked the wrong source. I corrected it and now everyone weighing in needs to review the source again. It is not based on case studies but just lists three cases as illustrative.  The report relies upon 17 other sources compiled as a warning about Venlafaxine. Alatari (talk) 08:52, 3 August 2014 (UTC)


 * Reference 8 seems fine but does not document most of these AEs
 * Reference 9 strikes me as primary research
 * Possibly. He is analyzing the usage of the term across patient and pharmaceutical sites.  Many are 404.  "In this paper, I look at the emergence of ‘brain shivers’ as a side-effect that appears to have emerged online, in the context of antidepressant side-effects and withdrawal. I discuss possible biological explanations for this strange, possibly new, complaint, as well as the emergence of particular symptoms as a sociological phenomenon aided by new technology."
 * It doesn't matter as the source is an etymology evaluation about how doctors and patients are referring to the electrical shock symptoms mentioned in other sources. It is not a determination of symptoms, it's not a basic mechanism paper, it's just about language usage to describe the symptoms that exist.  Alatari (talk) 10:01, 3 August 2014 (UTC)
 * Reference 10seems to me to be a letter to the editor that contains no general review of the literature, and no data.
 * Did you see the 8 or so references listed in this source? This would be a secondary source overview of several primary sources by a medical professional.Alatari (talk) 07:24, 3 August 2014 (UTC)
 * The same author makes reference to these terms again in a 6th addition of a classroom text book Stephens' Detection and Evaluation of Adverse Drug Reactions: Principles and Practice, John Talbot, Jeffrey K. Aronson

John Wiley & Sons, Dec 19, 2011. So it is not just a letter to the editor. Alatari (talk) 12:32, 3 August 2014 (UTC) 2) The section below is based on an excellent review. My concern is that while this is a high quality secondary reference, the level of drill down is inappropriate given that many of the individual trials being studied included 20 or fewer subjects.  The majority contained no placebo group. Those that did include a placebo group generally saw differences of only about 20% between withdrawal from SSRI and withdrawal from from placebo.  In fact, some of the studies found higher rates of withdrawal syndrome in the placebo arm compared to the SSRI arm, though these are not mentioned below.


 * Heightened media attention and continuing public concerns led to the formation of an Expert Group on the Safety of Selective Serotonin Reuptake Inhibitors (SSRIs) to evaluate all the research available prior to 2004. [18](piv) The high percentages were reflective of the nature of the studies. Some were based on case studies of fewer than 20 patients or larger studies of under 100 patients. The percentages nearing 80% came from studies involving missed doses for 3 to 8 days or abrupt discontinuation of the medicine. Among the studies referred to by the NY Times were two case studies with 12 of 14 (86%) patients (Black 1993) and 7 of 9 (78%) patients (Fava 1997) in withdrawal symptoms upon abrupt switching to placebo. The Rosenbaum double-blind study of 1998 had three study groups of about 80 patients each returned results of 14% (fluoxetine), 59% (sertraline) and 66% (paroxetine) withdrawal symptoms when patients were abruptly discontinued to simulate 5 to 8 days of missed doses.[18](p121) By the year 2000, larger studies had been concluded with lowered chance of discontinuation syndrome to between 5% and 23%[8] but the major difference to the older studies was that patients ended their treatment with the "consistent mandatory taper regimen". According to the CSM Expert Report, the later larger studies have between 5% and 49% incidence of withdrawal, depending on the particular SSRI, the length of time on the medicine and abrupt versus gradual cessation.[18](p126-136)"
 * Again, this is the History section of the article and is describing the data that the public and media had seen and used as a basis for their concern. An explanation as to how the public thought their maybe 80% withdrawal rates is appropriate. Alatari (talk) 08:52, 3 August 2014 (UTC)

3) I'm concerned about the extensive quoting of the NYTIMES and a primary research article for rates of discontinuation syndrome in the passage below:


 * "By then it had become clear that drug-company estimates that at most a few percent of those who took antidepressants would have a hard time getting off were far too low. Jerrold Rosenbaum and Maurizio Fava, researchers at Massachusetts General Hospital, found that among people getting off antidepressants, anywhere from 20 percent to 80 percent (depending on the drug) suffered what was being called antidepressant withdrawal (but which, after the symposium, was renamed “discontinuation syndrome”).— The New York Times, May 6, 2007[17]"
 * Yes I think i'd not use the NY times source. also the Brain Shivers and bottled lightning - I've never heard these terms used, and if they are only appearing in primary sources then they have not gained currency. Cas Liber (talk · contribs) 13:52, 1 August 2014 (UTC)\
 * I corrected the bottled lightning that was the title of the source but it should have stated brain zaps as was in the source. Alatari (talk) 09:33, 3 August 2014 (UTC)
 * Brain Shivers have caught on in popular, doctor and pharmacist usage. These are some of the 3,000 hits on a Google search "brain shiver" -
 * The symptom is described variously as “an electrical shock–like sensation in the brain,” “the sensation of the brain shivering,” “brain zaps,” “brain shocks,” “brain shivers,” “head shocks,” or “cranial zings.” - Jose A. Cortes, PhD and Rajiv Radhakrishnan, MD
 * Brain zaps, brain shivers, brain shocks, head shocks or electrical shocks are a common side effect and withdrawal symptom from antidepressants.  - Jean Pollack, Ph.D
 * Due to the large number of posts, the comments are spread out over two pages. Please be sure to click through to read them all. A description of what causes these Effexor withdrawal symptoms called "brain shivers" follows on page three.
 * In a minority of cases, patients won't be made aware that cessation of these types of medications can result in something referred to as "brain shivers." This is not a medical term, but one that began turning up largely on the Internet as people who were ceasing SSRI medications were looking for a term to describe what this process can cause. It is an apt description, as you will see in the following information.
 * The symptoms you describe have been alternately called “brain zaps,” “brain shock sensations,” and “brain shivers” by the patients who have experienced them. Drug manufacturers describe the sensations as part of what has been known as a “discontinuation syndrome” associated primarily with the use of selective serotonin re-uptake inhibitors (SSRIs) - Dr George Simon, PhD
 * Brain zaps have dual use in the media. One in connection to this symptom and the other in use to lucid dreaming studies.  Of the 21,000 hits I'm not sure of the split.  These two sources are notable usage as a description for the symptom in a couple court cases alleging addiction to Cymbalta.
 * Brain zaps mentions in a lawsuit against Eli Lilly - Law360, New York (December 17, 2013, 4:21 PM ET) '' A South Carolina federal judge ruled Monday that Eli Lilly & Co. did not fail to adequately warn an Iraq War veteran that the antidepressant Cymbalta can cause so-called brain zaps and other withdrawal symptoms, finding that a stronger warning would not have altered his treatment.
 * Class action law suit brought against Eli Lily over Cymbalta SSRI discontinuation syndrome Law360, New York (January 29, 2013, 4:24 PM ET) -- Eli Lilly & Co. on Monday pressed a California federal judge to toss a proposed class action from consumers who allege they experienced “brain zaps” and other side effects when trying to stop using antidepressant Cymbalta, saying it properly warned doctors of risks. 
 * same source as above
 * Another user (Svadhisthana) had completed a source search and evaluation on brain zap/brain shiverAlatari (talk) 10:33, 3 August 2014 (UTC)


 * References 7, 8, and 10 above are not reliable sources by Wikipedia standards for asserting the existence of adverse events. Why not just use reference 9? Is someone defending 7, 8, and 10? Why are they used at all?  Blue Rasberry   (talk)  15:31, 1 August 2014 (UTC)
 * Yes, 7, 9, and 19 are being defended. Please see above. Formerly 98 (talk) 16:22, 1 August 2014 (UTC)
 * Formerly 98 used the 8,9 and 10 sources in that section also I added 7 which which you'll need to look at again above as it was not properly linked on the talk page. Alatari (talk) 08:52, 3 August 2014 (UTC)


 * I came here from the note left at WT:WikiProject Pharmacology. It's a bit difficult to follow the discussion here, partly because of the comments inserted within other comments, but for me, the bottom line here is WP:MEDRS. For better or worse, Wikipedia is used by vast numbers of people when making medical decisions, more than websites set up by actual medical organizations. We have a very serious responsibility here, per WP:NOTHOW. Even though The New York Times is unquestionably a reliable source for most kinds of information, and can probably be used here as a source for things like government actions or for the existence of popular movements, it, and other sources that are not peer-reviewed summaries of medical knowledge, shouldn't be used for anything about the actions of medications. If there is a difference between the popular and the medical literature, we have to go strictly with the medical literature, and specifically secondary sources within it. --Tryptofish (talk) 22:53, 1 August 2014 (UTC)
 * The NY Times piece is being used only in the History sectio of the article to display the public concern and media attention the syndrome garnered.
 * About high quality popular news sources from WP:MEDRS: "'Conversely, the high-quality popular press can be a good source for social, biographical, current-affairs, financial, and historical information in a medical article. '"
 * It's very clear from the CSM panel that in the time before their expert panel was gathered there was high media coverage and public concern about anti-depressants withdrawal. They were put together to study all relevant data on the syndrome, reassure the public and return recommendations.  The public and media had received information of up to 80% withdrawal rates not understanding that it was from studies about abrupt discontinuance. Their introduction relates it clearly:


 * So the concerns about using popular news for sourcing would be valid in other sections of the article but not the History section as this syndrome had media attention and public concern and a major report about the syndrome confirms this. Other sources about the public concern would actually be appropriate.  Like a senator or public health official making a statement or a consumer advocacy group.  Alatari (talk) 07:24, 3 August 2014 (UTC)


 * Altari, please review WPMEDRS. It doesn't matter how many Google hits you get nor how often something in mentioned in the populuar media. These are not considered reliable sources for medical information.  There is a clear consensus that these sources you are using are inappropriate. Formerly 98 (talk) 10:34, 3 August 2014 (UTC)
 * I have and since you incorrectly cited the sources on this talk page for other editors to review, they haven't seen all the sources. The discussion is not finished and consensus is not reached.    Alatari (talk) 10:39, 3 August 2014 (UTC)


 * I don't know what you mean by your comment that I "incorrectly cited the sources". There is a clear consensus that the quoting of medical information from the NYTimes and the use of the primary sources describing the details of the parethesias in inappropriate, but you have re-added them after I removed them.
 * I can't make it any more clear. When [you linked source 7 you put in the wrong link.  No one saw the correct link.
 * We can not build a consensus on false information. You didn't give time for counter comment and there is a new source confirming resource 10.  Lastly, just because a source is primary and challenged is not automatic grounds for removal.  It means we seek a source to replace it.  If none is found there is nothing saying it must be removed in WP:MEDRS as long as it doesn't fail for other reasons.  Alatari (talk) 12:52, 3 August 2014 (UTC)


 * In general I have no objection to the inclusion of the various rates of incidence found in different studies, though I think the Expert Working Group explanation that the higher rates mostly refer to mild symptoms that were reported only on questioning should be included, as should the fact that non-zero rates were seen in patients who were discontinuing placebo. And its fine to include some discussion of the more serious and longer duration symptoms, but I think the overall tone of the article should reflect reliable medical sources, which emphasize repeatedly that in most patients the symptoms are mild and short lived. Formerly 98 (talk) 12:34, 3 August 2014 (UTC)
 * And the History section also includes public perceptions, media coverage, and other relevant information. Please review WP:MEDRS.  Search for history and historical and read those entire sections.  Also, review the Other section. There is a class action law suit against Ely Lily for this syndrome which specifically mentions "brain zaps".  That is not a medical source but it is extremely relevant to the history of this article.  Alatari (talk) 12:52, 3 August 2014 (UTC)
 * I think the existence of the NYTimes article can be mentioned and the fact that it raised or reflected heightened interest in this subject without putting in a large boxed quote stating that the incidence of the syndrome has been greatly underestimated and giving numerical values. I understand that you see this as a notability issue, but we don't quote medical information from the mainstream press per MEDRS.
 * I'm confused. The article has no boxed quote from the NY Times.  You removed it and I left it; just added some single line quote so that the later paragraphs flow properly.  Alatari (talk) 13:21, 3 August 2014 (UTC)
 * I think you can find descriptions of the parathesia's in MEDRS-compliant, secondary sources if you dig around. But again, we don't use primary sources for healthcare information.  Nor do we use legal documents. The existence of lawsuits, newspaper coverage, etc can all be discussed, but any discussion of the incidence of the syndrome, any description of the symptoms, and of their severity and treatment must come from secondary, peer reviewed medical sources. At this point I don't think we're terribly far apart on the content, I just want you to use appropriate sourcing. Formerly 98 (talk) 13:00, 3 August 2014 (UTC)
 * I don't think we are in agreement about source 9 being a primary source. It was a medical professional discussing usage of brain zap he found in public sources.  That source is odd and I would like to ask at sourcing what they consider it.
 * This comes down to electrical shocks that are mentioned in decent sources and what the public are calling it with the two common phrases brain zap and brain shiver which I found mentioned in a medical text book under a discussion of term defining. I switched the phrasing to indicate that brain zap is a non medical term in common usage.  Can you see a way to make that even more clear?  If I didn't find brain zap mentioned in so many sources that are attempting to describe to laymen this symptom of the syndrome I would remove my objection and delete it myself.  Alatari (talk) 13:21, 3 August 2014 (UTC)
 * If you can agree to leave out the boxed quote I removed and source the medical textbook for the "brain zap" description, I will consider this settled from my point of view. Formerly 98 (talk) 15:36, 3 August 2014 (UTC)

it is unclear to me what is at stake for you in this. Formerly is asking you to reach for the best sources available, and instead of doing that, you are reaching for suboptimal ones. What is the point? This is a mainstream topic and there are plenty of great and fairly recent reviews that fit the criteria:


 * Elana Sydney and Steven Hahn, "Depression" in ACP Smart Medicine & AHFS DI Essentials.  STAT!Ref Online Electronic Medical Library. 2013 by the American College of Physicians.  (article says "Abrupt discontinuation of some antidepressant agents, such as SSRIs, is associated with such symptoms as dizziness, nausea, paresthesia, rhinitis, and headaches in some people. Such symptoms are probably more likely and more severe with drugs with a short half-life, such as paroxetine and sertraline")


 * Haddad PM, Dursun SM. Neurological complications of psychiatric drugs: clinical features and management. Hum Psychopharmacol. 2008 Jan;23 Suppl 1:15-26. (has a section on SSRI discontinuation syndrome that includes discussion of "shock-like symptoms")


 * Smith PF, Darlington CL. A possible explanation for dizziness following SSRI discontinuation. Acta Otolaryngol. 2010 Sep;130(9):981-3. . (has a fine section reivewing the literature on the dizziness component)


 * Hosenbocus S, Chahal R. SSRIs and SNRIs: A review of the Discontinuation Syndrome in Children and Adolescents. J Can Acad Child Adolesc Psychiatry. 2011 Feb;20(1):60-7.


 * Warner CH, Bobo W, Warner C, Reid S, Rachal J. Antidepressant discontinuation syndrome. Am Fam Physician. 2006 Aug 1;74(3):449-56. Review.


 * Black K, Shea C, Dursun S, Kutcher S. Selective serotonin reuptake inhibitor discontinuation syndrome: proposed diagnostic criteria. J Psychiatry Neurosci. 2000 May;25(3):255-61.

It appears that this syndrome emerged in the late 1990s - there are about 5 reviews from 1997 discussing it. They are old, so I didn't cite them here.

I'd suggest we use these sources for the medical parts of this article. I didn't find any of them cited here.

I also want to note that under WP:MEDMOS, a culture/history section is appropriate to include, and this article doesn't have such a section. Reference 9 that is being discussed above, would best be included in such a section, since its focus is the way that the field became aware of SSRI discontinuation syndrome via use of internet chat boards by patients.

Finally, I also want to point out that there is a serious confusion in this article with Serotonin syndrome, which occurs when there is an excess of serotonin, which can arise from combining drugs with different serotonin-increasing mechanisms of action, like a MAOi and an SSRI. Reference 1, the NEJM article that is cited a bazillion times, is not about SSRI discontinuation syndrome - it is about serotonin syndrome. This article needs a lot of work to clear up that confusion. Jytdog (talk) 15:52, 3 August 2014 (UTC)


 * The term "withdrawal" is quite contentious, and in my searches far more secondary sources reject it that advocate it with respect to SSRIs. I don't think it belongs in the lede, and certainly not bolded. Thanks Formerly 98 (talk) 16:15, 3 August 2014 (UTC)
 * I hear you on that. I think it would be fine to reference it, and the change away from using it, in a history/culture section.  Current mainstream term is "discontinuation". Jytdog (talk) 16:31, 3 August 2014 (UTC)
 * , my motivation is to maintain the article, seek new sources and to keep a NPOV. I didn't know of many of the sources you list.  If they require subscriptions to medical portals; I do not have that access.  Are you asking about my qualifications or experiences relating to the syndrome?
 * Completely revamping the article was outside my scope and experience. Watching your revamp was instructive.  I'm a part time editor and am away for long enough periods of time to forget little details like the  template usage. Alatari (talk) 23:48, 3 August 2014 (UTC)
 * That is not what i was asking (we all want that!). but since we are at peace here on the surface we don't need to dig down into specific values/goals.  Thanks again. Jytdog (talk) 00:17, 4 August 2014 (UTC)

revisions today
am done with this for today. the Research section still needs a bunch of work, as does the History section, but my focus was getting the article overall into compliance with WP:MEDMOS and WP:MEDRS. Besides the structural/sectioning issues, there was a bunch of unsourced/essay-like content, and there was a boatload of apparently really old content and sources from the days when discontinuation syndrome may have been more controversial than it is today. Today this is well known, mainstream medicine. Thanks, formerly, for fixing the content and sourcing that confused this syndrome with serotonin syndrome and for the other clean up you did! Jytdog (talk) 21:57, 3 August 2014 (UTC)
 * actually I went back and cleaned up those 2 sections too. Jytdog (talk) 23:11, 3 August 2014 (UTC)
 * Thankyou for all the work, you are efficient and extremely experienced. The Culture and History section is an excellent solution to all the debate Fomerly 98 and I were having.  The controversial nature of the syndrome 15 years ago is something that can be represented in the History/Culture section and arc it into the mainstream view of 2014.  Alatari (talk) 23:56, 3 August 2014 (UTC)
 * glad you are pleased! there is almost always a third way that brings both sides together, but you have to escape "2 dimensional thinking" to see it sometimes.   a third set of eyes is usually helpful.  :) Jytdog (talk) 00:15, 4 August 2014 (UTC)  (NOTE - emphasis in the clip is not the inexperience part... it is the way we live or think or argue our way into corners of our own creations, and the corner is sometimes surprisingly simple to escape. Jytdog (talk) 00:19, 4 August 2014 (UTC))

Research
The leading explanation is not because of serotonin deficiency! That is easily restored by the brain within a few days. It is because of the structural changes of the brain. In an attempt to deal with the excess serotonin the brain adjust by down regulation of (auto) receptors. Therefor receptor distribution in a brain on SSRI/SSNRI is altered.

This theory applies to most physical addictions, including SDRI's, SNDRI's, opioids, benzodiazepines, ethanol, lyrica ect.. The subjective differences in the "serveness" of the withdrawal is then mostly do to the different psychological impacts these changes have. (Like extreme fear in the case of benzoes, extreme pain in the case of opioid, brain zaps in case of SSRI ect). These changes might be complex and based on poorly understood epigenetic change.

A good reference for physical addiction due to receptor changes is the huge work of Professor C. Heather Ashton DM, FRCP. Especially her work on the Benzo and SSRI withrawal syndrome. Her work is very practical and based on large amounts of actual cases.

I wish society would become much more aware of this condition :-)

— Preceding unsigned comment added by 37.120.106.146 (talk) 22:22, 17 June 2016 (UTC)
 * This Talk page is not a forum - see WP:NOTFORUM. If there is a source you would like to see cited, please provide it.  thanks Jytdog (talk) 04:17, 18 June 2016 (UTC)

Mention of Cymbalta (Duloxetine)
Through personal experience and online research, I really felt that duloxetine really needed a mention in regards to highly relevant drugs. The source isn't a journal article, but it is from the FDA website and I was careful to place it in its proper context (date and sources). Karkaus (talk) 00:45, 17 October 2016 (UTC)

proposed content
The following have been proposed to be added to the lead first by an IP here and then re-added by User: CompliantDrone here.

This to lead:

"It has been recently suggested to rename the the discontinuation syndrome to 'withdrawal syndrome' as symptoms and duration are comparable to those caused by benzodiazepines and opioids."

This, to the Signs and symptoms section:

"In the literature, the antidepressant syndrome has been reported to last for several months or even years."

And this, to the Culture and history section: "This is subject to controversy however. Scientists have recently for the reintroduction of the term 'withdrawal', after performing a literature review and finding that the vulnerabilities introduce by the discontinuation syndrome are significant and long lasting. Charities supporting patients in the process of withdrawing from antidepressants state that the symptoms can be severe, last for years and lead to suicide."

Several sets of issues here. First the edit reflects clear WP:SOAPBOX which is a policy issue, so it is worthwhile taking time to consider it. Second we should figure out the "recently" thing used in the lead. The document on the CEP advocacy site used in the third chunk of content has a "last updated" date of March 2014. We should figure out when this campaign began. The content in the middle is obvious alarmism.

We can work with some of this but it cannot stand as it is. Gotta run, will come back tonight. Jytdog (talk) 19:18, 17 November 2016 (UTC)


 * I don't really see this as a soapbox issue, but more of an attempt to frame vocabulary in a way that is favorable to the drug industry. The first ref which you have removed even states this almost verbatim in the abstract:

The term ‘discontinuation syndrome' that is currently used minimizes the potential vulnerabilities induced by SSRI and should be replaced by ‘withdrawal syndrome'. - CompliantDrone (talk) 19:28, 17 November 2016 (UTC)
 * ummm if you read the literature from the time that the current terminology was created, the reasons for choosing different language are very clear.  You should read those sources.  Has nothing to do with "favoring the drug industry".   But see, you just started discussing this exactly in the framework of SOAP.   The point here is that all three edits have a clear agenda and this needs to be handled carefully. Some of this can be used.  The addition to Signs and symptoms definitely needs to be contextualized with something like prevalence of various durations.  It is typical advocacy to just make the broad statement of horribles instead of stating the data.  Jytdog (talk) 19:44, 17 November 2016 (UTC)

I have to express concern at the renaming of the article - the symptoms or features that result after cessation of antidepressant use are typical of those which arise as a result of substance dependence. I think some are tying to conflate the lack of evidence of SSRIs being addictive with dependence. Withdrawal is what it is and what it should be called - the fact it is a medically supervised form of dependence and withdrawal is irrelevant. "Discontinuation" is a fudge. — Preceding unsigned comment added by 80.234.148.151 (talk) 08:37, 7 June 2017 (UTC)
 * Thanks for your note, but WIkipedia content about health is driven by MEDRS sources, not people's feelings. Jytdog (talk) 12:58, 7 June 2017 (UTC)

Diagnosis
The possibility to diagnose antidepressant discontinuation syndrome is now real, since diagnostic criteria have been published in 2013 (review article). According to me, this information should be included in this page since it represents a step forward a better knowledge of the syndrome. I introduced it twice but it was deleted, the first time I did not understand why, the second time I received the message that I was violating the copyright. I think three is no need to delete the topic, may be there is the need to modify the content such as for instance:

Diagnosis In 2015, Chouinard & Chouinard published the first diagnostic criteria for SSRI and SRNI withdrawal syndromes and identified 3 diagnoses: new withdrawal symptoms, rebound symptoms, postwithdrawal disorders. New withdrawal symptoms can be diagnosed when SSRI or SNRI was discontinued or tapered, new psychological or physical symptoms occurr (including specific serotonin-related new symptoms, symptoms have a peak of onset within 36 – 96 h after cessation of or dose reduction in SSRIs/SNRIs. Rebound withdrawal symptoms can be diagnosed when an SSRI or SNRI was discontinued or tapered, the original symptoms return, they have greater intensity than before treatment, they are rapid, transient, reversible, and the psychological belief of the need for drug can appear. These symptoms are characterized by a peak of onset within 36 – 96 h after cessation of or dose reduction in SSRIs/SNRIs. Finally, persistent post-withdrawal disorder can be diagnosed when an SSRI or SNRI was discontinued or tapered, the original symptoms return at a greater intensity than before treatment and/or return of the original illness with additional symptoms. Symptoms persist longer than 6 weeks after drug reduction or cessation, and are characterized by tgreater severity of illness than before treatment, reversibility with partial or total remission, partial or total response to reintroduction of discontinued drug. These symptoms have a peak of onset ranging from 24 hours to 6 weeks after cessation of or dose reduction in SSRIs/SNRIs and may last several months or more.

-- — Preceding unsigned comment added by Papilio2017 (talk • contribs) 08:42, 25 July 2017 UTC) (UTC)
 * Hi! First, thank you for using the talk page.
 * Second, please sign your posts (you do that by typing four tildas at the end. When you save the edit, the Wikipedia software will convert the four tildas into links to your user page, your talk page, and a date stamp.  Please always sign posts on talk pages.
 * Third, you have continued to ignore the instructions for formatting citations given in WP:MEDHOW. Please read that and learn how to do it.
 * Fourth, the source is not a review, it is an editorial. see the pubmed entry at . Per WP:MEDRS,  we do not base content about health on editorials. Jytdog (talk) 08:50, 25 July 2017 (UTC)

My signature is Papilio2017 and my name is Fiammetta Cosci, University of Florence, you are right, the paper written in 2015 is an editorial. However, I do not think the content of an editorial is lesse relevant than a content of a major textbook (which is considered a secondary source for wikipedia). It should be taken into account that an editorial is revised by referees while a textbook might not need referees. Please reply on the content of my suggestion, do you really think it is not important for clinicians and readers to know that we have today diagnostic criteria? If you want I can write a paragraph on the history of diagnostci criteria since before 2015, there were at least 2 other proposals. In this case we might include this information at least as an historical one.Papilio2017 (talk) 10:25, 26 July 2017 (UTC)
 * The reason why we rely on WP:MEDRS is that our mission is to provide accepted knowledge, as defined by the field. Lots of papers get published. Something like a diagnostic guideline needs to be issued by an authoritative body, or described as authoritative in a review.  The paper publishing the proposal is just that -- a proposal.   Please do actually read and try to understand MEDRS and its intention.  There is an essay that might help you understand why we rely on it so much - see WP:Why MEDRS? (NB, I initially drafted it) Jytdog (talk) 10:56, 26 July 2017 (UTC)

Fine, thus the second and the third reference (quote only as an example) should be deleted since if you serch for them in PubMED as review they do not appera Papilio2017 (talk) 13:47, 27 July 2017 (UTC)
 * Your reply is what we call WP:POINTY. If you are referring to refs #1 and #2 these are both reviews.  #1 is a bit old and we should update it Jytdog (talk) 14:43, 27 July 2017 (UTC)

I am not frustrated with the way a policy or guideline is being applied. I have the impression the content of this page does not represent the scientific literature as a whole. The reasons why I have this impression are listed here: a. 4 out of 21 references quote Haddad PM who is of course an expert on the field (although his last publication on discontinuation was in 2011) but I do not feel he is the only one who has a scientific load on this topic. In addition, these 4 references refer to papers published between 2001 and 2008, it seems they are not exactly what it is usually considered recent. b. reference number 9 is not in PubMed (or at least I could not retrieve it). c. the sentence "With the lack of a definition based on consensus criteria for the syndrome, a panel met in Phoenix, Arizona in 1997 to form a draft definition,[16] which other groups continued to refine.[17][18]" refers to references 17 and 18 which were published in 2000 and 2003, further refinement were produced thereafter.

Once again, I do not see why we cannot refer to diagnostic criteria and assessment of this syndrome, in the page I can read "2013 class action lawsuit In 2013, a proposed class action lawsuit, Jennifer L Saavedra v. Eli Lilly and Company,[19] was brought against Eli Lilly claiming that the Cymbalta label omitted important information about "brain zaps" and other symptoms upon cessation.[20] Eli Lilly moved for dismissal per the "learned intermediary doctrine" as the doctors prescribing the drug were warned of the potential problems and are an intermediary medical judgment between Lilly and patients; in December 2013 Lilly's motion to dismiss was denied.[21]" which is news not exactly information.2.40.185.222 (talk) 12:29, 28 July 2017 (UTC)

Needs references, balance
Hello. I'd like to suggest some edits. I tried editing Wikipedia a long time ago and had a terrible experience, and I can't even remember the protocol since it's been so long, so I thought it'd be safer to post suggestions here and let someone else who's more in the know roll with them if they'd like to.


 * The introduction states, "The prescribing labels of some SSRIs note the possibility of 'intolerable' discontinuation reactions. Some patients have extreme difficulty discontinuing use of SSRI drugs." Not only are these claims not referenced, but they're misleading, given that the vast majority of patients, if they experience this syndrome, do not find the reactions intolerable and don't have "extreme difficulty" discontinuing. The introduction also says studies demonstrate "statistically and clinically significant indications of difficulties with the discontinuing of SSRIs," thus further espousing the difficulties of discontinuing SSRIs without balancing that with the fact that most people don't have major problems.


 * In the history section, last paragraph, fluoxetine is said to have "the highest number of drug dependence reports." The WHO site was down when I tried to check the reference, so I don't know what year that report was from or whether it really says people become dependent on fluoxetine (given that the quoted paragraph above this claim, from WHO, seems to dispute that notion), but to my understanding, it's generally accepted that people do not become dependent on antidepressants, in the way that the general public thinks of dependence.


 * Why is the section about sexual dysfunction in this article? It seems to be straight fear mongering. It even states, "It should be duly noted that this condition has not been well-established or proven in the field of medicine, thus patients are not warned of the potential condition by their physicians and it is not listed in consumer information leaflets." Um ... so ... again, why is it in here? It then lists a bunch of scary things that may--or apparently may not--happen to you when you go off antidepressants. It does not mention that one side effect of being on antidepressants is a low libido and so getting off them can actually result in a raised libido, as one of the comments above notes.


 * The controversy section is completely one-sided. Arguments from critics are explained in detail, but the other sides are not. There is no indication that these criticisms are from the minority or have evidence against them.

Overall, parts of this article seem misleading to me, and it concerns me because many myths and baseless fear mongering is out there about antidepressants already. People who are depressed deserve to know the facts, and to understand that these drugs are approved because the benefits far outweigh the risks, according to mainstream medicine. This is literally a life-or-death topic and must be handled in an unbiased manner. I'm obviously not arguing for side effects and concerns to be deleted. I'm urging for them to be presented appropriately, with the weight that most experts believe they actually carry--no more and no less. JustFactsPlease (talk) 07:23, 15 October 2010 (UTC)

I was going to comment on the lack of sources as well. Though the commenter above sounds bias, there are statements that require references in accordance with wikipedia guidelines. Jdabs (talk) 01:44, 28 March 2018 (UTC)

Apologize, I missed the references on first read. Please ignore my comment. Jdabs (talk) 01:55, 28 March 2018 (UTC)

Also the words "withdrawal" and especially "addiction" are not clearly defined (in general use) and "discontinuation" seems to be created due to the confusion. The justification of the use of "discontinuation" instead of "withdrawal" seems unclear, especially since "addiction" is so unclear. Sam Tomato (talk) 17:13, 20 April 2018 (UTC)

Therapeutics initiative source
See discussion at Wikipedia_talk:WikiProject_Medicine. Jytdog (talk) 22:33, 24 August 2018 (UTC)
 * I've removed it, pending consensus that this is a WP:MEDRS ref. Jytdog (talk) 22:39, 24 August 2018 (UTC)

rename to Antidepressant discontinuation syndrome
I intend to rename this to "Antidepressant discontinuation syndrome". The effect is not limited to SSRIs. See this and many other sources. The current name is misleadingly narrow. Jytdog (talk) 19:27, 3 August 2014 (UTC)
 * support Formerly 98 (talk) 19:29, 3 August 2014 (UTC)
 * i went ahead and did it, since my edits today pretty much made it obvious... :) Jytdog (talk) 23:31, 3 August 2014 (UTC)

Dear all! Why it's called discontinuation syndrome, not withdrawal syndrome?--Mladovesti (talk) 11:17, 11 November 2019 (UTC)

Reference 2, culture and history, pharmaceutical pressure
Nowhere under reference 2, full study, does it state that pharmaceutical company pressure caused withdrawal to be relabelled as discontinuation syndrome. In fact, the industry is not referred to at all in that context.

It may well be true, but should be backed up by solid evidence. Revamped01 (talk) 03:27, 13 March 2020 (UTC)