Many people wean off antidepressants too quickly. That can be dangerous.

When people taking an antidepressant stop the drug, doctors often worry that their mental illness might reappear. But few physicians focus on a different problem—debilitating withdrawal symptoms that include both physical and psychological ailments and are more prevalent and life-altering than is generally appreciated.

In a survey published in a recent issue of the Journal of Affective Disorders Reports, researchers interviewed 1,100 people suffering from post-withdrawal symptoms and found that it impaired the ability to work for most: 20 percent lost jobs as a result; and 25 percent of the respondents said their personal relationships were affected. Symptoms included agitation, brain fog, heart palpitations, tinnitus, burning or electric sensations, and dozens of others.

“People are told, ‘You’re on 20 milligrams, go down to 10, then five, then zero.’ But the effect on the brain is not linear, and that last reduction is like jumping off a cliff,” says Mark Horowitz, a clinical research fellow in the United Kingdom’s National Health Service, who coauthored the JAD Reports study and advocates a much more gradual tapering regiment than is recommended in the United States.

Experts agree more data is needed to accurately determine the number of people who experience withdrawal and how long their symptoms last. But one review article found more than half of those taking antidepressants experience some disruptive effects upon stopping, with nearly half of those rating their symptoms as severe. In the JAD Reports, limited to people impacted by withdrawal, 40 percent said their symptoms lasted two years or longer.

Antidepressants can offer health benefits, especially for major depressive disorder. But with 13 percent of U.S. adults currently on these medicines for a wide range of physical and mental conditions, withdrawal issues might eventually affect millions.

Too much emphasis and research dollars have been placed on getting people started on antidepressants and not on safely stopping it, says Bryan Shapiro, a psychiatrist at the University of California, Irvine Medical Center who has surveyed people suffering from antidepressant withdrawal.

“The emphasis has been on prescribe, prescribe, prescribe and less on the exit strategy,” Shapiro says.

Doctors frequently attribute withdrawal symptoms to a return of the mental illness that drove the person to the medication, but for many people this is not the case, Horowitz says. His JAD Reports survey found similar psychological withdrawal issues, including anxiety and mood swings, in people who had been prescribed the drugs for physical conditions like migraines, chronic fatigue, or pain.

The brain adjusts to the drug

Antidepressants work in part by increasing levels of neurotransmitters like serotonin, although it’s become clear over the years that more complex mechanisms are also involved.

One type of antidepressant—selective serotonin reuptake inhibitors (SSRIs)—blocks the absorption of the neurotransmitter serotonin, leaving more of the chemical for the brain to use for sending messages from one neuron to another. Once the brain adapts to the medication, it reduces the number and activity of its own serotonin receptors.

When the drug is removed, the lower number of serotonin receptors creates an imbalance. “When you take the medication away and the receptors haven’t had time to repopulate, there will be a massive deficiency, leading to withdrawal,” Shapiro says.

While the drug leaves the body within a few days, it can take much longer for the brain to adjust. This is like the challenges long-term drinkers have reorienting their brain to the absence of alcohol.

(What’s worse than a hangover? Hangxiety.)

Of course, some people experience zero or very mild symptoms when an antidepressant is discontinued, so experts are still trying to understand all the mechanisms involved in withdrawal.

Removing the last of the medicine, even if it is a low dose, has the largest impact. Shapiro’s review of studies involving serotonin receptors found some 80 percent of an antidepressant’s activity happens at the lowest treatment doses. “What psychiatrists may consider a minimum therapeutic dose is having a profound effect on the receptor,” Shapiro says.

In some cases, the psychological symptoms people experience upon stopping may stem from a relapse of their mental-health condition indicating they should speak to their physician right away.

But when symptoms are physical or the psychological symptoms are new or more severe than before they began the medication, the person is likely experiencing withdrawal, Horowitz says.

Taking years to recover

Stopping his antidepressant proved to be a major problem for Peter Eliasberg, a 63-year-old Los Angeles attorney who began taking a serotonin–norepinephrine reuptake inhibitor when severe depression struck in his early 30s. After 23 years on the medicine, and two unsuccessful attempts to wean himself off, Eliasberg decided seven years ago that he felt well enough to stop. His psychiatrist instructed him to halve his dose several times over a six-week period before discontinuing.

Eliasberg decided to take twice that time, but it still proved too fast for his brain. He quickly experienced severe insomnia, the sensation that his nerves were on fire, and a depression deeper than he’d ever known—symptoms that, along with subsequent memory issues and brain fog, plagued him for years.

His psychiatrist insisted the SNRIs withdrawal wasn’t responsible, since the drug was long out of his system, and prescribed several other medicines.

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Eventually Eliasberg tapered off all the drugs using a much more incremental schedule. Only in the last year have all his symptoms disappeared. “All told, it was a six-year journey until I was fully healed,” he says.

Patients share similar stories in burgeoning online social media groups dedicated to antidepressant withdrawal, Horowitz says. There are several dozen online groups with some 180,000 cumulative members, which are growing at a rate of 25 percent annually, according to Horowitz. Some groups focus on specific antidepressants, such as one for mirtazapine, for example (nearly 6,000 members) or for escitalopram (another 6,000).

The United Kingdom altered its guidance

Psychiatric guidance in the U.K. changed in recent years to advocate for a more gradual tapering approach.

By contrast, the American Psychiatric Association generally recommends stopping the drugs after reducing the dosage over a period of several weeks, although it acknowledges that a small number of patients may require a longer timeline. Depression management guidelines from the Veterans Administration make no mention at all of stopping the antidepressants.

Tapering over “days to a few weeks is usually sufficient,” says Jonathan Alpert, a psychiatrist at the Albert Einstein College of Medicine in New York and chair of the American Psychiatric Association’s Council on Research. He does note, though, that the APA guidelines are currently under review.

Alpert acknowledges this advice comes from studies in which patients consumed the medicine for brief periods. In some research, people were on the medicines for four weeks or less. Yet patients frequently stay on antidepressants far longer, in many cases for decades.

The psychiatric association guidance does caution against abruptly stopping without any tapering to avoid what it terms “discontinuation syndrome.” But the guidance states that this almost always resolves “over one to two weeks.”

As the JAD Reports survey found, for some people both the length and breadth of the problem is vastly understated. In addition to the more common complaints, sufferers in the survey experienced memory lapses, brain zaps, muscle spasms, an intense urge to move the body, increased sensitivity to noise and light, libido issues, and more.

Josef Witt-Doerring, a psychiatrist whose online private practice specializes in antidepressant post-withdrawal, says he fields calls from dozens of new patients each week who are struggling months or years after stopping. Psychiatrists’ belief that symptoms are typically short-lived and mild comes from consensus panels, like one held in 2004, Witt-Doerring says, rather than from the experience of patients.

The 2004 panel was funded by a pharmaceutical company and many of its experts received funding from various antidepressant manufacturers, as the journal article derived from the event states.

Withdrawal seems to be more prevalent and severe in people who take antidepressants for a year or longer, one study found. Certain antidepressants, including serotonin and noradrenaline reuptake inhibitors and paroxetine, are associated with higher odds for problems.

In Witt-Doerring’s practice, older people take longer to recover than younger ones. But it’s currently impossible to predict who might be at risk.

Phil, a 32-year-old business executive in New Jersey who asked that his last name not be used, was on a tetracyclic antidepressant for just three months in 2022 when he decided to stop the medicine, using his doctor’s instructions to taper down over four weeks.

More than a year later (despite eventually going back on the drug and others and starting a new, slower tapering regimen), he continues to struggle with exhaustion, memory issues, and an inability to feel pleasure. “The withdrawal symptoms have completely stripped me of any quality of life. My former personality—gregarious and outgoing—is completely gone,” Phil says.

A different tapering regimen

Guidance from England’s Royal College of Psychiatrists recommends gradual tapering, working with a physician to begin reducing the dose by as little as 10 or even 5 percent.

Similar recommendations appear in a new book coauthored by Horowitz and psychopharmacologist David Taylor, The Maudsley Deprescribing Guidelines: Antidepressants, Benzodiazepines, Gabapentinoids and Z-Drugs. They base their recommendations on a Lancet study of brain imaging results the pair coauthored that examined antidepressants’ effects at various doses.

Rather than reduce by even amounts of the drug, they advise reducing by how each dose affects the brain, with doses becoming minutely smaller at the lower end, in some cases taking several years to complete. Liquid suspensions—or pills from compounding pharmacies—are generally required to accomplish such incremental reductions.

Shapiro advises patients to remain on each newly lowered dose for at least a month, “which is how long it takes receptors to adapt,” he says.

This regimen is often recommended in the online groups, which is where Horowitz learned of it several years ago after he unsuccessfully tried to stop his own SSRIs after 11 years. His depression, which he rates as a four out of 10 before he started the medicine, swiftly skyrocketed to a 10, accompanied by intense anxiety and the need to constantly move his body.

“I thought, this is utterly ridiculous. How come I have six degrees—including a Ph.D. in antidepressants—and I’m getting advice on how to come off my drugs from a retired software engineer and a truck driver on a peer-support site,” he says.

Most people are not informed by their healthcare provider about the potential for withdrawal problems when they start an antidepressant, Shapiro found when he analyzed thousands of posts from the online support group Surviving Antidepressants. He believes this must change.

He also wants patients to be clear-eyed about both the potential benefits and the downsides of antidepressants. “The decision to take a psychiatric medication is an important one and should not be taken lightly,” Shapiro says.