II. Pathophysiology

  1. Occurs with sudden Antidepressant Withdrawal
    1. Selective Serotonin Reuptake Inhibitor (SSRI)
    2. Tricyclic Antidepressant
    3. MAO inhibitor
  2. Symptom onset occurs within 24 hours to 2-3 weeks
  3. Likely results from Cholinergic overdrive
    1. Symptoms similar to Organophosphate Poisoning
  4. Most common with Paxil
  5. Least common with Prozac (naturally tapers)

III. Symptoms

  1. Cholinergic rebound (See Cholinergic Toxicity)
    1. Diaphoresis
    2. Nausea or Vomiting
    3. Diarrhea
  2. Non-specific Withdrawal symptoms
    1. Dizziness
    2. Anxiety
    3. Headache
    4. Malaise
    5. Myalgias
    6. Weakness
    7. Sleep Disturbance
  3. Extrapyramidal effects
    1. Paresthesias
    2. Restless legs

IV. Differential Diagnosis

  1. Bipolar Disorder with Antidepressant-induced mania

V. Management: Approach

  1. Mild Symptoms: Resolve spontaneously
    1. Withhold treatment
    2. Reassurance and observe
  2. Moderate to severe symptoms
    1. Restart medication and then slowly taper
      1. See specific medications for taper schedule
    2. Symptoms abate soon after restarting medication

VI. Management: Specific Withdrawal Symptoms

  1. Cholinergic rebound symptoms (See above)
    1. Atropine 0.8 mg PO tid to qid
    2. Cogentin 0.5 to 4 mg PO qd
    3. Artane 1-4 mg PO tid to qid
    4. Donnatal 2 tablets PO tid-qid
  2. Anxiety
    1. Lorazepam 0.5 to 1 mg PO tid prn
  3. Dizziness
    1. Antivert 12.5 to 25 mg PO q6 hours prn
    2. Dramamine 50 mg PO q6 hours prn

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