Switching—And Stopping—Antidepressants

Antidepressants work by balancing different chemicals in the brain—called neurotransmitters—that play a role in mood regulation. There are several types of antidepressants and a doctor must determine which one is best for each specific individual who needs them; the antidepressant your friend or family member takes may not necessarily be the best one for you, explains Danielle Hairston, M.D., a double board-certified psychiatrist.

Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed type of antidepressant, adds Jonathan Metzl, M.D., a psychiatry professor at Vanderbilt University and the author of several books. He explains that they work by increasing the amount of the hormone serotonin in the brain. “The idea is that if you have more serotonin in your synapses [where neurons connect], the better your mood will be,” he says.

Another common antidepressant, according to Dr. Hairston, is serotonin-norepinephrine reuptake inhibitors (SNRIs). As a psychiatrist, she says she decides which type of antidepressant to prescribe to someone based on their symptoms. “For example, if someone is experiencing the typical symptoms of depression including low energy, feeling worthless and having problems with sleep, I may prescribe an SSRI. But if someone is experiencing depression and also physical pain, I may prescribe an SNRI instead,” she says. This is because, she says, SNRIs can also help with pain relief, and are often prescribed to people with fibromyalgia or other types of chronic pain.

Further, amplified pain or a higher sensitivity to pain is a symptom of depression for some individuals, so an SNRI may help those who have pain complaints as part of their depression.

Still, it isn’t always easy to know what type of antidepressant will work best for someone with depression. Dr. Hairston says there is a bit of trial-and-error involved—if one doesn’t seem to be working or the side effects are too unpleasant, someone may want to switch to another antidepressant.

Below, we outline a few common antidepressants:

• SSRIs: Examples of common SSRIs include fluoxetine (Prozac), paroxetine (Paxil, Pexeva), sertraline (Zoloft), and escitalopram (Lexapro). SSRIs work by increasing serotonin activity in the brain. Besides depressive disorders, SSRIs are also used to treat mental health disorders including anxiety disorders such as panic disorder, social anxiety disorder and generalized anxiety disorder, bipolar disorders and post traumatic stress disorder.

• SNRIs: Similar to SSRIs, SNRIs work by balancing the chemicals in your brain, and boosting serotonin activity. The difference is that they also increase the amount of another neurotransmitter, norepinephrine. Examples of SNRIs include desvenlafaxine (Pristiq), duloxetine (Cymbalta), milnacipran (Savella) and venlafaxine (Effexor). SNRIs can be used alone or combined with an SSRI prescription if the person has only been receiving minimal or partial benefit from the SSRI. It can be especially helpful for people who experience lethargy, mental and physical slowing and fatigue as part of their depression.

• Tricyclic antidepressants (TCAs): TCAs increase the amounts of serotonin and norepinephrine in the brain, while also blocking another neurotransmitter, acetylcholine. They are often used to treat depression and obsessive compulsive disorder (OCD), and common types include clomipramine (Anafranil) and amitriptyline (Elavil). This type of antidepressant is not as common due to its potential side effects. However, it can be beneficial for some individuals who have treatment resistant depression, or if they’re experiencing co-occurring chronic pain or fibromyalgia syndrome.

Other types of antidepressants include noradrenergic and specific serotonergic antidepressants (NASSAs) and monoamine oxidase inhibitors (MAOIs). Lithium and mood stabilizers are sometimes also used in individuals with bipolar disorder (which consists of both mania/hypomania and depressive episodes) or borderline personality disorder, in addition to a depression diagnosis.

Atypical antipsychotic medications are also sometimes used as an additional treatment for treatment resistant depression (including severe depression with accompanying psychotic symptoms), but are used with caution due to their higher risk of adverse effects.

Both psychiatrists say that there are several reasons why someone may want to switch to a new antidepressant. “Just like any other medication, antidepressants come with side effects,” says Dr. Hairston. She says that the most common side effects someone may experience from any type of antidepressant include:

• Headaches
• Dizziness
• Low sex drive
• Increased appetite or loss of appetite
• Gastrointestinal problems
• Trouble sleeping
• Weight gain

Experiencing these side effects are all reasons why someone may want to try another type of antidepressant. “If someone wants to switch, it’s best to try another class of antidepressants, because if someone switches from one type of SSRI to another type of SSRI, for example, they will probably experience the same side effects,” says Dr. Hairston. For this reason, she says, it would be more effective to switch from an SSRI to an SNRI, for example.

Both experts emphasize that deciding which new antidepressant to switch to should be determined by a doctor.

Besides unpleasant side effects, Dr. Metzl says that a second key reason why someone may want to switch antidepressants is because they don’t believe their initial medication is working anymore. “Someone may get used to the medication, not noticing its effects as much,” he says. “There is a lot of anxiety and depression in the world right now. Someone’s depression may be getting worse, while the medication is working the same amount. Because of this, they may think it’s no longer working.” The solution, Dr. Metzl says, is very individual and, once again, should be left up to one’s doctor.

If you just started taking an antidepressant and want to switch because you don’t believe it’s working, doctors recommend sticking with it for at least a month before ultimately deciding to switch or stop. This is because it generally takes antidepressants two to four weeks to begin working, and it can take even longer for the treatment response to the medication to be maximized or optimized. If you’ve been taking an antidepressant for four to six weeks and haven’t noticed any improvements to your symptoms, talk to your health care provider, who may recommend upping the dosage or switching to a new medication.

Just like how someone’s doctor determines the type of antidepressant and dosage to initially try, one’s doctor will provide instructions for how to switch to a new one.

“If someone has been taking their antidepressant for several months, it’s best to taper the dosage slowly and not just switch immediately,” says Dr. Hairston. This involves lowering the dosage of the current medication in increments and then starting the new medication slowly in increments before reaching the desired dosage.

However, Dr. Hairston adds that if someone has not been taking their medication long and the side effects are overwhelming, this would be a case for them to stop completely instead of in increments.

There are times when someone may want to stop taking their antidepressant medication altogether. “Someone may not feel the medication is working or they may be tired of being on medication,” says Dr. Metzl.

Another reason why someone may want to stop taking antidepressants, adds Dr. Hairston, is because they feel their mental health is in a better place and they no longer need them.

“Someone may say that they feel mentally stable, have a good support system and have healthy lifestyle habits in place and that they no longer need to take the medication,” says Dr. Hairston. This can especially be the case if someone started taking medication in the midst of a difficult time—such as a divorce, job loss or after the death of a loved one—but time has passed and they are no longer in the throes of that crisis.

Dr. Hairston says that if this is the reason someone wants to stop taking their antidepressants, it’s important to have an emergency plan in place—created with a health care provider—for if they start feeling down again, including suicidal. The reason for this is because someone may think they no longer need their medication, but the medication is actually what is making them feel more stable. “This is also why it’s important to follow up with your psychiatrist or health care provider after stopping taking antidepressants,” she says.

Both psychiatrists say that it’s not recommended that someone quit taking their antidepressant medication cold turkey; it’s important to come up with a plan with your doctor.

If someone does want to stop them, their medical provider will work with them to make sure they have a good support system and healthy lifestyle habits in place, says Dr. Hairston, adding that they may also suggest working with a therapist, if the individual isn’t doing so already. “It’s also important that they continue to follow up with their psychiatrist or primary care doctor. Someone should never just stop taking their antidepressant medication and not talk to their provider again,” she adds.

Similarly to how switching antidepressants is done slowly, Dr. Hairston recommends stopping antidepressant medication this way, too. A doctor will offer guidance on lowering the dosage slowly over time as opposed to stopping the medication completely at once. This, she says, will help make the withdrawal symptoms less severe.

Withdrawal Symptoms

When someone stops taking an antidepressant—especially after taking it for longer than six weeks—they can experience withdrawal or side effects for a few weeks. These can include:

• Flu-like symptoms
• Nausea
• Low energy
• Anxiety
• Trouble sleeping
• Vivid dreams
• Insomnia
• Irritability
• Headaches
• Abdominal pain
• Diarrhea

Additionally, an estimated 20% of people who stop taking antidepressants may experience antidepressant discontinuation syndrome, which encompasses the withdrawal symptoms listed above as well as sensory disturbances (such as tingling or burning sensations)^[2]Gabriel M, Sharma V. Antidepressant discontinuation syndrome. Canadian Medical Association Journal. 2017;189(21):E747. . This can last from between one day to two weeks.

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It bears repeating that no one should attempt to switch antidepressants or stop taking an antidepressant without the help of a medical professional, such as a primary care doctor or psychiatrist. Additionally, it’s important to continue to see your provider after stopping taking an antidepressant so they can monitor how you are doing.

If depression is something you are experiencing and you aren’t taking an antidepressant, Dr. Hairston says that this is another time to make an appointment with your primary care doctor. Your doctor can help connect you to a therapist as well as help determine if medication could be right for you. Primary care doctors can also prescribe antidepressants; it doesn’t have to be a psychiatrist. However, a psychiatrist is especially trained to treat mental health conditions, and working with a specialist may be more helpful and appropriate for you if you’re experiencing significant mental health symptoms, a more complicated depression course and/or more than one condition (e.g., both a depression and an anxiety disorder, or a severe depression with psychotic features).

Whether or not you choose to take an antidepressant, there is help available. When it comes to depression and other mental health conditions, there are many treatment options out there; it’s just a matter of finding what works for you.

If you are feeling suicidal or need mental health help immediately, call 988, the Suide and Crisis Lifeline, to be connected to a mental health professional.