How do you taper off Selective Serotonin Reuptake Inhibitors (SSRIs)?

How to Safely Taper SSRIs

The most effective approach to tapering SSRIs is to use a hyperbolic tapering schedule with dose reductions of approximately 10% per month, continuing until reaching very low doses before complete discontinuation. 1

Understanding SSRI Withdrawal

SSRI discontinuation syndrome is characterized by physical and psychological symptoms that typically:

• Begin within 1 week of stopping or reducing medication
• Resolve spontaneously within 3 weeks if untreated
• Include dizziness, nausea, lethargy, headache, irritability, anxiety, and sensory disturbances 2

The syndrome occurs because of transient serotonin dysregulation when medication levels decrease too rapidly. Pharmacokinetic differences between SSRIs account for variations in withdrawal severity, with shorter half-life medications (paroxetine) generally causing more pronounced symptoms than longer half-life medications (fluoxetine).

Recommended Tapering Protocol

Step 1: Preparation

• Assess readiness for discontinuation
• Choose a period with minimal life stressors
• Consider switching to fluoxetine before tapering if currently on a short-acting SSRI 3

Step 2: Implement Hyperbolic Tapering

• Reduce dose by 10% of the original dose per month 1
• Example for 20mg starting dose:
  • Month 1: 18mg/day (10% reduction)
  • Month 2: 16.2mg/day (another 10% reduction)
  • Month 3: 14.6mg/day
  • Continue this pattern until reaching the smallest available dose

Step 3: Final Phase

• When reaching the smallest available dose, consider:
  • Taking medication every other day before complete discontinuation
  • Using liquid formulations for more precise dosing at very low doses 3
  • For patients who have taken SSRIs long-term, consider an even slower taper of 5% per month 1

Step 4: Monitoring

• Schedule follow-up visits at least monthly during the tapering process 1
• If withdrawal symptoms emerge:
  • Pause the taper at the current dose for 1-2 weeks until symptoms stabilize
  • Resume tapering at a slower rate (5% reduction instead of 10%) 1

Managing Withdrawal Symptoms

If withdrawal symptoms occur despite careful tapering:

Non-pharmacological approaches:

• Regular exercise
• Sleep hygiene practices
• Stress management techniques 1

Pharmacological support (if needed):

• Trazodone for insomnia and anxiety
• Hydroxyzine for anxiety and agitation
• NSAIDs/Acetaminophen for pain symptoms 1

Special Considerations

Medication-specific factors:

• The FDA label for sertraline notes: "If the decision has been made to discontinue treatment, medication should be tapered, as rapidly as is feasible, but with recognition that abrupt discontinuation can be associated with certain symptoms" 4

Patient-specific factors:

• Elderly patients require more gradual tapering (5% reduction every 2 weeks) 1
• Patients with anxiety disorders may benefit from adjunctive treatments during tapering 1
• For children and adolescents, tapering should be informed by the medication's pharmacokinetic properties 5

Common Pitfalls to Avoid

1. Tapering too quickly: Guidelines that recommend short tapers of 2-4 weeks show minimal benefits over abrupt discontinuation 3

2. Not tapering to low enough doses: Successful tapering requires reducing to doses much lower than minimum therapeutic doses 3

3. Mistaking withdrawal for recurrence: Withdrawal symptoms can be mistaken for recurrence of the underlying disorder, leading to unnecessary long-term medication 3

4. Abrupt discontinuation: This approach significantly increases the risk of withdrawal symptoms and should be avoided unless a serious adverse effect occurs 4

By following a gradual, hyperbolic tapering schedule with careful monitoring and support for withdrawal symptoms, most patients can successfully discontinue SSRIs while minimizing discomfort and the risk of relapse.