When should a patient wean off antidepressants?

When to Wean Off Antidepressants

Antidepressants should be continued for 9-12 months after recovery from a depressive episode before considering discontinuation. 1

Duration of Treatment Before Discontinuation

• For first episode of major depressive disorder: Continue treatment for 4-9 months after achieving a satisfactory response 2
• For patients with 2 or more prior episodes: An even longer duration of therapy is beneficial, often requiring indefinite treatment 2
• Minimum continuation period: The 9-12 month timeframe after recovery represents the standard recommendation across guidelines 1

The rationale for this extended treatment period is that premature discontinuation significantly increases relapse risk, with evidence showing hazard ratios of 2.09 to 2.97 for relapse when stopping antidepressants compared to continuation 3. This risk is particularly pronounced in patients with recurrent depression.

Criteria for Considering Discontinuation

A patient should meet ALL of the following before attempting to wean off antidepressants:

• Complete symptom remission maintained for at least 9-12 months 1
• Absence of psychosocial stressors that could precipitate relapse 4
• No history of multiple prior episodes (if 2+ episodes, strongly consider indefinite treatment) 2
• Patient understanding and agreement with close monitoring plan 5, 6

Discontinuation Method

Gradual tapering over 10-14 days is the minimum standard for most antidepressants to limit withdrawal symptoms. 1, 7

Specific Tapering Approaches:

• Short half-life agents (paroxetine, venlafaxine, fluvoxamine): Require gradual tapering, potentially over several weeks to months for patients on long-term treatment 5, 8
• Fluoxetine exception: Due to its extended half-life, fluoxetine may not require gradual tapering 9, 5
• Practical taper schedule: Reduce dose by approximately 25% every 3-4 days over 2 weeks minimum 7
• For patients with prior withdrawal symptoms: Consider hyperbolic tapering regimens extending over several months 8

The 10-14 day guideline represents a minimum duration—many patients, particularly those on long-term treatment, require slower tapers to avoid withdrawal symptoms 7, 8.

Critical Pitfalls to Avoid

Do not confuse withdrawal symptoms with relapse of depression. 5, 3, 6 Withdrawal symptoms include:

• Dizziness and sensory disturbances (electric shock sensations) 9, 5
• Flu-like symptoms (myalgia, chills, fatigue) 5
• Anxiety, irritability, crying spells 5
• Nausea, insomnia 9, 5

These symptoms typically emerge within days of discontinuation and are generally self-limiting, whereas true relapse develops more gradually over weeks 5, 6.

If intolerable symptoms occur: Resume the previously prescribed dose and taper more gradually 9, 4

Enhanced Discontinuation Success

Combining gradual taper with cognitive behavioral therapy (CBT) or mindfulness-based cognitive therapy (MBCT) improves discontinuation success rates to 40-75%. 3, 4 This approach reduces relapse risk compared to tapering alone, though the evidence quality is low due to small study numbers 3.

Special Populations

• Elderly patients and those with hepatic impairment: May require even slower tapering due to altered drug metabolism 9
• Patients with recurrent depression (2+ episodes): Strongly consider indefinite maintenance treatment rather than discontinuation 2, 4
• Pregnancy considerations: Both depression and antidepressants are associated with preterm birth; discontinuation decisions require careful risk-benefit analysis 4

Monitoring During Discontinuation

• Begin monitoring within 1-2 weeks of dose reduction 2
• Continue close follow-up for at least 6-8 weeks to distinguish withdrawal from relapse 2, 5
• If no adequate response to taper (worsening symptoms): Resume previous dose and reassess timing 9