How should I taper a selective serotonin reuptake inhibitor (SSRI) safely?

How to Safely Taper an SSRI

All SSRIs except fluoxetine require gradual tapering over a minimum of 2–4 weeks for short-term therapy, with extended tapers of several months necessary for patients on long-term treatment to minimize withdrawal symptoms and avoid relapse. 1, 2

Minimum Taper Duration

• For short-term therapy (less than 4–12 months): Taper over a minimum of 2–4 weeks 1, 2, 3
• For long-term therapy (4–12 months or longer): Extend the taper over several weeks to months, as slower tapers are more appropriate than rapid discontinuation 1, 2
• Fluoxetine is the exception: Due to its extended half-life, fluoxetine does not require gradual tapering and can be discontinued more abruptly 4, 5

Recommended Tapering Strategy

The taper rate should follow a hyperbolic (exponential) reduction pattern, decreasing by approximately 10% of the current dose at each step, rather than fixed-dose reductions. 6, 7

• Reduce the dose by 10% of the most recent dose (not the original dose) every 1–2 weeks for shorter half-life SSRIs like sertraline, paroxetine, and fluvoxamine 2, 4
• Some patients may tolerate faster reductions of 25% of the current dose every 1–2 weeks if no withdrawal symptoms emerge 2
• Final doses before complete cessation may need to be very small (as low as 1/40th of the therapeutic dose) to prevent large drops in serotonin transporter occupancy 6, 7

Example Tapering Schedule for Sertraline 100 mg Daily

• Week 1–2: Reduce to 90 mg daily (10% reduction)
• Week 3–4: Reduce to 81 mg daily (10% of 90 mg)
• Week 5–6: Reduce to 73 mg daily (10% of 81 mg)
• Continue this pattern until reaching very low doses (e.g., 12.5 mg or less) before complete discontinuation 2, 6

Managing Withdrawal Symptoms

If moderate to severe withdrawal symptoms occur, immediately reinstate the previous dose and hold for 1–2 weeks before attempting a slower taper. 2, 8

Common Withdrawal Symptoms to Monitor

• Somatic symptoms: Dizziness, light-headedness, nausea, vomiting, fatigue, myalgia, flu-like symptoms, sensory disturbances (paresthesias, "electric shock" sensations), sleep disturbances 1, 2, 4, 5
• Psychological symptoms: Anxiety, agitation, crying spells, irritability 4, 5

Symptomatic Treatment Options

• For increased sympathetic activity: α2-adrenergic agonists (clonidine, lofexidine) may reduce withdrawal symptoms, though evidence is limited for SSRI discontinuation specifically 1, 8
• For muscle aches and pain: Acetaminophen or NSAIDs can provide symptomatic relief 1, 8

High-Risk Patients Requiring Slower Tapers

• Patients with a history of severe withdrawal symptoms on prior taper attempts 2
• Patients with comorbid anxiety disorders 2
• Patients on higher doses or longer treatment duration (greater than 12 months) 2
• Patients with treatment-emergent anxiety or medication noncompliance history 9

Critical Monitoring During Taper

Monitor closely for three distinct problems that can emerge during tapering:

1. Withdrawal symptoms (described above) 2, 4
2. Return of the original psychiatric condition (depression, anxiety) that may be mistaken for withdrawal 2, 4
3. Suicidal ideation, particularly in patients under age 24 years 1, 2, 3

• Weekly monitoring is recommended during active dose reductions, especially in the first months 1, 2
• Use standardized symptom rating scales to distinguish withdrawal from relapse 2

Patient Education Before Starting Taper

Before initiating the taper, establish a collaborative plan that includes:

• Clear explanation of why gradual tapering is necessary (to allow neuroadaptations time to resolve) 2, 6
• Discussion of potential withdrawal symptoms and their typical duration (usually self-limiting within 1–2 weeks) 4, 5
• Agreement on the taper schedule with flexibility to slow down if needed 2
• Reassurance that withdrawal symptoms do not indicate addiction or dependence 5

Common Pitfalls to Avoid

• Never stop SSRIs abruptly (except fluoxetine), as this dramatically increases withdrawal symptom severity 1, 2, 3, 4
• Do not use fixed-dose reductions (e.g., reducing by 25 mg every week regardless of current dose), as this causes disproportionately large drops in serotonin transporter occupancy at lower doses 6
• Do not mistake withdrawal symptoms for relapse and unnecessarily restart full-dose therapy; instead, reinstate the previous taper dose and slow the reduction rate 2, 4
• Do not abandon patients during tapering; continued monitoring and support are essential 8
• Avoid switching between generic manufacturers during taper, as up to 20% bioequivalence differences can trigger withdrawal symptoms 9

Special Considerations for Specific SSRIs

• Sertraline, paroxetine, fluvoxamine (shorter half-lives): Require more gradual tapers with dose adjustments every 1–2 weeks 2, 4
• Citalopram, escitalopram (intermediate half-lives): Can tolerate slightly faster tapers but still require gradual reduction 2
• Fluoxetine (very long half-life): Does not require formal tapering due to self-tapering effect from its extended elimination 4, 5