After that one can experience severe symptoms. Headache, diarrhea, nausea, vomiting, cold fit, dizziness and fatigue, insomnia, agitation, impaired concentration, vivid dreams, depersonalization, irritability and suicidal thoughts are the most be widespread symptoms of withdrawal syndrome. Abovementioned symptoms can vary in wide range in intensity (from a total absence of to very severe) and time duration (from one to seven weeks) in different people.

It is induced with decreasing dosage or discontinuing of antidepressant medications. This phenomenon is known as SSRI discontinuation syndrome. It can become real Gehenna for the human creature.

One of its reasons is very short half-life of some SSRI medications. Very short half-life leads to absence of active metabolites that can help the drug to stay in the body for a long term. Such medications go in, last a few hours, and are excreted.

SSRIs are divided on two categories depending on their half-life: long acting and short acting. Prozac is a longer-acting SSRI while Paxil, Effexor, Zoloft and Luvox are short-acting. Decreasing dosage or discontinuing SSRIs with shorter half-life cause so-called anticholinergic rebound. That rebound is defined by an interruption in production of the key neurotransmitter acetylcholine which is used more when a person is under greater stress. The duration time of those symptoms varies in range from 1 to 7 weeks.

Symptoms of SSRI Discontinuation Syndrome

• Neurologic symptoms include:

  • Dizziness;
  • Vertigo;
  • Light headedness;
  • Difficulty walking

• Somatic (bodily) complaints include:

  • Nausea/vomiting;
  • Fatigue;
  • Headaches;
  • Insomnia

• Less common difficulties:

  • Shock-like sensations;
  • Parasthesia (skin crawling, burning or prickling);
  • Visual disturbances;
  • Diarrhea;
  • Muscle pain;
  • Cold fit

• Non-specific mental symptoms:

  • Shock-like sensations;
  • Agitation;
  • Impaired concentration;
  • Vivid dreams;
  • Depersonalization – sense of unreality and loss of self;
  • Irritability;
  • Suicidal thoughts

It was found out due to some double-blind controlled studies that 35-78% of patients who, after five weeks or more of treatment with the medication, abruptly had discontinued certain antidepressants or used 10mg increments or more, experienced one or more of the withdrawal symptoms. When antidepressant therapy had been renewed abstinency’s symptoms severity were ranged from mild-moderate in most patients, to extremely distressing in a small amount and have been lasting from one to seven weeks

A rare but life-threatening adverse drug reaction known as serotonin syndrome can happen if Prozac is taken together with triptans, tramadol or other serotonergic agents

A black box warning predicating about increased risk of suicide in persons younger than 25 is required by FDA for all antidepressant medicications. Dualfold growth of the suicidal ideation and behavior in children and adolescents was observed by two independent groups of the FDA experts. 1.5-fold augmentation of suicidality was reported in the age group of 18–24 years old.

It was observed that suicide addiction in patients olden than 24 had been declined in a minor way while it had decreased in a great measure in group in the age of 65 and older. Donald Klein criticized that analysis. He suggested that suicidality (that is defined as suicidal ideation and behavior) should not be undoubtedly a good surrogate marker for completed suicide. He also supposed that antidepressant medications increasing suicidality might avert actual event of suicide. That supposal runs counter to current beliefs in which suicidal ideation has been in one-to-one correspondence with attempt of suicide in retrospective studies and with suicide in prospective studies.

Suicidality and Prozac

It is hard enough to study suicidal ideation and behavior in clinical trials due to their infrequency. The results of 295 trials of 11 antidepressants for psychiatric indications should be united by FDA experts in order to obtain statistically significant data and analyze them. Probability value of suicidality in children using Prozac amplifies in half as large again (those data are not statistically significant in view of paucity of cases). While it was reported about reduction of probability value of suicidality in adult patients taking Prozac around at one third (those data are statistically significant).

The UK Medicines and Healthcare products Regulatory Agency (MHRA) pursue similiar investigation. The experts of UK MHRA reported about1.5-fold augmentation of probability value of suicide-related events in the children and adolescents on Prozac therapy as opposed to placebo group. Those data also didn’t reach statistical significance. They assert that the rate of self-harm for adults taking Prozac is similar to placebo group while suicidal ideation decreased twice (statistically significantly data)

Nausea (22% vs 9% for placebo), insomnia (19% vs 10% for placebo), somnolence (12% vs 5% for placebo), anorexia (10% vs 3% for placebo), anxiety (12% vs 6% for placebo), nervousness (13% vs 8% for placebo), asthenia (11% vs 6% for placebo) and tremor (9% vs 2% for placebo)are the common adverse effects caused with Prozac and greatly differing from placebo therapy.

7% of patients taking Prozac in clinical trials reported about rash or urticaria, sometimes serious. Discontinuation of the Prozac therapy leaded to that side effect in 32% of those patients. There are some reports about several cases of complications developed in patients with rash. Vasculitis and lupus-like syndrome were observed in those cases. Those systemic events gave occasion to death.

Akathisia is a common side effect of Prozac . It is often accompanied by purposeless movements of the feet and legs, constant pacing, and marked anxiety. Akathisia usually appears after the beginning of the Prozac therapy or increase of the dose. Reducing of Prozac dose, discontinuation of drug or treatment with propranolol can remove or relieve akathisia symptoms. There are proves that akathisia and suicidal attempts are relative. It was reported that there were patients who had been feeling better after the withdrawal of Prozac , but relapsed severe akathisia symptoms after resumption of Prozac therapy. The development of the akathisia forced those patients to wish to make quietus and that it had brought back about their prior suicide attempts. Physician should describe symptoms of akathisia to patients and staff because of coupling of akathisia with suicide and the distress. More rarely, Prozac can cause side effects related with movement disorders such as acute dystonia and tardive dyskinesia.

Increase of rate of poor adaptation of newborns can be resulted with taking Prozac during pregnancy. Mothers having Prozac therapy shouldn’t breastfeed because Prozac was found in milk. Prozac is classified by the American Association of Pediatrics as a drug for which the effect on the breastfeeding baby is still unknown but may be of great importance.

It is instructive to consider the experience in general practice. One way to do this is to look at prescription records for a large number of patients and compare the doses initiated with how many remained on the medication for 4-6 months. The assumption is that if the doseis ineffective or intolerable the clinician will either raise the dose or stop the medication. This naturalistic experiment has been done with medicaid populations in California and Texas. The results are rather remarkable. About 90% of patients started on fluoxetine at 20mg/day remained on this dose at 6 month. On the other hand only about 25% of patients started on sertraline at 50mg/day (which is suggested as a therapeutic dose) remained on that dose for the entire 6 months. Frequently patients were switched to another antidepressant without the benefit of a trial of higher doses.

The implication is that a large number of clinicians do not feel comfortable titrating the sertraline. This creates a situation of prolonging the treatment trial in many patients. It would probably be better to start off with a drug and quickly titrate to a dose which is most likely to achieve remission.