CEimpact Podcast

The Pharmacist's Role in Safe Discontinuation of Antidepressants

Share episode

Tapering antidepressants requires careful planning to minimize withdrawal symptoms and ensure patient safety. This episode provides pharmacists with a brief update on antidepressant therapies and essential education on tapering, including recognizing withdrawal risks, adjusting schedules, and counseling patients effectively. Don’t miss this opportunity to stay informed and enhance your skills in supporting patients through their mental health treatment journey.

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Sara Grady, PharmD, BCPS, BCPP
Professor, Clinical Pharmacist
Drake University
Broadlawns Medical Center

Pharmacist Members, REDEEM YOUR CPE HERE!
 
Not a member? Get a Pharmacist Membership & earn CE for GameChangers Podcast episodes! (30 mins/episode)


CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Describe the mechanisms of action of antidepressant therapies and their implications for patient care.
2. Explain best practices for tapering antidepressants, including recognizing withdrawal risks and providing effective patient counseling.

0.05 CEU/0.5 Hr
UAN: 0107-0000-25-075-H01-P
Initial release date: 3/24/2025
Expiration date: 3/24/2026
Additional CPE details can be found here.

Follow CEimpact on Social Media:
LinkedIn
Instagram

Josh Kinsey:

Hey, ce Impact subscribers, Welcome to the Game Changers Clinical Conversations podcast. I'm your host, josh Kinsey, and, as always, I'm super excited about our conversation today. Tapering antidepressants is a delicate process that requires careful planning to ensure patient safety and minimize withdrawal symptoms. In this episode, we'll cover the latest updates on antidepressant therapies, discuss best practices for tapering and highlight how pharmacists can guide patients through this critical phase of their mental health journey. It's so great to have Sarah Grady with us for this episode. It's good to see you, sarah.

Sarah Grady:

Nice to see you, Josh.

Josh Kinsey:

Thanks again for taking time out of your schedule. I know that the semester just started up, so I appreciate you spending this afternoon with us. Thank you For our learners, sarah, that are not familiar with you. Go ahead and take a couple of minutes to introduce yourself. Tell us a little bit about your practice site and maybe why you are passionate about today's topic.

Sarah Grady:

Hello everyone, it's wonderful to be with you this afternoon. My practice site is Broadlawn's Medical Center in Des Moines, iowa, the county hospital. I have many patients that take antidepressants for any number of reasons, including depression, anxiety, insomnia, pain conditions. So I talk with patients each and every day, have a lot of questions and a lot of discussion about antidepressants, so very passionate about this topic today in particular.

Josh Kinsey:

Yeah, awesome. And Sarah's being a little modest, she's just, in general, very knowledgeable in this whole space of psych and therapy and everything. So I would be remiss if I just made you think that she was an expert in antidepressants. She's an expert in a lot of that space. So thanks again for spending your day with us. So let's jump in. I always like to lay the foundation for our listeners, so let's just review briefly, sarah, if you don't mind, some of the common classes in antidepressants and maybe just briefly touch on their mechanism of action and just kind of their place in therapy right now.

Sarah Grady:

Absolutely. I think all of us are most familiar with the SSRIs. We obviously have six. Their primary mechanism of action is serotonin reuptake inhibition, but beyond that they do have different secondary mechanism of action is serotonin reuptake inhibition, but beyond that they do have different secondary mechanisms of action and most of them have different structures, with the exception of citalopram and escitalopram, which are enantemers of one another. Then we have the SNRIs. They have serotonin and norepinephrine reuptake inhibition. Our most common one that we see there in practice is going to be venlafaxine and also duloxetine. Then we have bupropion, which doesn't have serotonin reuptake inhibition but has dopamine reuptake inhibition and norepinephrine reuptake inhibition. And then we have mirtazapine, which increases serotonin and norepinephrine in the synaptic cleft but not through reuptake inhibition. And so I want to highlight those last two, bupropion and mirtazapine because they do not have serotonin reuptake inhibition. So that may come into play a little bit when we talk about today's topic regarding tapering antidepressants.

Josh Kinsey:

That's great, that's a great call out. So tell us why that connection exists then. So obviously the tapering is because of serotonin reuptake, I assume, or because of serotonin, so maybe talk a little bit about that because of serotonin.

Sarah Grady:

So maybe talk a little bit about that. Yeah, so we think that antidepressants that may have a higher risk of antidepressant discontinuation syndrome include those that have serotonin reuptake inhibition, specifically also those that have shorter half-lives. So you remember, we all know that something like fluoxetine, while it does have serotonin reuptake inhibition as its primary mechanism of action, it has a long half-life, so we may not have to taper that one as much as some of the others.

Josh Kinsey:

Gotcha. Okay, that's great. That's a great reminder. It's been a while since I sat in the classroom for talking about SSRI, so definitely a great reminder there. So let's then, as we're talking about tapering, let's go ahead and talk about why is that a topic for us to talk about? What are the risks of abrupt discontinuation and the impact on our patients' quality of life and their outcomes?

Sarah Grady:

and the impact on our patients' quality of life and their outcomes. Yes, a couple of risks. First and foremost, if someone has been taking an antidepressant longer than six weeks, they may have what we call an antidepressant discontinuation syndrome, otherwise known as antidepressant withdrawal. And I know that all of you in the pharmacies you have had shifts where patients have been telling you about some of these symptoms, not knowing what they are. But you know what they are. You've heard people describe them to you. So things like flu-like symptoms, insomnia, anxiety, mood changes, brain zaps, electrical shocks You've heard lots of these things, lots of these reports from your patients. So that's first and foremost an issue. A second issue would be if we abruptly stop the antidepressant too quickly, any one of them what we are actually taking the antidepressant for symptoms of that condition may return, whether it's depression, anxiety, insomnia, pain. So we definitely want to educate our patients that if they at any point want to stop their antidepressant, they really need to contact their provider first for a specific schedule.

Josh Kinsey:

That's great. And just to go back and reiterate something I think it's key you said that anyone who's been on an antidepressant for six weeks, that is kind of our. I mean. That to me is not that long. So even just six weeks, we could see these issues if they have abrupt discontinuation, right.

Sarah Grady:

Yes, so six weeks is on the shorter end. That would probably most likely apply to agents that have serotonin reuptake inhibition, plus short half-lives. So things like paroxetine lives. So things like paroxetine, fluvoxamine, fluvoxamine, not fluoxetine. Remember, fluoxetine has got the long half-life Venlafaxine. Maybe does venlafaxine as well. But yes, people that are real sensitive to discontinuation syndrome. They've been taking their medication as prescribed every day for as little as six weeks. They're on a shorter half-life agent that has serotonin reuptake inhibition as a mechanism. They may indeed see some discontinuation symptoms.

Josh Kinsey:

Yeah, and I think that's key because you know to me at least, I guess I've always kind of thought that we're going to see these issues and abrupt discontinuation, that like they've been on it for five years and then they just decide they don't want they're, they're better and they don't need it anymore and they stop it and like that's where we're going to have the issue.

Josh Kinsey:

But something in as little as six weeks, like that could still be the time when someone's deciding whether or not they like it and want to take it, you know.

Josh Kinsey:

And so I think that brings us to our next point, which is one of the key things for us as pharmacists to do is make sure that we're educating the patients about that and the fact that you know because I know we always usually say, give it at least two weeks to see if you you know if it's going to work, like it may take that long, but also realizing that in just as quick as six weeks you can't just stop it if you decide you don't like it. So I think that's something really important to talk about. So with that, let's discuss, like, what are some of those talking points that we as pharmacists should have to kind of set up. We'll talk specifically in a minute about setting the schedules and discussing that, but setting up the discussion when patients are getting antidepressant for the first time, what are some of the things we need to say so that we're making them aware of it but not scaring them?

Sarah Grady:

Yeah, absolutely Wonderful question. I think some key points to touch on in any setting when someone is starting an antidepressant for the first time is number one we want to review that average time course to therapeutic benefit, as you mentioned and alluded to already, josh. The second thing we want to tell them about is maybe some common side effects. You know so it's an ssri. They may have a stomach upset, they may have sleep disturbances initially, they may have sexual side effects as well. And then I always add in my initial counseling of an antidepressant is you know, if you have been taking this for a while and you want to stop the medication, it is vital that you speak with your provider for a person-specific tapering schedule Because depending on which antidepressant it is, people can certainly have those withdrawal effects.

Josh Kinsey:

Quickly. Yeah, yeah, very interesting. I can tell you so many times when practicing, how many patients would say, either I've been told I don't have to take it anymore, or I've decided I don't want to take it anymore. I think I'm better. Whatever I know, I remember you telling me I couldn't just stop it, so help me, how do I get about? You mentioned that they're individualized, so I think that's something key. But let's just in general, talk about that, and is that something that we, as pharmacists, should be doing, or should we be being one of them?

Sarah Grady:

But first and foremost, I think it's important for us to let our patients know, just kind of briefly review, what could happen if they abruptly stop their respective agent. And again, depending on if it has serotonin reuptake inhibition or not, and depending on the half-life, will guide maybe the severity, I guess, of symptoms. But I think it's just first and foremost important to educate our patients about what those symptoms may look like. Number one and number two, to also remind them that whatever they're taking that agent for symptoms of that condition may return. So education on that piece. Third, we do want to loop their provider in on this discussion because we will need a person-specific schedule. And what does that look like? It depends on a couple things that we've talked about already.

Sarah Grady:

Obviously, if our drug has serotonin reuptake inhibition, it's got a shorter half-life, something like paroxetine, fluvoxamine, venlafaxine, desvenlafaxine, even duloxetine. We definitely want to taper those. So mechanism is the first thing we look at. Also, any antidepressant agent that has anticholinergic properties. If we abruptly stop an anticholinergic drug we can have cholinergic type side effects. So that could be present with something like paroxetine as well as TCAs. So looking at mechanism first, looking at half-life second, how long they've been on the drug. So you gave the example of someone that had been on it for several years. If somebody has been on something for several years, we want to take that into account. If their dose is high, if they're at maximum daily dose we want to take that into account as well.

Sarah Grady:

The other question I ask people that we don't think about sometimes is I'll just ask them hey, we're all busy, have you ever missed a dose of your, of your venlafaxine or your paroxetine? And they'll say yes yes, I have Cause.

Sarah Grady:

I'm a human being and I'm going to miss a dose here and there and I will say what, what happened. And in the case of something like paroxetine or venlafaxine, they usually tell me oh, I felt weird, I didn't sleep. Well, you know. So, knowing what they had experienced missing a couple doses you can bring that in as well. Okay, so remember how you felt.

Sarah Grady:

This is why we really don't want to stop this abruptly. We need to taper you over a certain specified amount of time. So you know, longer they've been on the drug, the higher the dose especially if it has serotonin reuptake inhibition, has anticholinergic effects and they've had experienced withdrawal symptoms and missing a few doses. You know, depending on the answers to all those questions, that will kind of target what kind of tapering regimen you want to use. Now, josh, the interesting thing is that this may happen with some pharmacists, because it happens to me well, probably on a daily basis. The patient you know is switching or you know wants to get off the drug. So you call the provider, you guys are having a conversation. The provider will ask you the pharmacist, potentially how quickly can I taper?

Sarah Grady:

Exactly so that's why you want to maybe have those answers already. Um, what's the mechanism of the drug, how long they've been on it, how high their dose has been? You, as the pharmacist, will have the pills or capsules strength, so you can tell can we cut these, can we force these? All these things the providers are going to be asking you, the pharmacist, and so the good news is is pharmacists can get really involved with this individualized, personalized process. That's the good news. The challenging news is that there's not a one size fits all and every guideline says something different. So just to give you some examples, we can look at the American Psychiatric Association guidelines on this topic and they just say taper over several weeks to a longer period of time, and they don't specifically give you a time. Another set of guidelines, the British Association for Psychopharmacology. They say taper four weeks to several months.

Josh Kinsey:

So I love the use of several in both of those that doesn't have an exact definition at all.

Sarah Grady:

Yeah, very open to interpretation, honestly. So again, that's why it's important, as you the pharmacist, to have all those answers. What's the mechanism? What capsules or tablets do I have? Can I half those? Can I third those? Can I quarter those? I know that's not ideal, but that's something we'll maybe have to work with. We also find that dropping down a dose on a weekly basis might be easier for somebody, so really just have to personalize the regimen. And yeah, like I said, the guidance is very wide all over the literature. The take home point is not a good idea to stop something abruptly unless one of our patients is having a pretty serious side effect or going into anaphylactic shock or something along those lines.

Josh Kinsey:

Sure, so would you say, and I'm not going to pinpoint you into like giving a week, because giving a number of weeks, but it sounds like the minimum is at least four weeks, like I mean, something needs you know, this therapy needs to continue and or discontinue over at least four weeks of time. Is that accurate to assume?

Sarah Grady:

That's what I'm finding in a lot of the guidelines. As far as what is written, now, again, that's going to depend to some degree how long they've been on it and how high? Their dose is.

Josh Kinsey:

Right.

Sarah Grady:

So we talked in the beginning of the podcast about oh hey, maybe somebody does want to get off of something. At six to eight weeks, you know like they. Just they don't feel it's working at all.

Sarah Grady:

They haven't seen a decrease in any of their symptoms of depression or they're just having some side effects they're not willing to have sure well, obviously if, depending on what the drug is, but you know, if they've been on it six to eight weeks, we could probably taper off much quicker. You know, probably probably over the course of a week. You know maybe two, um, maybe you know one to two weeks if it's something like paroxetine, and that's that specific example. But if they're on like fluoxetine, something with a long half-life, even though it has serotonin reuptake inhibition, if you've only been taking it, you know, for six to eight weeks, it's probably just going to self-taper you know, so you may not even need to taper that one off necessarily Okay, but if for longer term use the minimum is probably around four weeks.

Sarah Grady:

Yes, I would say, if we step back more broadly and think about, let's say, someone is diagnosed with depression and they get placed on an antidepressant and then the guidelines say, you know, most guidelines say, if it, if it is working for you, you want to stay on it for a minimum of six to 12 months. Okay. So let's say, you know, we are on an antidepressant for about a year and we're doing okay, it's our first episode, we don't have a family history, our stressors are mild I'm not sure who has mild stressors in life, but I'm sure there's somebody out there that does. But you get the point Not super stressful time in one's life. Then if somebody is on something for about a year, I would say again, depending on what the agent is, its mechanism, I would say probably taper over the course of four weeks.

Josh Kinsey:

Yeah Now. So we talked about, well, a couple of things I wanted to point out. I think it's really important to remember that, because you're talking about how let's say that it's I'm making up're talking about how you know, let's say that it's I'm making up random numbers right now, but let's say that something is a 300 milligram, it also comes in 150 milligram and a 50 milligram. Then you know, potentially we're going to need new prescriptions for those, right, if we're changing the actual dose. So that's another reason to make sure that the provider is looped in. Yes, in general they should already be looped in because we want their opinion and their feedback. But that's another reason is, you know, we're going to probably need new prescriptions to be able to process those Absolutely.

Josh Kinsey:

But the other thing I wanted to mention so that was one thing, and then we were talking about you know the factors that affect, so, the length of time, and you know what else does, like the age of the patient. Does that come into play? What about their weight? You know, like, are we, because you mentioned like, if they're on, like the highest dose? Are they on the highest dose because it's weight-based? Or you know what I'm saying Like what are other factors that we could look at the patient and say, okay, well, I have an obese patient or I have a very frail patient or whatever. How would that kind of play into our decisions?

Sarah Grady:

Yes, I would say I would kind of describe those as maybe special populations. So anytime we have special populations we probably want to go even more slowly. If you have an older adult probably want to go even more slowly. If you have a an older adult, you know, probably want to go a little bit more slowly compared to middle-aged adult.

Josh Kinsey:

Sure, sure. And and one other thing too with you know we were talking about how they might be taking it for depression or for pain or for whatever you know if, and how it's important to make sure they realize that those symptoms, those issues, could return. You know, like if someone is taking, say, duloxetine for their, for their pain in their back or their legs because of diabetes or whatever you know, or something else that they have like, are we anything special there? Do we need to also factor in the fact of other medications being affected? I guess I'm just trying to think of is there a longer reach for or a bigger issue if we're discontinuing this therapy?

Sarah Grady:

Yeah, there could be a multitude of other issues, right, if we just step back and think of the symptoms of discontinuation syndrome itself. I'm thinking like the GI issues.

Josh Kinsey:

Sure.

Sarah Grady:

You know we have potentially we have patients already have gastric reflux peptic ulcer disease. You know we already have, maybe patients that have diabetes and have a neuropathy, so we're giving them additional tingling sensations. That isn't pleasant. It can just contribute to, I think, lots of other potentially medical and mental health issues I have found over time. Just working with people that are they're taking antidepressants coming on them, coming off of them, I feel like slower if possible, slower is better.

Josh Kinsey:

Is better, yeah, if possible.

Sarah Grady:

Now there's always, you know, some exceptions to that. Again, the exception I gave if somebody's been on it six to eight weeks they're not liking the side effects. That's a whole different story, you know, because sometimes the side effects might be worse than some of the discontinuation symptoms. So there's a lot we have to factor in. But really slower is better. A lot of these symptoms can be minimized just by a slower taper.

Josh Kinsey:

Yeah, this is all just such good information, because something as simple as the question from the patient of I want to get off of this because of A, b or C, whatever, and can you help me? And I remember in that space being like, yeah, sure, let's figure it out, and, quite honestly, like I don't know that I ever I probably asked some of those questions. You know, just in general, because it's come up in conversation about, like you know, making the plan. But to hear these specific things, that all of these things we need to consider with something as simple as coming off a med like I, i's eye-opening and it should be for us as pharmacists because this is something that we really can do and it's very important in the outcome for our patient, in their quality of life and everything. So, yeah, this is a great episode. I say that every time, but it never fails, so that's great.

Josh Kinsey:

So let's talk then, a little bit about just again. I want to reiterate the importance of setting the stage. So we need to make sure that we are relaying this to our patients that there could be a problem if you stopped abruptly. So just reiterating the importance of initial consultation for antidepressants and you know, I know we talked about it earlier, but so people don't have to rewind and listen to it again, just to remind us, like, what are those key things we need to do when someone is starting an antidepressant? Setting up the stage for please come to me if you decide you want to stop? You know, like to make sure that they're on the same page.

Sarah Grady:

Yeah, absolutely yeah, and you just add it into your repertoire, because I know everyone is discussing average time course to therapeutic benefit, discussing those common side effects that may occur before you even get to therapeutic benefit, unfortunately, and how to manage those. And then I always tell people look, not a good idea to stop this abruptly. These things have been reported. If, for any reason, you want to discontinue treatment, please contact your provider because you know, based on your individual person characteristics, a really I just tell them a special kind of tapering regimen, may you know, may need to be developed.

Josh Kinsey:

Yeah, yeah. And when you say contact your provider, we as pharmacists, we can, we can be that initial contact right because absolutely then the other person who may have prescribed it, or, you know, whatever caregiver is, is um actually writing the prescriptions.

Sarah Grady:

So yeah, absolutely, absolutely. Because, like I, like I said, uh, particularly pharmacists that you know, work with or serve a lot of communities with primary care physicians. You can certainly call them, but a lot of times they're going to ask you okay what pills do they have?

Josh Kinsey:

What do you recommend?

Josh Kinsey:

I'm going to immediately say you're the medication expert. Help me. So, yeah, yeah. So one last thing to do before we run out of time and get you know wrapped up for the day is and there may not be anything in this space, but if there's anything you could think of, like are there certain? Not that we would ever stereotype at all, but are there certain signs that we should look for in patients who are starting antidepressants, where we might would think they seem like someone who might abruptly stop? I really want to make sure I'm talking about this and how it can be dangerous. Like, are there any things that we need to look forward to? We should be doing those counseling talks with everyone, but are there certain populations or drugs or anything you can think of? Just to kind of again make it easier for us, as we're counseling and talking, to make sure that we're covering the right things for the right people.

Sarah Grady:

Yeah, I think the first thing that kind of pops into my mind is anyone that seems to either voice or look like they are just uncomfortable with taking the drug sure either voice that or they look uncomfortable or say something like I still haven't decided if I'm going to do this or not.

Josh Kinsey:

Yes, yeah, yeah, I don't.

Sarah Grady:

I don't know. I you know my friend takes these and I'm not so sure you, you know. So just, I think that's kind of the, the characteristic that really um sticks out at me, and I don't know that there's a um a specific age or you know gender or anything like that. Just how does you know someone? Look, are they not asking you any questions, or are they asking you too many questions?

Sarah Grady:

You know, are they too worried about, you know? But basically that discomfort, either verbal or nonverbal, that people express. Also I know a lot of. You know patients that you take care of, so you know their previous history. Do they have a history of abruptly stopping other medications, not necessarily antidepressants, but just you know, do they abruptly stop antihypertensives or statins or antibiotics? You know, do they kind of have a personal history of that that they mentioned to you? Or you know they don't ever come back for refills.

Josh Kinsey:

Right, or you. Yeah, you notice, with adherence issues.

Sarah Grady:

Yeah, yeah, yeah, or they tell you they. They just tell you like, look, I um, it's hard for me to remember to take medication every day. You know, um, if that's the case and you see a a script for a shorter acting SSRI, you know, maybe they would be a better candidate for a longer acting SSRI. You know, maybe they would be a better candidate for a longer acting SSRI or a different antidepressant altogether that doesn't have major SRI characteristics.

Josh Kinsey:

Yeah, that's exactly what I was fishing for. I don't know if I set up the question right, but you answered it correctly. That's what I was looking for is like, who should we really be worried about, with abrupt discontinuation. So I think that was exactly what I was looking for, so thank you. Well, we're almost out of time, so before we wrap up, I always like to have our guests kind of summarize the topic for us. Sarah, tell us what the game changer is here. Like you know, the topic for the day is tapering antidepressants, but what's the take-home point for our listeners?

Sarah Grady:

Yeah, number one, I feel what we do best education, education, education. Let's talk to our patients, let's let them know at that initial antidepressant counseling session not a good idea to stop this abruptly. You may not feel so well for a couple of days to a couple of weeks. I can, in conjunction with your provider, we can work together to safely get you off of this medication. So I think education is the biggest piece. And then also just remembering when you get those questions. If and when you get the questions from the doctors, how do I taper? Think about the half-life of the drug, or we can look it up if we don't remember. Most antidepressants have serotonin reuptake inhibition, but not all. That's a factor as well. If they've been on a medication for several years and their dose is higher, we definitely want to have a longer taper for that one, as opposed to a patient that's on a low dose and has only been on something for a couple of months.

Josh Kinsey:

Sure, Sure. That's great. So if I could summarize in three small words, it would be educate.

Josh Kinsey:

Well, maybe it's four words educate, ask questions and then collaborate, and yes, collaboration the individualized plan with the patient included, because, again, as with any treatment plan that we come up with, the patient has to be on board. So if we're going to go back and say you know, you're going to have to taper this over eight weeks, they need to be on board with that and it needs to be something that they're going to buy into as well. So, yeah, Well, Sarah, thank you so much. This was such a great topic. I think it's really an important one. You know, we see a lot of I mean, it's probably one of the most popular classes of medications that we see in pharmacy, and so this question I know every listener out there has had this multiple times and so it's important to make sure that we understand our role and what we can do as a pharmacist. So thank you so much for your time today, Sarah.

Sarah Grady:

Thank you for having me.

Josh Kinsey:

Yeah, if you're a CE plan subscriber, be sure to claim your CE credit for the episode of Game Changers by logging in at CEimpactcom. And, as always, have a great week and keep learning. I can't wait to dig into another game-changing topic with you all next week.