Guidance for tapering antidepressants in adults is often applied to kids: Go slow, avoid paroxetine and venlafaxine, lean on fluoxetine. This systematic review gives us some more specifics for the pediatric population.
The authors reviewed 28 studies and regulatory and pharmacokinetic sources, including 13 RCTs involving more than 3,000 patients ages 7–17. Withdrawal symptoms were common and sometimes resembled relapse: irritability, dizziness, nausea, and sleep disturbance. Venlafaxine was notable for “brain zaps” and tricyclic antidepressants for cholinergic rebound.
Medications with short half-lives, especially paroxetine and venlafaxine, carried the highest risk. Fluoxetine, with its long half-life, was least likely to cause withdrawal. When switching antidepressants, cross-titration was better than stopping one drug abruptly before starting another.
The review covers discontinuation of many specific medications and differentiating withdrawal from relapse, eg, more rapid onset and recovery for relapse.
CARLAT TAKE
Although many of the authors reported relationships with pharmaceutical companies, the takeaway from this review is sensible: Stopping antidepressants requires as much planning as starting them. Avoid paroxetine and venlafaxine as both carry high withdrawal risk, paroxetine has a suicidality signal, and SNRIs lack efficacy for depression in children and teens. Schedule the discontinuation process to avoid periods of higher stress. Reductions should be non-linear, reducing by a percentage of the remaining dosage over many months, so that later decreases are smaller; this accounts for the higher impact of the reductions on receptor coverage. Warn families that withdrawal symptoms can look like relapse, and don’t rush to restart a medication because of transient discomfort. Finally, fluoxetine remains your safest exit ramp when tapering gets rocky.
