| Distinguishing between clinical features of a medication discontinuation syndrome, adverse events, depression symptoms (or exacerbation) and a serotonin syndrome |
|
| Discontinuation | Adverse events | Depression | Serotonin syndrome |
|
| Clinical features | Dizziness, nausea, anxiety, headache (most commonly reported symptoms) | Asthenia, diarrhoea, nausea, anxiety, dizziness, insomnia, nervousness, somnolence, tremor (most common symptoms) | Depression and lack of interest predominate, but can have prominent anxiety and sleep disorder | Abdominal cramps, diarrhoea, tremulousness, myoclonus, coma, tachycardia, hypo- or hypertension, confusion, disorientation, diaphoresis, hyperpyrexia, etc. |
| Context |
- Rapid reduction or stopping of SSRIs
- Check if patient has altered dose, `forgotten' tablets, or `run out'
|
- Mostly in the first 1-2 weeks of treatment
- Mostly settle if medication is continued
- Check not a drug interaction, especially SSRI with TCA; stop concurrent TCA
|
- Continuation or worsening of initial illness
- About 10-20% of patients relapse with continued treatment; some improve with an increased dose, others need change of medication
|
- Over dosage
- Drug interaction (especially SSRI + MAOI, or SSRI + TCA)
- Inadequate drug free interval in changing medications
- Idiosyncratic reaction
|
| Response to increased SSRI dose | Usually relieved | Usually worsens | No acute change, except possible adverse event | Worsens - could be dangerous |
| Response to decreased SSRI dose | Usually worsens | Usually relieved | No acute change, or subsequent worsening with relapse, or discontinuation syndrome | Usually relieved if SSRI ceased, and ceasing interacting medicines if possible |
| Symptoms persist despite intervention | Seek a psychiatric second opinion | Seek a psychiatric second opinion | Seek a psychiatric second opinion | Emergency, seek immediate second opinion, possibly hospitalise |
|
| Note: There may be overlap between these conditions and the differentiation may be clinically difficult.
SSRI - selective serotonin reuptake inhibitor
TCA - tricyclic antidepressant
MAOI - irreversible non-selective inhibitors of monoamine oxidases A and B |
