Symptoms caused by drug withdrawal	Symptoms caused by relapse
• usually happen very soon after you start to come off. But this is related to half-life – withdrawal effects will be delayed by as much as two weeks in a drug with a long half-life such as fluoxetine	• are delayed, and are not related to the half-life of the drug
• are often different from anything you have had before	• are the same as the symptoms you had before – when you started the drug
• go as soon as you re-start the drug	• get better slowly if you re-start the drug
• will eventually subside without treatment if you don’t re-start the drug	• continue indefinitely without other treatment

What are the withdrawal effects of the different types of drugs?

All psychiatric drugs change brain and body chemistry, and so they may all cause withdrawal symptoms, especially if you have been taking them for a long time. You will not necessarily get any of these symptoms when coming off, but many people do. The symptoms differ to some extent between drug types.

Drugs with ‘anticholinergic’ effects

These are withdrawal effects which can happen with any drugs that cause a set of adverse effects called ‘anticholinergic’ or ‘antimuscarinic’ effects. These drugs are mainly the older antipsychotics and tricyclic antidepressants.

The withdrawal effects associated with this are:
• feeling sick and being sick • flu-like symptoms • stomach cramps • runny nose • watery eyes	• too much saliva, so that you may dribble • indigestion • sweating • vivid dreams • insomnia

Antidepressants

This table shows the withdrawal effects associated with the different types of antidepressants.

MAOIs e.g. moclobemide	Tricyclics e.g. amitryptiline	SSRIs and SNRIs e.g. citalopram
• agitation • irritability • being unsteady on your feet • movement problems • difficulty sleeping • extreme sleepiness • vivid dreams • difficulty thinking • hallucinations • paranoid delusions	• ‘anticholinergic’ effects, mentioned above • headache • restlessness • diarrhoea • lethargy • movement problems • mania • disturbances of heart rhythm	• flu-like symptoms • electric shock sensations in head • stomach cramps • dizziness; vertigo • crying spells • sleep disturbance • weird dreams • fatigue • sensory disturbance • tinnitus • movement disorders • concentration and memory problems • mood swings • suicidal thoughts

SSRIs

The withdrawal symptoms of SSRIs divide into two groups:

• Those that are unlike anything you have had before – dizziness, ‘electric head – like the brain is having a version of goose pimples’, electric shock-like sensations, tingling or painful sensations, feeling sick, diarrhoea, wind, muscle spasms, tremor, agitated or other vivid dreams, agitation, hallucinations, tardive dyskinesia.

• Those which may lead your doctor to think that your original problem has come back – depression and anxiety, mood swings, irritability, confusion, flu-like feelings, insomnia or drowsiness, sweating, feelings of unreality, feelings of hot or cold, personality changes.

SSRIs are also associated with:
• Mania – they can cause a manic episode while you are taking them and also if you stop them suddenly. This can cause you – and your doctor – to think that you actually have bipolar disorder, rather than depression, and that you should be started on mood stabilisers. But if the manic episode was caused by the drug or its withdrawal, this should not be necessary.

• Suicidal thoughts and violent behaviour – especially with changes in dose. This may happen when reducing as well as increasing the dose, and may be associated with an intense physical and emotional restlessness and turmoil called ‘akathisia’, which is more commonly associated with antipsychotics.

See Antidepressants for more information.

Anti-Parkinson’s drugs

These are taken for some of the adverse effects of antipsychotics.

Withdrawal effects include:
• feeling sick and being sick
• chills
• weakness
• headaches
• insomnia, restlessness.

Antipsychotics

Antipsychotics are associated with:

• Psychotic episodes – if you have been taking antipsychotics for more than three months, your brain will probably have adjusted to them. This means you are at greater risk of having a psychotic episode if the drug levels drop rapidly. This may not happen for some weeks after you have stopped, and may be interpreted as your original symptoms returning, but is likely to be a withdrawal psychosis. This is the main reason for withdrawing antipsychotics very gradually.

• Tardive dyskinesia – a medical term for tics, twitches and other involuntary movements which are a side effect of antipsychotics, but may not appear until you try to come off them. For more information see Mind’s online booklet Understanding tardive dyskinesia.

• Neuroleptic malignant syndrome – a rare adverse effect of antipsychotics which may occur while you are taking them, and may also occur on drug withdrawal. The symptoms include high fever, loss of consciousness and abnormal movements. It can be life-threatening and should be treated in hospital as an emergency.

Other withdrawal symptoms are:
• mood disturbances • restlessness, agitation and irritability • anxiety • feeling withdrawn socially • sleeplessness • abnormal pain • feeling sick and being sick • diarrhoea	• loss of appetite • headache • aching muscles • shaking • abnormal skin sensations • vertigo and dizziness • disturbed temperature regulation so that you feel too hot or too cold.

See Antipsychotics for more information.

Benzodiazepines and Z sleeping pills

Withdrawal effects of benzodiazepines and z sleeping pills (which work in a very similar way) include anxiety, insomnia and irritability; these are conditions which the drugs are prescribed to treat, and so you may assume your original symptoms have come back – but withdrawal effects will pass.

Other withdrawal symptoms are:
• muscle twitches and shaking • seizures • fast heart rate and palpitations • confusion • panic attacks • difficulty sleeping • nightmares • dizziness • headache • depression • hallucinations • suicidal thoughts • memory problems	• cold sweats • breathing problems • high blood pressure • stomach ulcers • feeling sick • loss of appetite • weight loss • nose bleeds • ringing in the ears • light-headedness • detachment • feeling poisoned.

You are more likely to get them if:
• your drug has a short half-life (see ‘Planning withdrawal’)
• you have taken a high dose
• you have taken it for a long time
• you have anxiety
• you are very sensitive to light and sound
• you stop taking it suddenly.

See Sleeping pills and minor tranquillisers for more information on these drugs.

Lithium and anti-convulsant mood stabilisers

When coming off mood stabilisers it is very helpful if you monitor your mood carefully, perhaps using a mood diary. See Understanding bipolar disorder and Understanding hypomania and mania for more information and support.

Lithium

There do not appear to be physical withdrawal symptoms with lithium.

However, if you come off lithium too quickly you are very likely to have a rebound manic or psychotic episode and become quite ill, so you need to be cautious, reduce gradually – over at least one month, and much longer if you have been taking it for years.

If relapse occurs, it happens in the first few months after withdrawal and then tails off.

Anticonvulsants

Withdrawal effects associated with anticonvulsants include:
• mood swings, anxiety and irritability which may be very like the symptoms you were taking the medication for • headache • dizziness • stomach and gut problems • coughs and colds • liver problems • anaemia • pancreatitis	• difficulties with memory, learning and thinking • eye and sight problems • sensory disturbances • abnormal menstrual periods • difficulty sleeping and fatigue • weight gain • muscle spasms, twitches and shaking • fits, even if you have never had one before.

Additional withdrawal symptoms of individual drugs:

• Valproate – weakness, feeling sick and being sick.
• Carbamazepine – aching muscles, unsteady gait, sleeping problems, loss of energy, loss of appetite, depression; low blood pressure and fast heart beat.
• Lamotrigine – fits which may be severe and difficult to control.
Loss of pleasure, moodiness, hostility, fast heart beat, sweaty hands, tingling sensations.

Plan your withdrawal

Having a personal withdrawal plan for reducing your medication over a number of weeks, months or even years can help you to stick to your original aim. If you make a chart showing how much of the drug you will be taking each day it keeps the end goal in site and prevents you getting confused as to where you’ve got to with the reduction process. This may be something that a psychiatrist, doctor or pharmacist can help with, providing they are in agreement with your decision.

Tell people close to you

Explain to your friends and family what you are planning to do and how this may impact on your mood and emotions. It might also be helpful for them to understand that you may experience ‘big feelings’ and that it may take some time for you to get used to having such powerful emotions again. If they understand about withdrawal symptoms, then they are more likely to be sympathetic if you experience them.

Get to know your triggers for crisis

Many people get to know what situations they find stressful, and either prepare themselves carefully so as to minimise the stress, or avoid them completely. You may find it helps to keep a diary so that you can spot patterns.

Monitor your mood

Monitoring your mood during the withdrawal process can help you to spot subtle trends that might otherwise get overlooked. You can use your own methods, e.g. a diary, or an online tool such as Moodscope (moodscope.com). Also, recording any side effects can help you to remain objective and recognise any less obvious patterns that occur.

Trust your own feelings

If you feel that something you are experiencing is a side effect of medication or a withdrawal effect, take this seriously. Other people may think that your symptoms mean that your illness is coming back, but you may feel sure it is not. If you are following a programme of slow dose reduction, and you reach a difficult phase, don’t be afraid to slow down, or to stop at the dose you are on for longer than you had planned; adapt your plans to fit your experience.

Learn how to look after yourself

Don’t be afraid to say ‘no’ if you feel something you’ve been asked to do will be too much for you. Be prepared to ask your friends or family for help, if that’s what you need to keep well. For example, you may find it much easier to keep an appointment if you have someone to go with you.

You may find it possible to do something you find stressful if you take a particular comforter with you (a scarf, a special stone to hold in your pocket, a teddy, or whatever works for you). Don’t be afraid to use such things if they help you to get on with your life.

Look after your diet

It’s a good idea to eat regularly, starting with breakfast. You may want to avoid sugary foods and drinks as they cause big fluctuations in blood sugar which can cause mood swings and anxiety. Be aware of foods and drinks that trigger depression or other mood changes in you. Keeping a diary of what you’ve eaten may reveal reactions that you weren’t aware of.

Get enough sleep

Sleep is one of the most important factors in maintaining mental health. If you are coming off medication, and one of the withdrawal effects is sleep disturbance, you may have to be prepared to put up with this for a while and find ways to minimise the ill effects. (See How to cope with sleep problems).

Exercise

Some people find exercise can help to reduce stress and anxiety, and it can be prescribed as a treatment for depression. Taking exercise out in the fresh air, in the country or the park is most effective. (See Physical activity – tips.)

Be prepared to change your plans

Coming off can sometimes be a big disappointment for people, if it doesn’t bring the improvement they hoped for. But even if you don’t manage to come off completely, you may succeed in reducing your dose, and this could make a significant difference to how you feel. In fact, trying to come off a particular medication can be a good way of finding your ‘threshold dose’. This is the lowest amount of medication required to relieve your symptoms and keep you well.

You can also consider trying again at a later time. The fact that things did not go as you wished this time does not mean that they never will.

Some people find out that they are happier taking medication after all. This is also helpful to know. It may be easier to get on with the rest of your life once you have accepted that medication is part of it, and you feel that the decision was yours rather than your doctor’s.