Standard reduction approaches

Selective serotonin re-uptake inhibitors (SSRIs):¹⁴³ Due to the long half-life, the following can be stopped at standard daily doses: citalopram 20mg, escitalopram 10mg, fluoxetine 20mg and sertraline 50mg per day. However, individuals may prefer or require a slower reduction with lower doses.

Example SSRI dose reduction steps

• Steps: the rate of withdrawal will vary with individual needs e.g. weekly to four weekly reductions for some
• All doses are single daily doses
• * Alternate day dosing 40mg/20mg
• ** Alternate day dosing with 20mg capsule, or consider using fluoxetine liquid
• † Some individuals may require to be switched to an alternative SSRI if experiencing significant withdrawals, see below.
• †† Half a 10mg tablet

Most individuals will be able to slowly withdraw and discontinue duloxetine and venlafaxine without any adverse effects. Where individuals experience discontinuation/withdrawal effects after stopping, it may be appropriate to restart the antidepressant at the previous dose and frequency for seven days then switch to a long-acting SSRI if interactions and contra-indications allow.

Example SNRI dose reduction steps

Steps: the rate of withdrawal will vary with individual needs e.g. weekly to four weekly reductions for some, or longer and slower reductions for others.

Note: Venlafaxine 300mg daily used as example, as individuals on higher doses are usually under the care of community mental health teams who should be involved in decisions to reduce or withdraw.

1. BNF only has 60mg dose listed for treatment of major depressive order. Duloxetine SmPC (data sheet) quotes up to 120mg daily. However, there is no clinical evidence suggesting that individuals not responding to the initial recommended dose may benefit from dose up-titrations.¹⁴⁴
2. If receiving modified-release (MR) preparations as split dose e.g. twice daily, please consider that MR preparations are intended as once daily preparations.
3. Some individuals may have a preference for reducing the night-time or morning dose first.
4. If needed venlafaxine 37.5mg MR daily could be used for another step before stopping.

Frail and/or older adults may require and need slower reduction to minimise the risk of cholinergic rebound (nausea, vomiting, headache, restlessness). Therefore, slow reduction over longer than six weeks, or months, may be needed for some individuals depending on their preference and/or needs.

Example TCA dose reduction steps

1. The same reduction schedule could be advised for: Clomipramine, Dosulepin (dothiepin), Doxepin, Imipramine, Nortriptyline, Trimipramine
2. Older adults and some individuals may require reductions using smaller dose increments to minimise the risk of adverse withdrawal effects/harms.
3. Dosulepin and doxepin not available as 10mg dose, therefore, consider if necessary, using 25mg capsules on alternate days, then stop.
4. If dose is split morning and night, consider reducing and stopping morning dose first, and then continuing reduction with nighttime dose.
5. Tablets are less suitable for halving as they have a film coating. If necessary, a 35mg dose can be given using lofepramine 70mg/5ml oral suspension.

Example dose reduction steps for other antidepressants and MAOIs

Steps: the rate of withdrawal will vary with individual needs e.g. weekly to four weekly reductions for some.

1. Some individuals may find the 15mg dose more sedating than higher doses due to greater antihistamine effects at lower doses.
2. For higher doses consider reducing at each step by 50mg. However, clinical need and/or individual preferences may require larger reduction steps e.g. 100mg.
3. Isocarboxazid, phenelzine and tranylcypromine inhibit monoamine oxidase A and B for up to two weeks after stopping. Consider risk of interactions for two weeks after stopping.
4. Moclobemide is a reversible inhibitor of monoamine oxidase A.