Voiceover: Welcome to NP Certification Q&A, presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
Margaret Fitzgerald: A 38-year-old woman presents for a sick visit with a two-day history of "not feeling right. I've never felt like this before." Approximately four days ago, she self-discontinued a standard dose SSRI after taking this medication for the past 18 months, stating, "I feel like my depression had gotten much better." She denies alcohol or recreational drug use. When considering the diagnosis of antidepressant discontinuation syndrome, which of the following is most likely to be reported?
A. Tremor, diaphoresis, tachycardia, hypertension, agitation.
B. Yawning, rhinorrhea, abdominal cramping, diarrhea, piloerection.
C. Dizziness, nausea, body aches, sleep disturbance, irritability, brief vibrating sensations.
D. Restlessness, sweating, diarrhea, tremor, fever, and involuntary muscle jerking.
The correct answer is C. Dizziness, nausea, body aches, sleep disturbance, irritability, and brief vibrating sensation.
Where should you start? First, determine what kind of a question this is. Given we're provided with a clinical condition and then asked to identify its key components, this is a diagnosis question.
A bit of background information. Antidepressant discontinuation syndrome is a condition that occurs when certain psychotropics are rapidly withdrawn after being taken for a period of time, and usually that period of time is more than four to six weeks at therapeutic doses. And that's exactly what has happened in this clinical scenario. She's been on the SSRI for the last year and a half, feeling better, and then decided, well, I don't think I need this medication anymore, and now she feels poorly.
What happens with antidepressant discontinuation syndrome? What's its pathophysiology? It's thought to be a result from the sudden reduction in synaptic serotonin activity after the brain has adapted to long-term antidepressant exposure. The onset of the withdrawal is related to the half-life of the drug. And if you remember back from pharmacology, you need three to five drug-free half-lives before a medication fully clears from the body. And that is why what we're hearing from this woman is she stopped taking her medicine four days ago, but only started feeling poorly two days ago. Her first couple of days off the medicine, she still had a decent amount of her SSRI on board, but now she's got to the point where she has truly withdrawn. And you will hear this from people who suddenly discontinue their SSRI, SNRI, or a number of other psychotropics.
Here's one of the key points with antidepressant discontinuation syndrome: it is disturbing, it is uncomfortable. This syndrome is not dangerous or life-threatening. And that's in contrast to benzodiazepine, alcohol withdrawal, a few other withdrawal syndromes that are potentially life-threatening. Antidepressant discontinuation syndrome generally resolves within a few days to a few weeks.
Can this be avoided? Of course it can be avoided. And this is why, when treating a person with depression, anxiety, something along those lines, we're always advised, when people are ready to come off of their medication, if they ever are, because some people will stay on this lifelong, what we want to do is at least a four, maybe more like a six-plus week gradual taper of the drug's dose prior to discontinuation, and careful monitoring for worsening symptoms of depression, anxiety. In other words, whatever the person was originally taking the med for should be monitored during the tapering period.
With this for background information, let's take a look at the question and options. A 38-year-old woman presents for a sick visit with a two-day history of "not feeling right. I've never felt like this before." About four days ago, she self-discontinued a standard dose SSRI after taking this for the past 18 months, stating, "I feel my depression has gotten much better." She denies alcohol or recreational drug use. When considering the diagnosis of antidepressant discontinuation syndrome, which of the following is most likely to be reported?
A. Tremor, diaphoresis, tachycardia, hypertension, agitation. This is incorrect and is far more consistent with the description of alcohol withdrawal. As mentioned previously, antidepressant discontinuation syndrome is quite uncomfortable, it's not potentially life-threatening as untreated alcohol withdrawal could be. Treatment, of course, is available for alcohol withdrawal and should be offered and encouraged.
B. Yawning, rhinorrhea, abdominal cramping, diarrhea, piloerection. If you're wondering what piloerection is, it's literally goosebumps. This is incorrect and describes more of a scenario with opioid withdrawal, a condition that's quite uncomfortable but usually not life-threatening. And of course treatment is available and should be offered for opioid withdrawal.
C. Dizziness, nausea, body aches, sleep disturbance, irritability, brief vibrating sensations. This is, of course, the correct answer. And by the way, let me just throw this in there: the sleep disturbance, really scary nightmares, I've had so many patients tell me over the years when they quickly discontinued their psychotropic med that they had epic nightmares. And I always warn patients about that, because otherwise they're so scared by the scary dreams they're having.
As was mentioned, this can be avoided by slow taper of the psychotropic meds. For this patient today, this patient today feels poorly. Couple of different ways you can handle it. One is to advise the patient, yep, you feel poorly, you probably will feel poorly for about another week and then the sensations will resolve, and have that dialogue with the patient. Do they feel like they can "put up with it" for another week? Or, if they're really uncomfortable, what they can do is go back on their psychotropic drug today at their former dose. They'll feel much better within about 24 to 48 hours, then leave them be for a couple of weeks, and then have a discussion with them about tapering their dose over a four to six week period of time, right? And so, you know, there's no right or wrong way to deal with this. Most of the time, what I have found is if the person really, really wants to come off the medication, like if there's a pregnancy that was not anticipated, that type of thing, what they'll usually do is say, "I'm just going to put up with feeling this way for the next week. Thank you for letting me know."
Okay, option D. Restlessness, sweating, diarrhea, tremor, fever, and involuntary muscle jerking. This is a scenario that's more consistent with serotonin syndrome, which would be found in the excessive ingestion of a medication, such as an overdose of an SSRI, SNRI, tricyclic antidepressants, and a variety of other meds. And this is a potentially life-threatening situation.
Key takeaway: recognizing select medication withdrawal syndromes and whether it's life-threatening or not is key to safe prescribing.
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