HALF-LIVES
This SSRI has the longest effective half-life
What is fluoxetine? due to its active metabolite norfluoxetine (~4–16 days).
The common lay term for the paresthesia-like symptom frequently reported during SSRI/SNRI withdrawal.
What are "brain zaps" (or electric shock sensations)?
Hyperbolic tapering is based on the non-linear relationship between drug dose and occupancy of this receptor/transporter for SSRIs.
What is the serotonin transporter (SERT)?
According to most guidelines, after a FIRST episode of depression in youth, the minimum duration of stability/remission before considering tapering is this.
What is 6–12 months?
In N=1 placebo-controlled crossover trials, approximately this percentage of youth on long-term methylphenidate were successfully discontinued.
What is 38.5% (approximately 38%)?
This antidepressant's parent compound has a half-life of only ~5 hours, contributing to its notoriously high withdrawal risk.
What is venlafaxine?
The mnemonic FINISH is used to remember SSRI/SNRI discontinuation symptoms. Name at least 4 of the 6 symptoms it stands for.
What are Flu-like symptoms, Insomnia, Nausea, Imbalance, Sensory disturbances, Hyperarousal?
At typical therapeutic SSRI doses (e.g., fluoxetine 20 mg), approximately this percentage of serotonin transporters are already occupied.
What is ~80%?
For recurrent depressive episodes or high-risk patients, guidelines recommend maintaining treatment for at least this duration before considering deprescribing.
What is 2 years (or longer)?
Longitudinal data suggest that approximately this fraction of children with ADHD will no longer need stimulant medication as adults.
What is one-third?
This one has the shortest half-life (~21 hours) AND no active metabolites, making it the hardest SSRI to taper.
What is paroxetine?
When a patient on paroxetine has severe withdrawal symptoms despite gradual tapering, this long half-life SSRI is commonly used as a "bridge" for cross-tapering.
What is fluoxetine?
Using a ~25% dose reduction approach for escitalopram 20 mg, the first reduction would be to approximately this dose.
What is 15 mg?
This term describes a period of at least 2 months during which a patient with MDD has either no symptoms or no more than 1–2 mild symptoms.
What is remission?
This atypical antipsychotic requires especially cautious tapering not primarily because of dopaminergic rebound, but because of cholinergic rebound causing profuse sweating, nausea, and vomiting.
What is clozapine?
This alpha-2 agonist used in ADHD has a half-life of 6–10 hours in children, but its abrupt discontinuation is dangerous not because of short half-life but because of this rebound phenomenon.
What is rebound hypertension?
This term describes withdrawal symptoms that persist well beyond the expected pharmacokinetic clearance of the drug — lasting weeks to months — and may be mistaken for relapse of the original condition.
What is persistent post-withdrawal disorder?
When deprescribing an antipsychotic in a youth, monitoring for this movement disorder is important because it can paradoxically EMERGE or WORSEN during dose reduction.
What is withdrawal dyskinesia (or tardive dyskinesia)?
A patient with depression achieves remission at week 8 of treatment. At week 16, full symptoms return. This is classified differently than if the same thing happened at month 12. Name both terms and the distinction.
What are relapse (return of symptoms before recovery — same episode re-emerging) and recurrence (a new episode after recovery has been achieved)?
A 15-year-old is on aripiprazole 15 mg and carbamazepine 600 mg. The team tapers carbamazepine to 200 mg. The fellow should anticipate that aripiprazole levels will do this — and should respond by doing this.
What is aripiprazole levels will RISE (due to decreased CYP3A4 induction), and the aripiprazole dose should be reduced?
This is the approximate half-life of quetiapine's active metabolite norquetiapine, which helps justify once-daily dosing despite the parent compound's ~7-hour half-life.
What is 12 hours?
A 12-year-old on risperidone 2 mg for irritability is being tapered. Two weeks after reducing to 1 mg, he develops involuntary tongue movements. This movement disorder can paradoxically emerge during antipsychotic dose reduction.
What is withdrawal dyskinesia?
This mood stabilizer requires monitoring of drug levels during tapering because dose reductions can alter the levels of co-prescribed medications through changes in hepatic enzyme induction.
What is carbamazepine (or valproate)?
A 16-year-old in foster care is on sertraline 200 mg, quetiapine 400 mg, clonidine 0.3 mg, and methylphenidate ER 54 mg. She has been psychiatrically stable for 8 months with active CBT. Using deprescribing principles, name the medication you would taper FIRST and give one reason why.
Acceptable answers include:
Quetiapine — highest metabolic risk, may be a prescribing cascade for irritability that has resolved, or duplicative sedation with clonidine
Clonidine — if originally added for sleep/irritability that has resolved, though must taper slowly due to rebound hypertension risk
A 13-year-old with ASD and ADHD is on methylphenidate ER 36 mg, guanfacine ER 3 mg, sertraline 150 mg, and risperidone 1.5 mg. He has been stable for 14 months. His BMI has crossed from the 75th to the 95th percentile. The team decides to deprescribe one medication first.
Name the medication,
the primary reason, and
one monitoring concern during the taper.
Risperidone
primary reason: metabolic side effects (weight gain driving BMI increase)
monitoring concern: withdrawal dyskinesia or rebound irritability