Withdrawal symptoms as a consequence of NaSSA discontinuation

Introduction: Selective serotonin reuptake inhibitors and serotonin-noradrenaline reuptake inhibitors are widely used in clinical practice although they can induce withdrawal symptoms similarly to other CNS drugs. The present case shows that also the discontinuation of noradrenergic and specific serotonergic antidepressant (NaSSA) might induce withdrawal symptoms. Case description: S. is a 32-year-old woman. At 30 years of age, she presented depressed mood, panic attacks, avoidance. She was first treated with psychodynamic therapy and later with drugs (i.e., alprazolam, aloperidol, quetiapine, escitalopram, citalopram, fluvoxamine, venlafaxine, mirtazapine, valproic acid) with poor results. At first visit she was under valproic acid (1000 mg/die), sertraline (75 mg/die), mirtazapine, (30 mg/die), lorazepam (1 mg/die) from a 6-month period. Via the MINI International Neuropsychiatric Interview the diagnoses of panic disorder with agoraphobia and major depressive episode were formulated. The patient did not have a history of bipolar disorder or recurrent depression. She complained about intense anxiety, nightmares, low mood. The psychiatrist discontinued valproic acid and lorazepam, tapered slowly and discontinued mirtazapine at the rate of 7.5 mg every other week, prescribed clonazepam (2 mg/die), and referred her to CBT. Despite slow tapering, once mirtazapine was discontinued, the patient experienced post-withdrawal disorders consisting of nocturnal panic attacks, agitation, mood swings, nightmares. The introduction of clonazepam faded away mood swings and panic attacks. After three months, S. still had nightmares, thus 2 CBT sessions were proposed to let her identify daytime thoughts on threatening situations and interrupt them. Nightmares slowly disappeared. Comment: NaSSA can induce withdrawal symptoms at discontinuation.