Withdrawing from Paxil - The Almost Complete Guide
-By J.B.

The only complete information about withdrawing from Paxil, from beginning to end, has been piecing together message board postings from those folks who have actually done it. There has been a big need for this information in one source - not just bits and pieces. I've tried to gather as much as I could from former Paxil patient's experiences (including my own) to share with those attempting to quit Paxil. Now there can be a source to direct people to for all of this information ; instead of having to post it over and over again. Feel free to print, share, and give links to this document.
When withdrawing from Paxil, you have to decide which method is right for you. Everyone is different, so experiment. Tapering the dosage down over a period of time seems to be the preferred way to stop - versus quitting Paxil "cold turkey". The withdrawal symptoms during tapering are generally much less intense than cold turkey quitting.
Although some people can quit Paxil and suffer no withdrawal repercussions, countless numbers of folks have quit or tapered and have suffered nausea, dizziness, electric shock sensations known as "the zaps", headache, flu-like symptoms, balance problems, anxiety, sleep problems, gastro-intestinal problems, sweats, vivid dreaming, sensitivity to light and/or sound, etc. The list goes on and on…..Withdrawal from Paxil is happening in much greater numbers than the manufacturer has reported to the FDA.

Withdrawal can be miserable, so it's important to figure out what works BEST for you and puts you in the least, if any, discomfort. Plus, it really helps to plan.
*Sadly, a lot of doctors/psychiatrists don't know about the withdrawal effects of Paxil. Some even will deny that they happen. In a perfect world, you should have been told about the potential for withdrawals from Paxil at the time it was prescribed for you! Most folks aren't. Withdrawal from Paxil and SSRI drugs is a documented fact and I will provide a list of medical journal articles later that you can copy and take to your doctor if he/she is an "unbeliever".
*The most important thing is to make sure your doctor is aware of the withdrawals from Paxil and understands the tapering method. How you decide to taper is up to you, because some doctors will taper a patient too quickly. Tapering has to be individualized. One size does not fit all - and don't let any doctor tell you otherwise.
*The Vicious Circle of Paxil:
Quite often, Paxil patients, who are unaware of withdrawal, go to doctors - who are also unaware of the withdrawal - and the ignorant doctor diagnoses the withdrawal symptoms as depression or anxiety "relapse". The doctor will then try to actually INCREASE the patients Paxil dosage!
When you withdraw from Paxil, it's not always pleasant - but have some judgment here, especially if your doctor tries to increase your dosage and starts talking about 'relapse' returning. This mistake of doctors diagnosing 'withdrawal' as being 'relapse' has been noted and journaled in several medical publications. Make sure your doctor knows about and ACCEPTS the fact of withdrawals from this drug! If not, find a new doctor that does!

Okay, so you're ready to quit Paxil? Before you begin…..Withdrawal effects usually start between 2 to 3 days after reducing or stopping the dosage - but they can start as soon as 1 day or take as long as 7 days. Generally, by day three….you should start to know. If you taper too fast, believe me, you'll know.*When decreasing your dosage, be aware of how you act & react emotionally to situations with others- after all, this is a psychological drug. Be prepared for mood swings.
It's also best to try this when you have days off from work. It's not fun to get nauseous, dizzy, anxious, etc. at work - and then have to drive home? In other words, if you have Sat./Sun. off, try tapering your dose on Friday - you should start know something by Sunday in most cases. Be sure to keep that little 10 mg. piece (explained below) of Paxil with you. Don't leave home without it, and don't go away for the weekend without your normal dosage with you. I don't suggest experimenting with tapering on a "weekend getaway" trip either. Do it in your normal surroundings.
*Plan a schedule for tapering in advance. By learning what to expect and
informing yourself, you will save yourself a lot of unnecessary worrying.

Tapering down method
-If you are taking 30 mg. and above, you can start by dropping down 10 milligrams lower than your normal dose and see if you start to experience any withdrawal effects. Save the 10 mg. piece and take it with you.
-If you are taking 20 mg. or lower, start with a 5 mg. decrease. The example below refers to the 10 mg. drop. Follow the directions with 5 mg. drop instead of 10. Save the 5 mg. piece and take it with you.
-If you DON'T have noticeable withdrawal effects from this decrease - remember; give it 3 to 7 days for withdrawal effects to start. Stay at this minus 10 mg. dosage until you've determined you're out of the woods. Decide how long your body needs to adjust to this decrease before lowering dose again. 1 week? 1 month? Longer? You have to decide this, based on how you feel physically and psychologically.
-Once you eventually taper down to taking only 10 mg. a day, then go to 5mg. for a while, then 2.5mg., and then try zero. The last 10 mg. has been the most difficult drop for some. And some people don't develop withdrawals until the last 10 mg.
-If you DO HAVE noticeable, unbearable withdrawal effects from this decrease - STOP. Take the 10 mg. piece to finish out your regular daily dosage. If you start to have unbearable withdrawal symptoms, a 10 mg. drop is too much for you. Start taking your regular full dose again tomorrow and wait a few days to start this process over with a 5 mg. decrease. Most withdrawal effects subside after taking the regular dose again. The next step now is to try decreasing Paxil by 5mg., and if the withdrawal effects start with this decrease, repeat the above steps with the 5 mg. piece that you saved and hopefully have with you. You may have to decrease dosage in 2.5 mg. increments if the withdrawal effects from a 5 mg. drop become intolerable.
*This is the point where you have to figure out if you are one of the lucky ones and can taper off Paxil with ease - or if this is going to be a long and tedious process - or if you're somewhere in the middle.
Some people can come off Paxil with no problems. Others, on the extreme, have found it necessary to drop in increments as low as 2.5 mgs. for months and then taper the last few milligrams with the Paxil liquid. You have to find what works for you. And if you do develop some withdrawal symptoms, you must decide just how much withdrawal you can tolerate before having to return to your normal dose and start tapering in a smaller increment.

Cutting pills….. and Paxil liquid (suspension)
Any pharmacy can sell you an inexpensive pill cutter. With a pill cutter, you can cut a pill in half (and a half pill in half). People have also used razors, Exacto knives, and nail clippers to make really small doses. Eventually, get your pharmacist to refill your prescription with the 10 mg. pills - it will be much easier to cut these into smaller doses once you've tapered below 10 mg.
Another great alternative to cutting or shaving pills is to get the liquid form of Paxil. The orange flavored Paxil liquid is good for accurate, small tapering doses as small as 1 mg.! Any pharmacy has it or can get it for you. Some pharmacists have never even heard of the Paxil liquid form - so don't let them tell you it doesn't exist! Here's the info in case they do:
Paxil Oral Suspension (liquid): Orange-colored, orange-flavored, 10mg/5 ml, in 250 ml white bottles. NDC 0029-3215-48
Take this NDC # with you to the pharmacy.

Your Paxil reduction schedule
As stated, tapering down Paxil is an individualized process. By having patience and sticking to a reduction schedule, you might not develop withdrawals. Below is Jeff's example of a reduction schedule and his comments.
"Here's the approximate schedule that worked for me.
From 60mg to 40mg in 10mg steps.
From 40mg to 30mg in 5mg steps.
From 30mg to 20mg in 2.5mg steps.
From 20mg to 0mg in 1mg steps.
Down to 20mg, I was chopping up tablets to control the
dosage. From 20mg down, I used the liquid Paxil.
Every change in step size indicates a point where the
withdrawal symptoms hit. When this happened, I went
back to my previous dose for a few days, then started
again with smaller steps.
I was decreasing my dose about every 4 days. This made
sense to me because if the withdrawal symptoms were
going to hit, it always seemed to happen in the 2nd or
3rd day after a dosage decrease.
I was stuck for a long time at 20mg. Fortunately I
changed doctors and the new one told me about the
liquid Paxil. From there on it was pretty smooth
sailing in 1mg steps all the way to 0mg unless I
missed a dose or got impatient and tried to go faster."

Cold Turkey Quitting - Zero
I quit Paxil cold turkey. For me, it was Hell and completely incapacitating for more than a week. By Day 3 with no Paxil, I knew something was really wrong - but it took 3 days for the withdrawal to even begin. Having no prior knowledge of withdrawals, and not being told by my doctor or pharmacist that this may occur - I was in for quite a ride. I now wish that I had known about the tapering method before I decided to cold turkey off Paxil.
Days 4 through 8 were the absolute worst. I had a low-grade fever, night sweats, headache, nausea, balance problems, sleep disturbances, upset stomach, and the zaps like you wouldn't believe! At one point, I was up to 14 zaps per minute - yes, I actually timed them! It took a total of 3 weeks for these symptoms to gradually subside.
For most, cold turkey is not the way to go.

What are "The Zaps"?
The zaps are little shock-like sensations, which occur during Paxil withdrawal. More annoying than painful, the sensation would start in my mouth and head and 'shoot out' towards my extremities for a split second - like a low voltage shock. If you were ever dared as a kid to touch a 9-volt battery to your tongue, then that's the best way I can describe a zap. They can happen with head and eye movement, or even while sitting perfectly still. After a while, you can begin to hear the zaps happening in your head - like a 'swoosh' sound.

The Switching method
Although I don't suggest switching drugs - one SSRI drug for another - some people have used this method to taper themselves off Paxil. Even if you decide to switch drugs, withdrawal from Paxil can still happen using this method. Prozac, Celexa, Zoloft, Luvox, and the others SSRI's also have their own, very similar problems as well. If you switch drugs, in a lot of cases, you're right back having to taper yourself off the new SSRI drug too. Some people have switched SSRI's with ease - others haven't. This method can start a merry-go-round of SSRI related problems.

Some suggestions during withdrawal
As far as alleviating the withdrawal symptoms, it seems folks have tried everything available, both over-the-counter and herbal remedies. You must make sure to read the product information for anything you try for potential interactions - especially if you take some other drug in addition to Paxil!
Here are some suggestions to help ease withdrawal:
-Drink large amounts of water! It really helps to keep your system flushed.
-A multi-vitamin and B vitamin complex are good.
-Try to keep something on your stomach. If you have to, eat several small meals a day, rather than large ones.
-For nausea: crystallized ginger, ginger chews, ginger tabs, ginger ale
(From the health food store)
-For nausea/dizziness: Bonine, Dramamine, (also know as Antivert) in the US, Meclizine in the UK
(From the drug store)
-For headache: Whatever over-the-counter 'headache drug' that you can normally tolerate is okay. Some have suggested the drowsy "P.M. formulas" at bedtime of Tylenol, Excedrin, etc., to help with sleep disorders, but again - read the label!
Some have tried cold formula remedies, but cold formulas sometimes have an ingredient which can 1.) cause anxiety, and 2.) interact with Paxil - in a bad way! It would be best to stay away from cold medications.
-For anxiety/nervousness:
Kava Kava capsules and tea
(From the health food store)

links for more information:
http://www.kcweb.com/herb/kavakava.htm
http://www.tnp.com/propages.asp?ID=30
http://www.herba-medica.com/reports/kava.htm
Valerian
(From the health food store)
Links:
http://www.theherbsplace.com/valerian.html
http://www.tnp.com/substance.asp?ID=94
http://www.nutramedix.com/text/Piu/thirdparty/valerian.htm
Inositol
(From the health food store)
Links:
http://www.tnp.com/substance.asp?ID=141
http://www.healthhelper.com/vitamins/vitamins/inositol.htm

*Dangerous combinations - Serotonin Syndrome
There are many herbal and natural remedies available as alternatives to taking prescription drugs. They should not be taken with Paxil (or any SSRI drug), or while tapering from Paxil. Serotonin syndrome can occur - and it is potentially fatal! Serotonin syndrome is basically 'serotonin overload' to your system. Paxil affects serotonin and so do many herbal and natural remedies! Do not mix Paxil and any drug/herb that also affects serotonin. It can be a terrible experience, if not deadly.
A link to Serotonin Syndrome:
http://rxweb.nlu.edu/ldpic/tempweb/Poison%20Pearls-Serotonin%20Syndrome.html

Post Paxil
If you are completely off Paxil - for no less than three weeks, you can think about taking an alternative herbal/natural. The side effects of herbals/naturals are usually much less harsh than taking a prescription SSRI drug. But, not all people tolerate herbs/naturals. Side effects with these can occur in some cases, but they are generally tolerated much better than prescription drugs. Some of these herbal/natural products claim to be just as effective as the prescription drugs for the treatment of depression.
The suggestions below are not to be taken in conjunction with Paxil.
St. John's wort
Warning! St. John's wort should not be combined with MAO inhibitors, SSRIs, other antidepressants, meperidine (Demerol), or dextromethorphan for fear of serotonin syndrome. When switching a patient from an SSRI to St. John's wort, a 3-week drug-free period should be observed, because some SSRI agents have a long half-life.
http://www.tnp.com/substance.asp?ID=89
http://www.hypericum.com/
http://www.kcweb.com/herb/stjohn.htm
SAMe
SAMe appears to raise levels of dopamine, an important neurotransmitter in mood regulation, and higher SAMe levels in the brain are associated with successful drug treatment of depression. SAMe possesses anti-inflammatory, pain-relieving, and tissue-healing properties that may help protect the health of joints.
http://www.smart-drugs.net/depression-SAMe.htm
http://www.healthyplace.com/Communities/Depression/ect/selfhelp/same.html
http://www.impakt.com/webArticles/same_shows_promise_for_depressio.htm
http://www.tnp.com/substance.asp?ID=212
5-HTP
5-HTP may increase serotonin synthesis, and thus researchers are studying the possibility that 5-HTP might help people with depression.
http://www.tnp.com/substance.asp?ID=127
http://www.mqrx.com/5-htp.asp
http://www.thehormoneshop.com/5-htplibrary.htm
http://www.raysahelian.com/5-htp.html
Good vitamin/herbal overview links regarding depression and anxiety:
http://www.vitaminshoppe.com/learning/healthguide/healthguide_topic_list.jhtml?dept=concern&letter=D (Click on "Depression")
http://www.tnp.com/topic.asp?ID=110
http://www.naturalhealthconsult.com/depression.html
http://www.vitaminshoppe.com/learning/healthguide/healthguide_topic_list.jhtml?dept=concern&letter=A (Click on "Anxiety")

Withdrawal syndrome documented in medical journals
Evidence of Paxil (paroxetine) withdrawal syndrome has been documented since the time that Paxil was first prescribed to the general public in 1993. It is a wonder why more doctors don't know about it. With so many drugs on the market, most doctors rely on the information from the pharmaceutical representative about new drugs, instead of informing themselves with outside, unbiased sources.
-Why would a pharmaceutical rep. risk hurting sales by telling a doctor about nasty side effects & withdrawals?
-How would a doctor know about a drug's side effects & withdrawals if his/her only information source was from the drug company representative?
Some doctors will not believe a patient's claims of withdrawal. They don't see message board postings and support sites as having credibility. The only valid sources that these doctors will believe are from well-known published medical journals.
The list below is a collection of published medical journal articles and studies on SSRI withdrawal syndrome from 1993 to present. It's a shame that so many doctors have never seen any of these articles. If your physician is one who needs highly credible medical journal sources, print out the list below and take it to them!

Independent Reports:

1993
Is there a serotonergic withdrawal syndrome?
Biol Psychiatry 1993;33:851-2. Mallya, White, Gunderson.
Paroxetine (Paxil) "We have received 78 reports of symptoms occurring on withdrawal of paroxetine, including dizziness, sweating, nausea, insomnia, tremor and confusion. Such reactions have been reported more often with paroxetine than with other SSRIs. Reactions tended to start 1-4 days after stopping paroxetine and in several patients resolved on re-instating treatment. Paroxetine should not normally be discontinued abruptly".
1993 Committee on Safety of Medicines & Medicines Control Agency (Great Britain)

1995
Withdrawal syndromes after paroxetine and seatrain discontinuation.
J Clin Psychopharmacol. 1995 Oct;15(5):374-5
Fava GA, Grandi S.
A possible paroxetine withdrawal syndrome.
Am J Psychiatry. 1995 Apr;152(4):645-6.
Phillips.
Paroxetine withdrawal syndrome.
Am J Psychiatry. 1995 Jan;152(1):149-50
Pyke.
Potential withdrawal syndrome associated with SSRI discontinuation.
Ann Pharmacother. 1995;29:1284-1285. Lazowick, Levin.
1996
More cases of paroxetine withdrawal syndrome.
Br J Psychiatry. 1996 Sep;169(3):384.
Pacheco, Malo, Aragues, Etxebeste.
Antidepressant withdrawal syndrome.
CNS Drugs. 1996;5:278-292.
Lejoyeux, Adès, Mourad, Solomon, Dilsaver.

1997
Paroxetine withdrawal syndrome in a neonate.
Br J Psychiatry. 1997 Oct;171:391-2
Dahl, Olhager, Ahlner.
Paroxetine discontinuation syndrome in association with sertindole therapy.
Br J Psychiatry. 1997 Apr;170:389
Walker-Kinnear, McNaughton.
Antidepressant withdrawal syndrome.
Br J Psychiatry. 1997 Mar;170:288
Young, Currie, Ashton.
Newer antidepressants and the discontinuation syndrome.
J Clin Psychiatry. 1997;58(suppl 7):17-22. Haddad
Possible biological mechanisms of the serotonin reuptake inhibitor discontinuation syndrome.
J Clin Psychiatry. 1997;58(suppl 7):23-27. Schatzberg, Haddad, Kaplan, Lejoyeux, Rosenbaum, Young, et al.
SSRI Withdrawal Syndrome
1997, American Society of Consultant Pharmacists, Inc. Skaehill, Welch
1998
Treatment of disequilibrium and nausea in the SRI discontinuation syndrome.
J Clin Psychiatry. 1998 Aug;59(8):431-2
Schechter.
Withdrawal syndrome associated with abrupt discontinuation of SSRIs.
J Am Pharm Assoc (Wash). 1998 Jul-Aug;38(4):500-1
Wincor.
Selective serotonin reuptake inhibitor discontinuation syndrome: a randomized clinical trial.
Biol Psychiatry. 1998 Jul 15;44(2):77-87
Rosenbaum, Fava, Hoog, Ascroft, Krebs.
Withdrawal syndrome caused by selective serotonin reuptake inhibitors.
Schweiz Rundsch Med Prax. 1998;87:345-348
Bryois, Rubin, Zbinden, Baumann.
Selective serotonin reuptake inhibitor discontinuation syndrome: putative mechanisms and prevention strategies.
Can J Psychiatry. 1998 Jun;43(5):523-4.
Rojas-Fernandez, Gordon.
1999
Selective serotonin reuptake inhibitor discontinuation syndrome: putative mechanisms and prevention strategies.
Can J Psychiatry. 1999 Feb;44(1):95-6.
Benazzi.

2000
Withdrawal syndrome after the use of serotonin reuptake inhibitors.
Tidsskr Nor Laegeforen. 2000 Mar 20;120(8):913-4.
Fagan.
Serotonin discontinuation syndrome: does it really exist?
W V Med J. 2000 Mar-Apr;96(2):405-7.
Nuss, Kincaid.
Paroxetine withdrawal syndrome.
Ann Med Interne (Paris). 2000 Apr;151 Suppl A:A52-3.
Belloeuf, Le Jeunne, Hugues.
Selective serotonin reuptake inhibitor discontinuation syndrome: proposed diagnostic criteria.
J Psychiatry Neurosci. 2000 May;25(3):255-61.
Black, Shea, Dursun, Kutcher.

The information provided here is not intended to replace that of your doctor. Having a doctor that knows and understands the withdrawals that occur from SSRI drugs like Paxil is of utmost importance.
Good luck!
-J.B.
03/05/01

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