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Clinician Article

Managing Antidepressant Discontinuation: A Systematic Review.



  • Maund E
  • Stuart B
  • Moore M
  • Dowrick C
  • Geraghty AWA
  • Dawson S, et al.
Ann Fam Med. 2019 Jan;17(1):52-60. doi: 10.1370/afm.2336. (Review)
PMID: 30670397
Read abstract Read full text
Disciplines
  • Family Medicine (FM)/General Practice (GP)
    Relevance - 6/7
    Newsworthiness - 6/7
  • General Internal Medicine-Primary Care(US)
    Relevance - 6/7
    Newsworthiness - 6/7
  • Psychiatry
    Relevance - 6/7
    Newsworthiness - 5/7
  • FM/GP/Mental Health
    Relevance - 6/7
    Newsworthiness - 4/7
  • Internal Medicine
    Relevance - 5/7
    Newsworthiness - 4/7

Abstract

PURPOSE: We aimed to determine the effectiveness of interventions to manage antidepressant discontinuation, and the outcomes for patients.

METHODS: We conducted a systematic review with narrative synthesis and meta-analysis of studies published to March 2017. Studies were eligible for inclusion if they were randomized controlled trials, quasi-experimental studies, or observational studies assessing interventions to facilitate discontinuation of antidepressants for depression in adults. Our primary outcomes were antidepressant discontinuation and discontinuation symptoms. Secondary outcomes were relapse/recurrence; quality of life; antidepressant reduction; and sexual, social, and occupational function.

RESULTS: Of 15 included studies, 12 studies (8 randomized controlled trials, 2 single-arm trials, 2 retrospective cohort studies) were included in the synthesis. None were rated as having high risk for selection or detection bias. Two studies prompting primary care clinician discontinuation with antidepressant tapering guidance found 6% and 7% of patients discontinued, vs 8% for usual care. Six studies of psychological or psychiatric treatment plus tapering reported cessation rates of 40% to 95%. Two studies reported a higher risk of discontinuation symptoms with abrupt termination. At 2 years, risk of relapse/recurrence was lower with cognitive behavioral therapy plus taper vs clinical management plus taper (15% to 25% vs 35% to 80%: risk ratio = 0.34; 95% CI, 0.18-0.67; 2 studies). Relapse/recurrence rates were similar for mindfulness-based cognitive therapy with tapering and maintenance antidepressants (44% to 48% vs 47% to 60%; 2 studies).

CONCLUSIONS: Cognitive behavioral therapy or mindfulness-based cognitive therapy can help patients discontinue antidepressants without increasing the risk of relapse/recurrence, but are resource intensive. More scalable interventions incorporating psychological support are needed.


Clinical Comments

General Internal Medicine-Primary Care(US)

It is eye-opening to see how few people are able to discontinue antidepressant therapy without support. The beneficial effects of cognitive therapy to facilitate medication discontinuation are marked. More evidence that access to CBT and related therapies could decrease the number of people requiring medication therapy as well as facilitate the discontinuation for those past an acute depressive episode.

Psychiatry

There is scarce information on the topic. Thus, this study is welcome. However, evidence supporting the add up of CBT or mindfulness seems scarce. I would like to see more RCTs on slow tapering, and in my experience, 1 week is a too short time to suspend antidepressants.

Psychiatry

Most depression is treated in primary care and depressions remit. Should antidepressants be stopped after 6 or 12 months? Depression may recur. This literature review addresses this question. When stopping antidepressants, they should probably be tapered down slowly (especially paxil). Psychological treatments help but they are expensive and time consuming. There are no clear answers and as always these difficult decisions should be individualized. This is a good discussion of a difficult question.

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