A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based?

Davies, James; Read, John

doi:10.1016/j.addbeh.2018.08.027

Cited by 273 publications

(345 citation statements)

References 53 publications

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“…This may be a contributory factor to our finding that many patients’ antidepressant status remaining essentially unchanged during follow‐up. Another factor may be difficulty stopping these agents due to withdrawal effects, which may be intense and prolonged (Davies & Read 2019, Horowitz & Taylor 2019). These may mimic aspects of depression and indeed some uraemic symptoms.…”

Section: Discussionmentioning

confidence: 99%

Antidepressant Usage in Haemodialysis Patients: Evidence of Sub‐Optimal Practice Patterns

Guirguis

Chilcot

Almond

et al. 2020

Journal of Renal Care

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SUMMARY Background Depression is common in patients on haemodialysis and associated with adverse outcomes. Antidepressant use is widespread though evidence of efficacy is limited. Objectives To study antidepressant management practices in patients on haemodialysis with reference to NICE guidelines on management of depression in adults with chronic physical health problems. Design Prospective, multicentre, longitudinal cohort study with 6–15 month follow‐up. Participants Patients on haemodialysis established on antidepressant medication. Measurements Baseline assessment of mood was undertaken using Beck Depression Inventory (BDI‐II). Demographic, clinical and medication data were also collected. Changes in clinical and life circumstances and medication during follow‐up were recorded. At follow‐up, BDI‐II was reassessed and diagnostic psychiatric assessment undertaken. Results Forty‐one patients were studied. General practitioners were the main prescribers (68%). Ten agents were in use, the commonest being Citalopram (39%). Doses were often suboptimal. At baseline, 30 patients had high BDI‐II scores (≥16) and 22 remained high at follow‐up. Eleven had BDI‐II < 16 at baseline. In five, this increased on follow‐up to ≥16. Sixteen patients (39%) had no medication review during follow‐up, 14 (34%) had a dose review, and 11 (27%) a medication change. On psychiatric assessment at follow‐up, eight patients had current major depressive disorder (MDD), seven recurrent and 20 evidence of past MDD. Six displayed no evidence of ever having MDD. Conclusions Antidepressant management in patients on haemodialysis reflected poor drug selection, overprescription, under‐dosing and inadequate follow‐up suggesting sub‐optimal adherence to NICE guidelines. Most patients had high depression scores at follow‐up. Antidepressant use in haemodialysis requires reappraisal.

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Section: Discussionmentioning

confidence: 99%

Antidepressant Usage in Haemodialysis Patients: Evidence of Sub‐Optimal Practice Patterns

Guirguis

Chilcot

Almond

et al. 2020

Journal of Renal Care

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“…18 There have been 2 systematic reviews focusing on the incidence of withdrawal symptoms after discontinuation. 12,19 We conducted a systematic review to address 2 questions: what interventions are effective in managing antidepressant discontinuation, and what are the outcomes for patients after discontinuation?…”

Section: Introductionmentioning

confidence: 99%

Managing Antidepressant Discontinuation: A Systematic Review

et al. 2019

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PURPOSE We aimed to determine the effectiveness of interventions to manage antidepressant discontinuation, and the outcomes for patients. METHODSWe 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. RESULTSOf 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). CONCLUSIONSCognitive 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.

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“…However, the withdrawal syndrome can be distinguished from a relapse or recurrence of the underlying disorder by its quickness of onset (days rather than weeks) 3,7,8 , rapid response to re-introduction of the antidepressant (generally within hours, certainly within days) 3,7,9 , and the presence of somatic and psychological symptoms quite distinct from the original illness (including, dizziness, nausea, and 'shock-like' sensations) 7,10 . The withdrawal syndrome can be misdiagnosed as depressive recurrence, leading to prolonged treatment for patients who may not require it [11][12][13] , but it is not clear how often this occurs 14 .…”

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confidence: 99%

Tapering of SSRI treatment to mitigate withdrawal symptoms

Horowitz

Taylor

2019

The Lancet Psychiatry

175

226

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All antidepressant classes are associated with a withdrawal syndrome. SSRI withdrawal syndrome occurs often and can be severe, and may compel patients to re-commence their medication. Although the withdrawal syndrome can be differentiated from recurrence of the underlying disorder, it may also be mistaken for recurrence, leading to long-term unnecessary medication. Authorities currently recommend short tapers, of between two to four weeks, down to therapeutic minimum, or half minimum doses before complete cessation. Studies have demonstrated that these tapers show minimal benefit over abrupt discontinuation, and are often not tolerated by patients. Tapers over months and down to doses significantly lower than minimum therapeutic doses have shown greater success rates. Other medications associated with withdrawal symptoms are tapered to reduce their biological effect at receptors by fixed amounts in order to minimise withdrawal effects. These are exponential tapering programmes which reduce to very small doses. We examined the PET imaging data of serotonin transporter occupancy by SSRIs to demonstrate that hyperbolically reducing doses of SSRI will reduce their effect on serotonin transporter inhibition in a linear manner. We therefore suggest that SSRIs are tapered hyperbolically and slowly to doses much lower than therapeutic minimums, in line with tapering regimes for other medications associated with withdrawal symptoms. Withdrawal symptoms will then be minimised.

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A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based?

Cited by 273 publications

References 53 publications

Antidepressant Usage in Haemodialysis Patients: Evidence of Sub‐Optimal Practice Patterns

Antidepressant Usage in Haemodialysis Patients: Evidence of Sub‐Optimal Practice Patterns

Managing Antidepressant Discontinuation: A Systematic Review

Tapering of SSRI treatment to mitigate withdrawal symptoms

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