Managing Antidepressant Discontinuation: A Systematic Review

Abstract

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.

Supporting antidepressant discontinuation: the development and optimisation of a digital intervention for patients in UK primary care using a theory, evidence and person-based approach

“…In the quantitative systematic review (see ref. 25 for full results), a variety of therapeutic techniques were implemented including a patient-specific letter to the GP with a recommendation to discontinue plus tapering advice; GP review of the patient’s condition and medication; CBT plus tapering; MBCT with tapering support gradual discontinuation and 1-week tapering. The results indicated that CBT or MBCT plus tapering are helpful for patients discontinuing antidepressants, with cessation rates of 40%–95%,23 compared with only 6%–8% cessation where health professionals are simply prompted to review patients.…”

“…Two systematic reviews were conducted: a quantitative review with meta-analysis, and a qualitative thematic synthesis, described in detail elsewhere 10 25…”

“…Both searches were developed by an experience librarian and systematic reviewer. Further details of the search strategies can be found in the full publications of these reviews 10 25…”

Antidepressant Discontinuation Syndrome: A Common but Underappreciated Clinical Problem

“…Therefore, discontinuation can cause a group of symptoms that are very unpleasant and can lead patients to continue to seek the medications. 5,8,10,[13][14][15] The persistent use is not for a high but to alleviate symptoms of disease or to avoid unpleasant ADSs.…”

In This Issue: Humans of Primary Care Research

“…Kendrick and a UK team reviewed studies on the care of adults with depression and conclude that risk of recurrence may be lessened with slow tapering of antidepressants and cognitive behavioral therapy. 1 In screening for depression and anxiety disorders in primary care, Graham and team show that a computerized adaptive test performed similarly to clinical interview and paper-and-pencil tests. Such technology might help screen more patients for these important problems and free up time for clinicians to spend more face-to-face time with patients.…”