Recognising and managing antidepressant discontinuation symptoms

Haddad, Peter M.; Anderson, Ian M.

doi:10.1192/apt.bp.105.001966

Cited by 93 publications

(136 citation statements)

References 54 publications

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“…For example, abrupt cessation of SSRIs produces unpleasant withdrawal symptoms [5]. If ATD produces the same effect in patients taking SSRIs, SSRI withdrawal symptomatology could be mistaken for depressive relapse.…”

Section: (B) Serotonin Dependence Of Ssrismentioning

confidence: 99%

‘It's the way that you look at it’—a cognitive neuropsychological account of SSRI action in depression

Harmer

Cowen

2013

Phil. Trans. R. Soc. B

152

128

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The fact that selective serotonin reuptake inhibitors (SSRIs) have antidepressant effects in some patients supports the notion that serotonin plays a role in the mode of action of antidepressant drugs. However, neither the way in which serotonin may alleviate depressed mood nor the reason why several weeks needs to elapse before the full antidepressant effect of treatment is expressed is known. Here, we propose a neuropsychological theory of SSRI antidepressant action based on the ability of SSRIs to produce positive biases in the processing of emotional information. Both behavioural and neuroimaging studies show that SSRI administration produces positive biases in attention, appraisal and memory from the earliest stages of treatment, well before the time that clinical improvement in mood becomes apparent. We suggest that the delay in the clinical effect of SSRIs can be explained by the time needed for this positive bias in implicit emotional processing to become apparent at a subjective, conscious level. This process is likely to involve the re-learning of emotional associations in a new, more positive emotional environment. This suggests intriguing links between the effect of SSRIs to promote synaptic plasticity and neurogenesis, and their ability to remediate negative emotional biases in depressed patients.

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Section: (B) Serotonin Dependence Of Ssrismentioning

confidence: 99%

‘It's the way that you look at it’—a cognitive neuropsychological account of SSRI action in depression

Harmer

Cowen

2013

Phil. Trans. R. Soc. B

152

128

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“…Patients should also be informed that sudden cessation of antidepressant medication may result in discontinuation symptoms; these may manifest as flu-like symptoms, insomnia, nausea and hyperarousal, (36) and are not a sign of addiction. This is important to improve understanding and adherence to medication.…”

Section: Pharmacotherapymentioning

confidence: 99%

Managing depression in primary care

How

2017

smedj

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“…The SSRIs paroxetine and escitalopram both have marketing authorisation for GAD, and there is little pharmacological difference between them and the SSRI sertraline. However, paroxetine has a more marked withdrawal syndrome than sertraline 21 and escitalopram was still on patent and significantly more expensive at the time of submitting the proposal. There are also more concerns about it extending the QT interval, although it is recognised that sertraline can do this in vulnerable cases.…”

Section: Sertralinementioning

confidence: 99%

Pilot of a randomised controlled trial of the selective serotonin reuptake inhibitor sertraline versus cognitive behavioural therapy for anxiety symptoms in people with generalised anxiety disorder who have failed to respond to low-intensity psychological treatments as defined by the National Institute for Health and Care Excellence guidelines

Buszewicz

Cape

Serfaty

et al. 2017

Health Technol Assess

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Background Generalised anxiety disorder (GAD) is common, causing unpleasant symptoms and impaired functioning. The National Institute for Health and Care Excellence (NICE) guidelines have established good evidence for low-intensity psychological interventions, but a significant number of patients will not respond and require more intensive step 3 interventions, recommended as either high-intensity cognitive behavioural therapy (CBT) or a pharmacological treatment such as sertraline. However, there are no head-to-head comparisons evaluating which is more clinically effective and cost-effective, and current guidelines suggest that treatment choice at step 3 is based mainly on patient preference. Objectives To assess clinical effectiveness and cost-effectiveness at 12 months of treatment with the selective serotonin reuptake inhibitor (SSRI) sertraline compared with CBT for patients with persistent GAD not improved with NICE-defined low-intensity psychological interventions. Design Participant randomised trial comparing treatment with sertraline with high-intensity CBT for patients with GAD who had not responded to low-intensity psychological interventions. Setting Community-based recruitment from local Improving Access to Psychological Therapies (IAPT) services. Four pilot services located in urban, suburban and semirural settings. Participants People considered likely to have GAD and not responding to low-intensity psychological interventions identified at review by IAPT psychological well-being practitioners (PWPs). Those scoring ≥ 10 on the Generalised Anxiety Disorder-7 (GAD-7) anxiety measure were asked to consider involvement in the trial. Inclusion criteria Aged ≥ 18 years, a score of ≥ 10 on the GAD-7, a primary diagnosis of GAD diagnosed on the Mini International Neuropsychiatric Interview questionnaire and failure to respond to NICE-defined low-intensity interventions. Exclusion criteria Inability to participate because of insufficient English or cognitive impairment, current major depression, comorbid anxiety disorder(s) causing greater distress than GAD, significant dependence on alcohol or illicit drugs, comorbid psychotic disorder, received antidepressants in past 8 weeks or high-intensity psychological therapy in previous 6 months and any contraindications to treatment with sertraline. Randomisation Consenting eligible participants randomised via an independent, web-based, computerised system. Interventions (1) The SSRI sertraline prescribed in therapeutic doses by the patient’s general practitioner for 12 months and (2) 14 (± 2) CBT sessions delivered by high-intensity IAPT psychological therapists in accordance with a standardised manual designed for GAD. Main outcome measures The primary outcome was the Hospital Anxiety and Depression Scale – Anxiety component at 12 months. Secondary outcomes included measures of depression, social functioning, comorbid anxiety disorders, patient satisfaction and economic evaluation, collected by postal self-completion questionnaires. Results Only seven internal pilot participants were recruited against a target of 40 participants at 7 months. Far fewer potential participants were identified than anticipated from IAPT services, probably because PWPs rarely considered GAD the main treatment priority. Of those identified, three-quarters declined participation; the majority (30/45) were reluctant to consider the possibility of randomisation to medication. Limitations Poor recruitment was the main limiting factor, and the trial closed prematurely. Conclusions It is unclear how much of the recruitment difficulty was a result of conducting the trial within a psychological therapy service and how much was possibly a result of difficulty identifying participants with primary GAD. Future work It may be easier to answer this important question by recruiting people from primary care rather than from those already engaged in a psychological treatment service. Trial registration Current Controlled Trials ISCRTN14845583. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 45. See the NIHR Journals Library website for further project information.

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Recognising and managing antidepressant discontinuation symptoms

Cited by 93 publications

References 54 publications

‘It's the way that you look at it’—a cognitive neuropsychological account of SSRI action in depression

‘It's the way that you look at it’—a cognitive neuropsychological account of SSRI action in depression

Managing depression in primary care

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