Tapering of SSRI treatment to mitigate withdrawal symptoms

Ruhé, Henricus G.; Horikx, Annemieke; Avendonk, M. J. P. van; Groeneweg, Bart; Woutersen-Koch, Hèlen

doi:10.1016/s2215-0366(19)30182-8

Cited by 23 publications

(33 citation statements)

References 3 publications

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“…Variables collected were: (i) age (in years); (ii) sex; (iii) type of medication and length of use prior to tapering; (iv) number of attempts to stop medication before using taperingstrips; (v) number of withdrawal symptoms during previous attempts out of a list of eight symptom groups, as described by Groot, 12 and included in the recent Dutch consensus document on tapering ( Table 1 ) 13 ; (vi) number of withdrawal symptoms experienced with taperingstrips out of the same list of eight symptom groups ( Table 1 ); (vii) outcome of tapering after 1–5 years (still off medication; on medication but lower dose; tapered but restarted medication due to relapse of illness; tapered but restarted medication for another indication; other). An additional dichotomous outcome was used in the analyses, comparing those still off medication ( n = 270, 66% of total), or using a lower dose ( n = 6, 2% of total), with the other three outcome categories ( n = 132, 32%).…”

Section: Methodsmentioning

confidence: 99%

Outcome of antidepressant drug discontinuation with taperingstrips after 1–5 years

Groot

2020

Therapeutic Advances in Psychopharmacology

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Background: Stopping antidepressants is often difficult due to withdrawal. Taperingstrips were developed to facilitate antidepressant discontinuation according to the recently described Horowitz-Taylor method, allowing for personalised titration of discontinuation to the intensity of withdrawal. A taperingstrip consists of antidepressant or other medication, packaged in a 28-day roll of small daily pouches, each with the same or slightly lower dose than the one before it. We previously reported that the short-term success rate of antidepressant taperingstrips was 71%. Here, we examine longer-term outcome after 1–5 years. Methods: Patients whose doctor had ordered taperingstrips between January 2015 and December 2019 were sent a questionnaire for participation in anonymised research in January 2020. Of 1012, 483 participated, of whom 408 (85%) had attempted antidepressant tapering. Results: Of the 408 patients included, 192 (47%) had used strips for tapering venlafaxine, 142 (35%) for paroxetine and 74 (18%) for other antidepressants. Median length of antidepressant use was 4 years, and most (61%) had tried to come off without taperingstrips at least once. After 1–5 years, 270 patients (66%) remained off antidepressants after tapering their antidepressant, 6 (2%) had successfully reduced their medication, 87 (21%) had restarted due to (self-reported) relapse, 35 had restarted for another indication (9%), and 10 (3%) reported another outcome. People with more severe experience of withdrawal prior to tapering, and people who had been on antidepressants for a shorter period of time, were more likely to remain off medication after 1–5 years. Conclusion: The previously reported 71% short-term success rate of taperingstrips in the most severely affected group, was matched by a 68% rate after 1–5 years. The evidence-based approach of personal tapering to counter withdrawal, as used for drugs causing withdrawal, for example, benzodiazepines, may represent a simple solution for an important antidepressant-related public health problem, without extra costs.

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Section: Methodsmentioning

confidence: 99%

Outcome of antidepressant drug discontinuation with taperingstrips after 1–5 years

Groot

2020

Therapeutic Advances in Psychopharmacology

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“…A clinical trial found that tapering over 2 weeks had no benefit over tapering over a few days (Tint et al, 2008), but this, in practice, is still considered a short-term timeframe. It has recently been suggested that antidepressants should be tapered down hyperbolically (by lowering the dose by smaller amounts over time) in the same manner as benzodiazepines (Horowitz and Taylor, 2019), which is further supported by a Dutch taskforce (Ruhe et al, 2019). However, reducing the antidepressant in such a way is impractical as current preparations of antidepressant do not allow for the dose to be reduced by such small decrements.…”

Section: Management Of Major Depressive Disordermentioning

confidence: 99%

“…While all patients are at risk of developing DaWS, the risk is greater among patients who have had higher doses than the minimum effective dose of the antidepressant (Haddad and Anderson, 2007), or have experienced withdrawal symptoms after missing a dose(s) (Harvey and Slabbert, 2014; Ruhe et al, 2019), or had a prior experience of DaWS after previously attempting to stop the antidepressant.…”

Section: Management Of Major Depressive Disordermentioning

confidence: 99%

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

Malhi

Bell

Bassett³

et al. 2020

Aust N Z J Psychiatry

285

342

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Objectives: To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility. Methods: Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders. Results: The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg2020) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care. Conclusion: The MDcpg2020 builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus. Mood disorders committee: Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.

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“…A hyperbolically decreasing pattern of SSRI dose decrease has been recently proposed to produce a linear reduction of pharmacological effect [131], but its validity needs to be tested in randomized controlled trials. A multistep dose reduction paradigm was suggested by Ruhe et al [132]. In this paradigm, the initial step is to reduce the dose to half of the minimally effective dose in 1 week and then reduce very gradually.…”

Section: Management Of Ssris/snris Discontinuationmentioning

confidence: 99%

Acute and Persistent Withdrawal Syndromes Following Discontinuation of Psychotropic Medications

Cosci

Chouinard

2020

Psychother Psychosom

149

177

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Studies on psychotropic medications decrease, discontinuation, or switch have uncovered withdrawal syndromes. The present overview aimed at analyzing the literature to illustrate withdrawal after decrease, discontinuation, or switch of psychotropic medications based on the drug class (i.e., benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonists, antidepressants, ketamine, antipsychotics, lithium, mood stabilizers) according to the diagnostic criteria of Chouinard and Chouinard [Psychother Psychosom. 2015; 84 (2): 63-71], which encompass new withdrawal symptoms, rebound symptoms, and persistent post-withdrawal disorders. All these drugs may induce withdrawal syndromes and rebound upon discontinuation, even with slow tapering. However, only selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors, and antipsychotics were consistently also associated with persistent post-withdrawal disorders and potential high severity of symptoms, including alterations of clinical course, whereas the distress associated with benzodiazepines discontinuation appears to be shortlived. As a result, the common belief that benzodiazepines should be substituted by medications that cause less dependence such as antidepressants and antipsychotics runs counter the available literature. Ketamine, and probably its derivatives, may be classified as at high risk for dependence and addiction. Because of the lag phase that has taken place between the introduction of a drug into the market and the description of withdrawal symptoms, caution is needed with the use of newer antidepressants and antipsychotics. Within medication classes, alprazolam, lorazepam, triazolam, paroxetine, venlafaxine, fluphenazine, perphenazine, clozapine, and quetiapine are more likely to induce withdrawal. The likelihood of withdrawal manifestations that may be severe and persistent should thus be taken into account in clinical practice and also in children and adolescents.

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Tapering of SSRI treatment to mitigate withdrawal symptoms

Cited by 23 publications

References 3 publications

Outcome of antidepressant drug discontinuation with taperingstrips after 1–5 years

Outcome of antidepressant drug discontinuation with taperingstrips after 1–5 years

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

Acute and Persistent Withdrawal Syndromes Following Discontinuation of Psychotropic Medications

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