New Study Explores Approaches to Discontinuing Antidepressants

Psychiatrist and psychologist outline pharmacological and psychotherapeutic strategies for discontinuing antidepressants

Hannah Emerson
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A study recently published in Psychotherapy and Psychosomatics examines the injustices and complexities associated with the process of discontinuing antidepressants (AD). The authors present a new treatment model tailored to address withdrawal symptoms, common during AD discontinuation, and outline a multidisciplinary approach for practitioners.

“The damages of miseducation are difficult to overcome. AD are important and potentially life-saving drugs if the proper indications are endorsed. However, the prescribing physician is currently driven by an overestimated consideration of potential benefits, with little attention to the likelihood of responsiveness and neglect of potential vulnerability to the adverse effects of treatment,” the authors, Giovanni Fava and Carlotta Belaise, write.

Photo Credit: Pixabay

Fava, the lead author, is a psychiatrist engaged in unpacking the relationship between antidepressants and withdrawal symptomology and treatment. Fava’s research if informed from his own clinical experience, which can be traced back to the 1990’s when several case studies indicated withdrawal symptoms linked to the discontinuation of a commonly prescribed antidepressant category, SSRIs. Though these reports were “downplayed” at the time, an increase in research on withdrawal symptomology and antidepressants has since emerged.

The second author, Carlotta Belaise, is a psychologist involved in treating withdrawal or post-withdrawal syndromes from antidepressants (specifically SSRIs and SNRIs) and recognizes the need for specific psychotherapeutic approaches to respond to antidepressant discontinuation.

Informed by a “failed trial and extensive clinical experience,” the authors set out to explore the process of discontinuation and suggest appropriate pharmacological and therapeutic treatment responses, arguing that “AD discontinuation that is performed without medical consultation and adequate psychotherapeutic support entails substantial risks for the patient and is often bound to fail.”

Reasons to discontinue antidepressants vary, including, medical reasons, pregnancy, and breast feedings, paradoxical effects, lack or loss of efficacy, unclear reasons for initial prescriptions and automatic prolongation of treatment, planned discontinuation, improved clinical conditions, and patient preference, among others. Discontinuing a drug “is a highly individualized process,” the authors write, “it is wishful thinking to believe that there is a single protocol that can be applied to all patients to whom AD are discontinued.”

Fava and Belaise delineate the following clinician responsibilities in this process:

  1. Thorough initial assessment
  2. Clear definitions of relapse/recurrence, new withdrawal symptoms, rebound, persistent post-withdrawal disorder
  3. Familiarity with withdrawal symptoms common for SSRI and SNRI antidepressants
  4. Knowledge of discrepancies between relapse and withdrawal syndromes

The authors examine pharmacological strategies for AD discontinuation, finding that “tapering slowly with frequent contacts appears to be a reasonable strategy for many patients,” with some exceptions.  Yet, they tell patients “it is like flipping a coin: we have no way to know what is going to happen” regarding individual withdrawal symptoms.

Fava and Belaise contend that abrupt switching from one AD to another due to lack of efficacy may be more effective than tapering, though the success of tapering one during the switch is not yet known. Another exception is the patient’s wish for abrupt discontinuation to reduce the tapering period in which one might experience withdrawal symptoms.

However, upon assessing the balance of potential benefits and adverse effects, the authors claim they “tend not to use AD treatment in case of withdrawal symptoms, even though we may be forced to use AD, for the shortest possible time, for mood fluctuations in persistent post-withdrawal disorders which reach the intensity threshold of a major depressive disorder.”

Together, Fava and Belaise developed a psychotherapeutic approach to manage AD discontinuation. It involves 3 modules of varying duration, where patients are seen every 2 weeks for a total of 16-24 sessions.

“Module 1 utilizes explanatory therapy, which involves providing accurate information, teaching the principles of selective perception, reassurance, clarification, and repetition. This module should begin before tapering and encourages patients to begin and maintain a diary throughout discontinuation.

Module 2 involves reassessment and cognitive behavior treatment, focused on reviewing the diary and paying particular attention to the trajectory of withdrawal symptomatology and affective symptoms.

Module 3 employs well-being therapy, a short-term therapy that “emphasizes self-observation of psychological well-being, with the use of a structured diary, cognitive restructuring of interfering thoughts and/or behaviors through cognitive behavioral techniques, and homework assignments.”

(See a full list of module goals in Tables 1, 2, and 5.)

Limitations to this study include the current lack of research examining the nuances of drug interactions across individuals. Fava and Belaise express particular concern around the lack of research on the polypharmaceutical effects of discontinuation, claiming “polypharmacy is simply not addressed by the literature on AD discontinuation and yet it is frequently encountered in clinical reality.” Furthermore, a review of other prospective psychotherapeutic approaches during discontinuation is lacking, as well as cross-cultural considerations.

This study adds to the extant research and endeavors to better understand and respond to withdrawal symptoms associated with antidepressant use. The authors draw attention to the deleterious impact of ignoring antidepressant withdrawal and provide pharmacological and psychotherapeutic strategies for practitioners.

“A rational use of AD that incorporates all potential benefits and harms consists in targeting their application only to the most persistent cases of depression, limiting their use to the shortest possible time, and reducing their utilization in anxiety disorders,” Fava and Belaise conclude, adding, “the lowest dose of these agents that seems to be both effective and well tolerated should be employed,” “augmenting strategies need to be carefully weighed,” and “one should be particularly concerned with young patients who are given AD for anxiety disorders and prolong this treatment indefinitely without undergoing any form of psychotherapy.”

 

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Fava, G. & Belaise, C. (2018). Discontinuing antidepressant drugs: Lesson from a failed trial and extensive clinical experience. Psychotherapy and Psychosomatics, 87, 257-267. doi: 10.1159/000492693 (Link)

12 COMMENTS

  1. The big worry with kids is AD induced suicide. Lots of controversy around data, but there is no doubt suicidality spikes on starting and stopping. The whole prescribing of ADs to kids is a scandal when we know they work even less well than in adults, if that were possible.

    My anecdotal research suggests informed consent is never followed.

    This study doesn’t really suggest fantastic solutions, people should do psychology and psychosocial stuff in any event.

    In the UK we need NICE to grow a pair, triple the tapering recommendations, and make smaller tablets available.

    To my knowledge , the smallest sertaline tablet in the UK is 50mg, which takes you from 75% inhibition to nothing at a stroke and will tip you into withdrawal for sure.

  2. Why can’t someone just bring themselves to state very clearly that the reason for quitting these devil’s tic tacs is that the damned things don’t work and that they’re dangerous to your health and well-being? The damned things don’t work any better than a placebo! Kirsch showed this years ago and yet we’re still standing out there in the crowd oowing and awing over how wonderful the emperor’s new set of clothes are! You hear the little kids honestly point out, every once in a while, that the emperor is buck assed naked, but then someone hushes the kid up and hustles them off into the crowd. I’m sick to death of it; the damned things almost caused my death ten years ago.

    • Very true. Since there is no way to determine “proper indications” with the current subjective diagnostic criteria, that claim you quote is ludicrous. Additionally, there has never been any evidence to suggest that antidepressants reduce the suicide rate, and in fact, there is evidence suggesting they most likely increase the suicide rate. “Antidepressants save lives” is drug company propaganda.

  3. I just flat quit Celexa and nothing much happened but for some reason I decided to take one like 3 weeks later and that night I had that restless movement thing come back that I had wile I was on it but didn’t notice it go away but I certainly noticed it come back. Last SSRI pill I ever took.

    Remeron I quit at the same time as benzos so that withdrawal got mixed up in that nightmare but I never should have been given depression pills. Who the heck could answer those pill company depression questionnaires 20 years ago and NOT come up positive as depressed ?

    I feel like a dumb ass now for taking them but it sounded legit “boost my serotonin” feel good why not ? Lots of reasons why not. that the whole serotonin thing was a marketing scam. How was I to know that 20 years ago ?

    That first poison Serzone they gave me taken off the market causing liver damage… That should have been a clue.

    • I wouldn’t be so hard on yourself if I were you. There were numbers of us who took the bait; hook, line, and sinker. How were we to know any different from what the drug companies and psychiatrists and GP’s were claiming that they did for people? They were all so convincing in their pushing of these dangerous drugs. I can remember how I got snookered onto them. A person I really respected, whom I thought was well informed, suggested that I ask my doctor for an SSRI. He said that they were so much better than the old “antidepressants” that they first came up with. Trazadone is dangerous enough that you can overdose on it and die. I’d never had any contact at all with the system, I still thought that psychiatrists actually sat down and listened to you and did real therapy! So I went to my GP and asked for an SSRI and he was more than happy to give me a script to fill. Good ol’ Zoloft! Of course it didn’t do a damned thing, except mess up all kinds of things that I never knew that it affected. I wonder how much of a bonus the drug rep for my GP was getting for pushing these damned things. Then we went on the great search for the “antidepressant” that would work better than the one that I was on at the time. I eventually ended up on 250 mg. of Effexor XR and that helped send me over the edge. I think I’m really lucky to be alive after my bout with “antidepressants”.

      The problem today is how do we go about making sure that more people don’t get snookered onto the damned things?

  4. These drugs are neurotoxins. They are dangerous and serve no purpose but making money for pharma and corrupt or ignorant doctors.
    My GP prescribed them after I made the mistake of telling her about the insomnia, weight loss, crying I had been doing for weeks after discovering my husband of 25 years was cheating on me with his young secretary. In other words, I had a reason to be feeling real emotions. She was too ignorant and numb to comprehend I needed a divorce and support and counselling. She prescribed poison Effexor for 12 YEARS.
    Each time I missed a dose, I got a pounding headache, felt odd, and started crying. I did not know this was “withdrawal”, not a “relapse” of my non-existent illness. Terrified, I kept taking them as I deteriorated- high blood pressure, diabetes, massive sweating, nausea, irritable bowel, zero libido, skin issues- not connecting them to this poison I was ingesting. Stopping the drug spun me into massive depression, anxiety, agitation, brain zaps- which was “treated” with multiple poisons. I was screaming with pain, holding my head, which snapped and zapped and caused excruciating pain. Terrified and lied to, called “treatment resistant”, I submitted to TMS and ECT, which destroyed my life, cost me 30 years of memories, and 27 IQ points, and my 31 year teaching career. I cannot learn, make new memories, or feel love. Each day I pray for a heart attack. Deeply suicidal ever since, my identity and sense of self, gone.
    And each day, I read of more ppl disabled by psychiatry.
    I have no doubt the latest shooter was being “treated” with psych drugs for his PTSD and was suffering brain injuries from his motor cycle accident. But the stories are all about his “mental illness”.

    What can be done to get these poisons off the market?

  5. It’s a coin toss how your body, brain, and CNS will react if you come off psych drugs.

    But guess what? It’s a coin toss how your system will react if you go ON them to begin with.

    If you get horribly sick, disabled or killed from going on them that’s okay. That’s an acceptable risk from standard care.

    If you get horribly sick, disabled, or killed from going off the drugs that’s a horrible tragedy. Your local NAMI chapter will probably lecture others about how only wrong headed fools disobey “doctors.'”

    Because $$$$. Love things and use people is the New Golden Rule adhered to by mainstream psychiatry. 🙁