In a new study, a team of researchers from the UK investigated what interventions are available for assisting people who are attempting to discontinue antidepressants. The systematic review of the existing literature, recently published in Annals of Family Medicine, identify Cognitive behavioral therapy (CBT) and mindfulness-based cognitive therapy (MBCT) as two psychological interventions that have been found to support discontinuation without increasing the risk of relapse/recurrence when compared with clinical management by primary care clinicians.
“Providing psychological therapies seems to enable significantly higher discontinuation rates as compared with brief guidance on tapering to primary care clinicians alone,” the authors write.
“This approach may work by providing support to patients to manage fears of withdrawal, relapse, and lack of self-efficacy, which are possible barriers to discontinuation. Alternatively, having an effective therapy for the depression or anxiety for which the medication was initially given removes the need for it, without increasing relapse/recurrence risk.”
Antidepressant prescriptions doubled in Western countries between 2000 and 2011. This increase is driven by the increasing number of people who are taking antidepressants long-term. Antidepressants are mostly prescribed by primary care clinicians. While some individuals may need the medication to prevent relapse/recurrence, research has indicated 30%-50% of those taking antidepressants have no evidence-based reason to continue long-term use (see, for instance, Cruickshank et al., Ambresin et al., and Piek, Kollen, can der Meer, Penninx, & Nolen).
Discontinuing antidepressants may be daunting because of the potential to experience withdrawal symptoms, which is often mistaken for relapse/recurrence. To lessen the chances of withdrawal, the American Psychiatric Association and the National Institute for Health and Care Excellence suggest tapering the dose over time as opposed to abruptly. CBT and MBCT have also been suggested as alternatives to antidepressants, without increasing the risk of relapse/recurrence. However, “current guidelines for antidepressant discontinuation are based on consensus and nonsystematic reviews,” necessitating more tangible data.
The researchers conducted a systematic review based on the following 2 questions, “what interventions are effective in managing antidepressant discontinuation, and what are the outcomes for patients after discontinuation?” The primary outcomes were discontinuation of antidepressants and associated symptoms. Secondary outcomes were relapse/recurrence, quality of life, antidepressant reduction, and sexual, social, and occupational function.
The authors define relapse as “the return of syndrome-level depression after remission during the first 4 to 6 months of treatment,” and recurrence as “a new episode occurring after recovery and lasting more than 4 to 6 months.” After searching multiple databases with relevant keywords and eliminating articles that did not meet criteria, 12 studies were analyzed.
Their findings suggest that antidepressants be tapered rather than abruptly stopped, although more trials to further evaluate slow tapering are needed. They also found that discontinuation rates for primary care clinicians were only 6%-7%, juxtaposed to 40%-95% for specialist psychological or psychiatric care. Rates of relapse/recurrence were lower in primary care settings than psychiatric or psychological therapy settings, though the research is too scant in primary care settings to clarify this effect.
Psychological interventions concurrent with gradual tapering appeared consistently effective. The combination of CBT and tapering significantly reduced relapse/recurrence as opposed to clinical management and tapering. MBCT combined with tapering “enabled high rates of discontinuation without increasing relapse/recurrence rates, as compared with maintenance antidepressants.”
This systematic review underscores a need for more research to evaluate appropriate interventions and measure the outcomes of antidepressant discontinuation, as evidenced by the low number of eligible studies. Interventions such as CBT and MBCT may not be readily available, so identifying alternative supports is vital in order for effective antidepressant discontinuation to be accessed.
The research team concluded with implications for practice and research. They suggest that primary care physicians, the leading prescribers of antidepressants, may need to become more active in the discussion of antidepressant discontinuation with their clients.
“It is important for primary care clinicians to discuss discontinuation symptoms with patients at the time of initiation of an antidepressant. Doing so will allows patients to make more informed decisions about whether they want to start an antidepressant in the first place.”
Maund, E., Stuart, B., Moore, M., Dowrick, C., Geraghty, A.W.A., Dawson, S., & Kendrick, T. (2019). Managing antidepressant discontinuation: A systematic review. Annals of Family Medicine 17(1). (Link)