Psychotherapy Can Prevent Relapse When Discontinuing Antidepressants

“Short and simple psychological programs can prevent people from relapsing when they stop their antidepressants.”

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When is it safe to discontinue antidepressant medications? If the drugs prevent relapse, then stopping them could lead to a return of the experiences (such as anxiety or depression) that made the person seek them out in the first place. But a new study—published in the top-tier journal JAMA Psychiatry—has found that psychotherapy is just as good at preventing relapse as continuing antidepressants.

A press release about the study summarizes their results: “Short and simple psychological programs can prevent people from relapsing when they stop their antidepressants.”

The study was led by Josefien Breedvelt and Claudi Bockting at the University of Amsterdam.

The researchers found four pre-existing studies which compared psychotherapy (and antidepressant tapering/discontinuation) with continued antidepressant use. The studies included 714 total participants and followed patients for 15 months after they stopped using antidepressants. The therapies provided were cognitive therapy or mindfulness-based cognitive therapy.

“This individual participant data meta-analysis suggests that delivering a psychological intervention while a patient undergoes antidepressant tapering may be an alternative to long-term use of antidepressants in the treatment of recurrent depression,” the researchers write in the JAMA Psychiatry article.

In the press release, Breedvelt writes that “We found that regardless of clinical risks, such as a high number of previous episodes or residual symptoms, patients can consider stopping antidepressants as long as they can receive a simple psychotherapy.”

According to Breedvelt and Bockting, clinical practice guidelines urge clinicians to continue antidepressant therapy long-term, even in people who no longer meet the criteria for depression or anxiety, as a “maintenance treatment.” However, they note that antidepressants have many adverse effects which can grow worse with long-term use, such as weight gain and sexual dysfunction, and people may not want to continue taking them long-term.

Contrary to those guidelines, their study found that discontinuing antidepressant treatment is possible without causing more relapse if simple psychotherapy is provided during discontinuation.

In the press release, Bockting writes:

“While clinical guidelines currently recommend long-term antidepressant use in high-risk patients, it is time to discuss alternatives.”

According to the researchers, there was no particular group of people for whom this worked better or worse than any others (even those who had previously experienced numerous recurring episodes of depression or anxiety), meaning this could be attempted with anyone.

Breedvelt and Bockting conclude that psychotherapy—along with medication discontinuation—is a viable alternative to continued antidepressant treatment once a person has experienced improvement.

 

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Breedvelt, J. J. F., Warren, F. C., Segal, Z., Kuyken, W., & Bockting, C. L. (2021). Continuation of antidepressants vs. sequential psychological interventions to prevent relapse in depression: An individual participant data meta-analysis. JAMA Psychiatry. Published online May 19, 2021. doi:10.1001/jamapsychiatry.2021.0823 (Link)

15 COMMENTS

  1. The problem with this issue is that I’m pretty certain I’m not the only one here who initially had the common odd, adverse, and withdrawal symptoms of an antidepressant misdiagnosed by a non-medically trained psychotherapist. Thankfully, once she said I no longer needed to see her, and her systemic child abuse covering up lies to my psychiatrist ended. My psychiatrist concluded she’d misdiagnosed me, and he started slowly weaning me off his drugs. And his belief I was misdiagnosed by the psychotherapist, is literally written into my former psychiatrist’s medical records.

    But this does mean we do need all the psychologists, social workers, and other “mental health” workers to either be properly medically educated, in regards to the common adverse and withdrawal effects of the antidepressants, and other psych drugs, of which the psychiatrists are still largely claiming to be ignorant. And this conundrum does make the proper education of the psychotherapists, and other “mental health” workers, nearly impossible, to this day.

    Plus I will ask, why would any person with a brain in their head, ever trust a psychotherapist to assist them in weaning off the psych drugs, when it was a psychotherapist who initially misdiagnosed them, and forced them to be massively psychiatrically neurotoxic poisoned in the first place?

    We won’t, ever again, once was too much. But we will point out the scientific fraud, and systemic child abuse covering up, and iatrogenic illness creating, crimes of the “invalid” “mental health professionals,” which are all by DSM design.

    https://www.alternet.org/2010/04/are_prozac_and_other_psychiatric_drugs_causing_the_astonishing_rise_of_mental_illness_in_america/
    https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis
    https://en.wikipedia.org/wiki/Toxidrome
    https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome
    https://www.indybay.org/newsitems/2019/01/23/18820633.php?fbclid=IwAR2-cgZPcEvbz7yFqMuUwneIuaqGleGiOzackY4N2sPeVXolwmEga5iKxdo
    https://www.madinamerica.com/2016/04/heal-for-life/
    https://www.psychologytoday.com/us/blog/your-child-does-not-have-bipolar-disorder/201402/dsm-5-and-child-neglect-and-abuse-1

    Not to be rude, Peter, but why do the systemic child abuse covering up American psychotherapy industry, who still today buy almost 100% into psychiatry’s “invalid” DSM, deserve a second chance, without repentance? Unless they completely disavow psychiatry’s DSM, and end their evil ways? Until such happens, I don’t think any of them deserve a third chance.

    Since repentance, and changing from one’s evil ways, is what is required for forgiveness, according to God and Jesus. It’s also how we maintain a civil an just society. I think that’s why a lot of the British psychologists are working to speak out against the evils of the psychiatrists and big Pharma.

    Yet the majority of American psychologists are still just trying to steal from those they – or other psychologists – have committed malpractice against, via fraud based conservator contracts, and lies, to “maintain the status quo.”

    When the psychological profession agreed to be the systemic child abuse cover uppers for their American religions, and turned the bishops of their religions into a bunch of systemic unrepentant child abuse cover uppers too, as happened with my former religion.

    https://books.google.com/books?id=xI01AlxH1uAC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false

    I have no doubt that those psychologists, psychiatrists, pastors, and bishops – who entered into this faustian deal – need to repent, and end their systemic crimes. Since their systemic child abuse covering up, and also – obviously hand in hand, systemic pedophile aiding, abetting, and empowering crimes – are destroying our country from within. Since we all now live in a “pedophile empire,” where child sex trafficking and pedophilia are running amok.

    https://www.amazon.com/Pedophilia-Empire-Chapter-Introduction-Disorder-ebook/dp/B0773QHGPT
    https://community.healthimpactnews.com/topic/4576/america-1-in-child-sex-trafficking-and-pedophilia-cps-and-foster-care-are-the-pipelines

    All I can say is, what a sick and disgusting shame it is that the formerly respectable religious and medical industries entered into this shameful “dirty little secret of the two original educated professions.”

  2. Thanks Peter,

    “….If the drugs prevent relapse, then stopping them could lead to a return of the experiences (such as anxiety or depression) that made the person seek them out in the first place..”

    A lot of Depression is fuelled by Anxiety – and there are reasonable non drug ways to overcome “Anxiety”.

  3. “Short and simple psychological programs can prevent people from relapsing when they stop their antidepressants.”

    I’m confused. In most cases, safe successful withdrawal isn’t “short and simple”, it’s slow and methodical, so how could the accompanying therapy be so?

  4. No conclusions can be drawn from the JAMA Psychiatry meta-analysis ‘Continuation of Antidepressants vs Sequential Psychological Interventions to Prevent Relapse in Depression’

    In a press release about a meta-analysis about continuing or not continuing antidepressant treatment that was recently published in JAMA Psychiatry(1) the results were summarised as follows: “Short and simple psychological programs can prevent people from relapsing when they stop their antidepressants.” This rather suggestive conclusion is problematic because it cannot follow from the study, in which confounding by withdrawal was not accounted for at all.

    The new study was based on a literature search that yielded 15,792 hits, of which 236 full-text articles were retrieved. Of these, 4 RCTs were included because they contained individual participant data. Closer inspection shows that all 4 studies were carried out and co-authored by the authors of the new meta-analysis. This makes the statement under data-collection that ‘the First authors of eligible articles were contacted . . . If we did not receive a response . . . we recorded that data were not available’ a bit weird’ unless we would expect that an author who asks to provide data to refuse this to him- or herself.

    In the new study the word ‘tapering’ is used 41 times, which at least suggests that tapering is considered to be important by the authors. One would expect therefore that in the study it would be made clear how patients in the 4 studies analysed – carried out by the authors themselves – had tapered their antidepressant. This is not the case. To find this out one has go back to the original studies, only to discover that also in these studies it is not made clear how patients tapered. Going back from these studies to older studies does shows that tapering schedules used were not well defined and cannot be considered safe tapering.

    What can be concluded is that the authors of the new study did not pay much (or even no) attention to the method of tapering. It is therefore impossible to now how many people suffered from withdrawal symptoms due to improper tapering and for how many of them it was subsequently incorrectly concluded that they were suffering relapse.

    When nothing is known about this it is impossible and scientifically very dubious to use this study as an argument for using psychological interventions (which I do not oppose) to prevent relapse.
    What I find very surprising and worrying is that the authors of this new study, who talk so much about ‘tapering’, do not mention or discuss the development and use of tapering strips in the Netherlands(2,3) and other important recent work(4-6) that has been done to achieve safe tapering and has been published in the scientific literature and of which they must be fully aware.
    Taken together, to me this suggests that the authors seem to be merely interested only in promoting their own favourite treatment. I find this worrying.

    References
    (1) Breedvelt JJF, Warren FC, Segal Z, Kuyken W, Bockting CL. Continuation of Antidepressants vs Sequential Psychological Interventions to Prevent Relapse in Depression: An Individual Participant Data Meta-analysis. JAMA Psychiatry. 2021.
    https://www.madinamerica.com/2021/05/psychotherapy-can-prevent-relapse-discontinuing-antidepressants/

    (2) Groot PC, van Os J. Antidepressant tapering strips to help people come off medication more safely. Psychosis 2018;10(2):142-145. https://doi.org/10.1080/17522439.2018.1469163

    (3) Groot PC, van Os J. Outcome of Antidepressant Drug Discontinuation with Taperingstrips after 1-5 Years. Therapeutic advances in psychopharmacology. 2020;10:2045125320954609. https://doi.org/2045125320954610.2045125320951177/2045125320954609

    (4) Horowitz MA, Taylor D. Tapering of SSRI treatment to mitigate withdrawal symptoms. The lancet Psychiatry. 2019;6(6):538-546. https://doi.org/10.1016/S2215-0366(19)30032-X

    (5) Horowitz MA, Jauhar S, Natesan S, Murray RM, Taylor D. A Method for Tapering Antipsychotic Treatment That May Minimize the Risk of Relapse. Schizophrenia Bulletin. 2021.
    https://doi.org/10.1093/schbul/sbab017

    (6) Groot PC, van Os J. How user knowledge of psychotropic drug withdrawal resulted in the development of person-specific tapering medication. Therapeutic advances in psychopharmacology. 2020;10:2045125320932452. https://doi.org/10.1177/2045125320932452

    • Thank you for your comments, the tapering procedures were looked into – they can be found in the supplement. We highlight it as a limitation that we don’t know what the exact tapering procedure is per patient it would be very valuable to have this! And we need more research into it.

      We also highlight in the discussion that there can be a difference between withdrawal syndrome and relapse, we argue for better reporting to assess the difference. If withdrawal syndrome would be mistaken for relapse the rates might even be lower among the discontinuation group.

      We do not advocate for either approach, our main message is that patients now have more choices.

      • I thank authorteam2 for their quick reply which I appreciate very much. I wholeheartedly agree that patients (and physicians, don’t forget them) need more choices. This was an important reason to develop tapering medication.

        In your response you say that tapering procedures were looked into. To find out what you meant by this I checked Table e7 of the supplement in which the tapering procedures used are described, I quote:

        – Kuyken 2008: ‘Tapering regimes were jointly determined by physicians and patients (within 6 months of MBCT group ending’

        – Segal 2010: ‘Tapered gradually, over a 4 week period, via reduced pill count at the recommended rate of the specific medication’

        – Kuyken 2015: GPs and patients jointly determined the tapering regimen (guidelines suggested after 6 weeks of treatment)

        – Bockting 2018: ‘Advised to taper in 4 weeks, in practice, 60% of patients tapered over 6 months. The GP or psychiatrist and participant received a letter with instructions to guide tapering and a tapering schedule per type of drug. Patients were allowed to restart antidepressants at any time’

        These descriptions make clear that tapering procedures in the 2008 2010 and 2015 studies were not clearly defined. It is now abundantly clear that tapering according to manufacturers recommendations was and often still is inadequate for lots of patients. And what does it mean that ‘GPs and patients jointly determined the tapering regimen’? How vague can a statement be? Finally, Bockting 2018 mentions that 40% was able to taper in 4 weeks according to the tapering schedule advised in the study protocol. This means that 60% were not able to do this but needed much more time and where allowed to restart antidepressants at any time. But there is no clarification about how many patients tapered in how much time or how they fared.

        Based on this (lack of) information about tapering procedures patients followed it is not correct science to make inferences about relapse. Because it cannot be made clear in how many cases withdrawal was mistaken for relapse and vice versa. Therefore I stand with my previous conclusion that withdrawal was not accounted for in this ‘meta-analysis’. The conclusion that ‘Short and simple psychological programs can prevent people from relapsing when they stop their antidepressants’ which is now touted into the media simply cannot follow from your study.

        Finally, what I’m sorely missing in your comment is an explanation of why you haven’t referenced and discussed recent scientific papers on important developments in the field of withdrawal and tapering.

    • Thank you, Peter Groot. And no offense intended toward Peter Simons but Mad In America would be a much more rigorous publication if its articles included this level of critical analysis. There is already more than enough fluff pop science ‘journalism’ that doesn’t really inform.

      • Peter Simons is certainly not to blame. This publication was sold with a convincing story, both through the audio interview on the JAMA website (https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2780290) and subsequently in the media. The message was one that many people, including me, would like to hear: that preventive cognitive therapy or mindfulness-based cognitive therapy can prevent against relapse after long term use of antidepressants.

        As very many others I consider it important that different forms of psychotherapy as well as many other forms of help or therapy that can all be helpful should be available, and this should not be limited to preventive cognitive therapy or mindfulness-based cognitive therapy. The problem is that this ‘meta-analysis’ does not prove (or disprove) that these particular two forms of psychotherapy prevent against relapse. Therefore, in my opinion, JAMA Psychiatry should not have published it. I really wonder why this happened and how it is possible that the reviewers of this study did not see its flaws.

        What this again shows is that so-called ‘prominent’ and high impact journals do not automatically publish the best and most relevant science. Therefore we must always be critical, also or perhaps even more so when a conclusion of a study is to our liking.

        • My main objection is reframing what is likely a wide range of withdrawal effects as “relapse.” I find this quite disingenuous. It assumes that the “antidepressants” are automatically helping in all cases and that the psychotherapy is needed because not having the pills to keep their “disease” under control means they’d need therapy. The idea that they feel bad because of the known and often serious withdrawal effects of stopping the pills themselves is completely discounted.

  5. Is this important, or just some indication of turf wars?

    The doctors want to keep their “patients” on drugs.
    The therapists want a reason to deliver therapy.
    So this “study” is pro-therapy, anti-doctor.

    What about actually helping someone get well? Although this issue is outside of the scope of this little article, it is dismaying how outside the scope of “mental health professionals” it seems to be.

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