An article recently published in the journal of Therapeutic Advances in Psychopharmacology reveals that the currently available Clinical Practice Guidelines (CPGs) for tapering antidepressants fail practitioners who wish to help their patients discontinue their medication.
Danish researchers Anders Sørensen, Karsten Juhl Jørgensen, and Klaus Munkholm conducted a systemic review of CPGs from high-income English-speaking countries. Their results highlight severe shortcomings in the guidelines that can mislead practitioners and put patients at risk. They write:
“About half of the patients on antidepressants who try to discontinue or reduce the dose experience withdrawal symptoms, including flu-like symptoms, anxiety, emotional lability, lowering of mood, irritability, bouts of crying, dizziness, shaking, fatigue, and electric shock sensations. The symptoms usually persist for weeks but can last months or even years, and half of the patients who experience them rate the symptoms as severe.”
“Beyond withdrawal, discontinuing antidepressants can be difficult for psychological reasons. These include worry of relapse, a perceived biochemical cause of depression, insufficient emotion regulation skills and coping strategies, need for social support, psychological dependence, and experience of previous unsuccessful discontinuation attempts.”
Discontinuing antidepressants is a notoriously challenging and long process. The journey to lowering a dosage, tapering, and discontinuing altogether is not easily done alone—often requiring close contact and support with a care team and prescriber, not to mention a robust network of peer and community supports. Despite this, the current guidelines to taper or discontinue are often vague and imprecise, not only for service users but practitioners too.
The initial guideline collection yielded 21 usable non-repeated Clinical Practice Guidelines proposed by major national or international health authorities and professional organizations. The CPGs were published over 20+ years (1998-2020). Of the 21 unique guidelines: seven were from the United States, five were from the United Kingdom, one each was from Canada, New Zealand, Scotland, Singapore, and Australia, respectively. In addition, three additional CPGs were issued by international organizations.
These guidelines were then combed through for data extraction independently by Munkholm and Sørensen. They were assessed and appraised for quality, i.e., if the current guidelines are comprehensive enough and relevant enough to practitioners in helping their patients manage and discontinue their antidepressants.
After an in-depth review of their extracted data and appraisal screening, the authors found the following:
“Discontinuing antidepressants by gradually tapering the dose was recommended in 15 (71%) of the CPGs. Nine (43%) of the CPGs recommended a certain period of time to taper ranging from at least four weeks to 6 months, six (29%) of the CPGs did not specify the duration of taper but recommended that anti-depressants be ‘tapered/discontinued slowly over an extended period of time,’ or to ‘taper over at least several weeks,’ and the remaining six of the CPGs provided no guidance related to tapering.”
“Rapid or abrupt discontinuation was suggested in two (10%) of the CPGs, either when serious adverse events occurred or for patients experiencing discontinuation symptoms despite a slow taper…maintenance antidepressant treatment after symptomatic remission was recommended in 17 (81%) of the CPGs…the remaining CPGs provided no direct guidance on what to do when maintenance treatment ends.”
The results revealed that most CPGs did recommend that antidepressants are tapered slowly and gradually, but very few CPGs specified what “gradual” and “slow” meant.
None of the CPGs explicitly recommended discontinuation or a taper, and none discussed what withdrawal symptoms might look like throughout the taper/discontinuation.
The authors feel that the clinical implication of the research is important, in particular:
“…the limited and vague guidance on tapering and discontinuing in current CPGs, which was hard to find in many cases, means that they provide little support for clinicians seeking to help patients stop or taper antidepressants. This may have the consequence that clinicians are hesitant to support patients in the process of discontinuing….”
“…the symptomatic overlap between potential withdrawal symptoms and depressive symptoms was acknowledged in only very few CPGs, and guidance on how to discern between these two fundamentally different clinical situations was not provided. Lack of such guidance may have the consequence that drug treatment is continued unnecessarily in some patients if withdrawal reactions are misdiagnosed as relapse, potentially leading to resuming drug treatment under the false assumption that the antidepressant was necessary to prevent relapse.”
Sørensen, A., Juhl Jørgensen, K., & Munkholm, K. (2022). Clinical practice guideline recommendations on tapering and discontinuing antidepressants for depression: a systematic review. Therapeutic Advances in Psychopharmacology, 12, 20451253211067656. (Link)
What I see is that the hesitation among doctors about tapering is largely caused by the lack of lower doses to be able to take the small steps in tapering.
The fact that pharmaceuticals do not make these lower doses can be blamed heavily on them. It is also scandalous that institutes such as FDA, EMA do not make the existence of lower doses a condition for registration. Why don’t doctors fight alongside patients to enforce this?
You might get the impression that they somehow don’t WANT people to successfully get off of them!