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.
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.
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.
(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
Tapering medication is NOT a one-size-fits all solution! On the contrary. Tapering medication (tapering strips, stabilisation strips) was developed to enable physicians to flexibly prescribe and adapt personalised, hyperbolic, responsible and safe tapering schedules to patients based on shared decision making and proper (self)monitoring. See this blog of Jim van Os on http://www.psychosisnet.com:
One of the mechanisms to quiet unwelcome voices is to reject them using arguments like this: “Unfortunately, because of the many submissions we receive and our space limitations in the Letters section, we are unable to publish your letter . . . “. MIA, August 1, 2019: “Helping People Come Off Medication – Bad for Business?” http://www.madinamerica.com/2019/08/helping-people-come-off-medication-bad-business/
One of the strategies mentioned in the review is the use of tapering strips. Tapering strips provide patients and doctors with a practical tool for flexible and personalised tapering and (self)monitoring.
More information about this can be found in the MIA article ‘Service-User Knowledge Helps Researchers Develop Psychiatric Drug Tapering Approaches’
or in the review ‘How user knowledge of psychotropic drug withdrawal resulted in the development of person-specific tapering medication’.
These articles and additional information about using and prescribing tapering strips can be found here:
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.
Report comment
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.
Report comment
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
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Tapering medication is NOT a one-size-fits all solution! On the contrary. Tapering medication (tapering strips, stabilisation strips) was developed to enable physicians to flexibly prescribe and adapt personalised, hyperbolic, responsible and safe tapering schedules to patients based on shared decision making and proper (self)monitoring. See this blog of Jim van Os on http://www.psychosisnet.com:
Tips for tapering off your medication.
https://www.psychosisnet.com/medication/quitting-medication/tips-for-tapering-off-your-medication/
In Dutch on http://www.psychosenet.nl:
Tips voor het afbouwen van medicatie.
https://www.psychosenet.nl/medicatie/medicatie-afbouwen/tips-voor-het-afbouwen-van-medicatie/
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One of the mechanisms to quiet unwelcome voices is to reject them using arguments like this: “Unfortunately, because of the many submissions we receive and our space limitations in the Letters section, we are unable to publish your letter . . . “. MIA, August 1, 2019: “Helping People Come Off Medication – Bad for Business?”
http://www.madinamerica.com/2019/08/helping-people-come-off-medication-bad-business/
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Cheaper treatment options seems to be not wellcome, even when they are way better for patients. I wrote about this in my blog for MIA of August 1, 2019: “Helping People Come Off Medication – Bad for Business?”
http://www.madinamerica.com/2019/08/helping-people-come-off-medication-bad-business/
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Tapering strips can be obtained upon prescription of a certified doctor/prescriber. See http://www.taperingstrip.org
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One of the strategies mentioned in the review is the use of tapering strips. Tapering strips provide patients and doctors with a practical tool for flexible and personalised tapering and (self)monitoring.
More information about this can be found in the MIA article ‘Service-User Knowledge Helps Researchers Develop Psychiatric Drug Tapering Approaches’
or in the review ‘How user knowledge of psychotropic drug withdrawal resulted in the development of person-specific tapering medication’.
These articles and additional information about using and prescribing tapering strips can be found here:
– https://www.madinamerica.com/2020/07/service-user-knowledge-helps-researchers-develop-psychiatric-drug-tapering-approaches/
– https://doi.org/10.1177/2045125320932452
– http://www.taperingstrip.org
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