Psychotherapy Ups Odds of Tapering Off Antidepressants

Marcia Frellick

January 22, 2019

Cognitive behavioral therapy (CBT) used with tapering is more effective than clinical management plus tapering in helping patients discontinue antidepressants without increased risk for relapse, according to a systematic review of 15 studies.

Emma Maund, MSc, MPhil, PhD, from Primary Care & Population Sciences at the University of Southampton, United Kingdom, and colleagues found that at 2 years the risk for relapse with cognitive behavioral therapy plus tapering was 15% to 25% vs 35% to 80% with clinical management plus tapering (risk ratio, 0.34; 95% confidence interval, 0.18 - 0.67), two studies showed. Relapse and recurrence rates were similar for mindfulness-based cognitive therapy (MBCT) plus tapering vs maintenance antidepressants (44% - 48% vs 47% - 60%), an analysis of two studies showed.

However, CBT and MBCT are costly and resource-intensive and more scalable solutions will be necessary as the use of antidepressants grows, Maund and colleagues say.

The authors reported their findings in the January/February issue of the Annals of Family Medicine.

Discontinuation Often Falls to Primary Care Physicians

Helping patients get off antidepressants is an ever-increasing task in western countries as prescriptions have doubled over 10 years with climbing long-term use, Maund and colleagues note.

In the United States, the median length of time on the drugs is 5 years and discontinuation efforts often fall to the primary care physician. While some patients will need to keep taking some amount of the antidepressants to avoid relapse, "30% to 50% of long-term users have no evidence-based indication to continue their medication," they write.

Coauthor Michael V. Moore, MBBS, a family physician and deputy head of the academic unit at Primary Care & Population Sciences, told Medscape Medical News that before starting any discontinuation plan primary care providers should engage with the patient personally. They should ask about residual symptoms and whether it is a good time in their lives to start the discontinuation. Physicians also should ask if the patient is expecting adverse events in the near future that may keep them from successfully discontinuing.

Ask patients if they have tried stopping before, he advises, and ask if they have fears or concerns. Acknowledge the fears and address them.

Also, make sure the patient understands the difference between symptoms related to relapse and symptoms related to discontinuation, he advises.

Discontinuation symptoms are common but will likely be more tolerable with tapering than abrupt withdrawal, Moore said. The authors note that both the American Psychiatric Association and the UK's National Institute for Health and Care Excellence advise tapering doses over weeks in most cases.

"Our findings tend to support consensus guidance that antidepressants should be tapered rather than discontinued abruptly, but more trials of slower tapering are needed," the authors write. "One ongoing study is comparing 1-week with 2-week tapering."

Cognitive Therapies Costly

The authors point out that while psychological therapies are helpful in discontinuation they may not always be readily available and the numbers of patients needing the services may overwhelm the system.

"It may be that a self-directed Internet-based intervention using psychological approaches with some remote support may provide effective support for discontinuation," Moore said. "If so, then such an approach is likely to be available to more people and cost effective. We are developing just such an intervention and have commenced recruitment to the first phase of the trial to test this approach."

15 Studies Reviewed

For the current review, the authors included studies if they were randomized controlled trials, quasi-experimental studies, or observational studies that evaluated strategies for stopping antidepressants in adults.

The investigators included 15 studies, eight of which were randomized controlled trials. None of the included studies had a high risk for selection or detection bias, according to the authors.

Several authors received funding from the National Institute for Health Research for the REDUCE (REviewing long term anti-Depressant Use by Careful monitoring in Everyday practice) applied health research program 2016-2022. One coauthor reports personal fees from the University of York, University College London, and Maverex, outside the submitted work.

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Ann Fam Med. 2019;17:52-60. Abstract

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