Managing Antidepressant Discontinuation

A Systematic Review

Emma Maund, MSc, MPhil, PhD; Beth Stuart, MSc, PhD; Michael Moore, BM BS, MRCP, FRCGP; Christopher Dowrick, MSc, MD, CQSW, FRCGP; Adam W.A. Geraghty, MSc, PhD, CPsychol, FHEA; Sarah Dawson, MSc; Tony Kendrick, MD, FRCGP, FRCPsych (Hon), FHEA

Disclosures

Ann Fam Med. 2019;17(1):52-60. 

In This Article

Abstract and Introduction

Abstract

Purpose: We aimed to determine the effectiveness of interventions to manage antidepressant discontinuation, and the outcomes for patients.

Methods: We conducted a systematic review with narrative synthesis and meta-analysis of studies published to March 2017. Studies were eligible for inclusion if they were randomized controlled trials, quasi-experimental studies, or observational studies assessing interventions to facilitate discontinuation of antidepressants for depression in adults. Our primary outcomes were antidepressant discontinuation and discontinuation symptoms. Secondary outcomes were relapse/recurrence; quality of life; antidepressant reduction; and sexual, social, and occupational function.

Results: Of 15 included studies, 12 studies (8 randomized controlled trials, 2 single-arm trials, 2 retrospective cohort studies) were included in the synthesis. None were rated as having high risk for selection or detection bias. Two studies prompting primary care clinician discontinuation with antidepressant tapering guidance found 6% and 7% of patients discontinued, vs 8% for usual care. Six studies of psychological or psychiatric treatment plus tapering reported cessation rates of 40% to 95%. Two studies reported a higher risk of discontinuation symptoms with abrupt termination. At 2 years, risk of relapse/recurrence was lower with cognitive behavioral therapy plus taper vs clinical management plus taper (15% to 25% vs 35% to 80%: risk ratio = 0.34; 95% CI, 0.18–0.67; 2 studies). Relapse/recurrence rates were similar for mindfulness-based cognitive therapy with tapering and maintenance antidepressants (44% to 48% vs 47% to 60%; 2 studies).

Conclusions: Cognitive behavioral therapy or mindfulness-based cognitive therapy can help patients discontinue antidepressants without increasing the risk of relapse/recurrence, but are resource intensive. More scalable interventions incorporating psychological support are needed.

Introduction

In Western countries, antidepressant prescriptions are rising steadily and have doubled over 10 years.[1–3] The main reason is increasing long-term use,[4,5] with a median duration exceeding 5 years in the United States[2] and most prescribing done by primary care clinicians.[2,5] Although some people need antidepressants to prevent relapse/recurrence, 30% to 50% of long-term users have no evidence-based indication to continue their medication.[6–8] This inappropriate use exposes patients to potentially serious adverse effects[9,10] and is costly.[11]

Stopping antidepressants, however, is frequently associated with withdrawal symptoms, which can be problematic, and mistaken for relapse/recurrence.[12] To minimize these symptoms, the American Psychiatric Association and the National Institute for Health and Care Excellence advise tapering doses over some weeks in most cases.[13,14] Psychological interventions such as cognitive behavioral therapy (CBT) and mindfulness-based cognitive therapy (MBCT) are potential alternatives to antidepressants for preventing relapse/recurrence.[15–17]

Current guidelines for antidepressant discontinuation are based on consensus, and nonsystematic reviews have identified a need for more controlled data.[18] There have been 2 systematic reviews focusing on the incidence of withdrawal symptoms after discontinuation.[12,19] We conducted a systematic review to address 2 questions: what interventions are effective in managing antidepressant discontinuation, and what are the outcomes for patients after discontinuation?

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