Cases in Deprescribing: When to Stop the SSRI

Charles P. Vega, MD

Disclosures

March 26, 2019

Door Number...

I choose "Try to taper off of sertraline entirely." I can already see our hypothetical patient's highly skeptical eyes narrowing at me.

This is a remarkably healthy 66-year-old patient for my practice. So it might be easy to say, "Well, she is just taking one chronic medication, as opposed to the seven that most of my older patients take. So how much harm can sertraline do?"

Plenty, actually. A study of over 60,000 older adults identified in a primary care database as having a diagnosis of depression found that selective serotonin reuptake inhibitors (SSRIs) were associated with a more than 50% increase in rates of falls and hyponatremia.[1] And those falls can lead to fractures.[2]

Compared with SSRIs, other antidepressant classes were associated with higher risks for mortality, fracture, stroke/transient ischemic attack, and epilepsy seizures. Surprisingly, tricyclic antidepressants were not the drug class most associated with these adverse events. The highest risk for adverse events was in patients taking trazodone, mirtazapine, or venlafaxine.[1]

Another retrospective cohort study of adults over 60 years of age found that the use of SSRIs was associated with a higher risk for dementia, even when compared with severely depressed adults who were not using SSRIs.[3] Use of other antidepressants was linked with a higher risk for depression as well.

Will this one patient's treatment with a low dose of sertraline promote a fall or serious hyponatremia? Probably not. But that potential risk should be balanced against the benefit provided by this medication. The usual course of initial therapy with an antidepressant should be less than 12 months.[4,5] However, overall use of antidepressants is climbing because many patients take these drugs for well over a year.[6]

There are a few more questions to ask: Is she experiencing anxiety, and what is the level of stress in her life right now? What about health habits, including positive interventions such as that exercise program, as well as potential risks such as heavy alcohol consumption? Most important, it is worthwhile to revisit the severity and persistence of her depression as well as what happened during her last attempt to discontinue sertraline 3 years ago.

It turns out that risk factors for prolonged use of antidepressants have been identified. And there is a review of best practices in deprescribing antidepressants. I will share those next month. I look forward to hearing your comments and wisdom.

Until then...

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