Withdrawal Symptoms after Selective Serotonin Reuptake Inhibitor Discontinuation: A Systematic Review

Perioperative Considerations for Patients With Major Depressive Disorder Undergoing Surgery

In the United States, approximately 15% of adults suffer from major depressive disorder (MDD), which results in an annual cost of over $200 billion per year. In the perioperative setting, MDD is associated with increased morbidity and mortality. The exact causes of the increase in adverse outcomes are unknown. Major depression affects virtually all major systems in the human body, and most antidepressants affect dopamine, norepinephrine, and serotonin levels or alter their target receptors. Unfortunately, anesthesia and medications used in the perioperative period affect the same neurotransmitters. As a result, patients with MDD are at an increased risk for cardiovascular effects, altered thermoregulation, and postoperative cognitive dysfunction. To determine when to continue or hold antidepressants preoperatively and avoid potential drug interactions, perioperative providers must understand the pharmacological action of antidepressants. This article reviews the pathophysiology of MDD, mechanism of action of antidepressants, and perioperative considerations for patients on antidepressant medications.

The antidepressant standoff: why it continues and how to resolve it

BACKGROUND

Antidepressant medications (ADMs) are widely used and long-term use is increasing. Given this extensive use and recommendation of ADMs in guidelines, one would expect ADMs to be universally considered effective. Surprisingly, that is not the case; fierce debate on their benefits and harms continues. This editorial seeks to understand why the controversy continues and how consensus can be achieved.

METHODS

'Position' paper. Critical analysis and synthesis of relevant literature.

RESULTS

Advocates point at ADMs impressive effect size (number needed to treat, NNT = 6-8) in acute phase treatment and continuation/maintenance ADM treatment prevention relapse/recurrence in acute phase ADM responders (NNT = 3-4). Critics point at the limited clinically significant surplus value of ADMs relative to placebo and argue that effectiveness is overstated. We identified multiple factors that fuel the controversy: certainty of evidence is low to moderate; modest efficacy on top of strong placebo effects allows critics to focus on small net efficacy and advocates on large gross efficacy; ADM withdrawal symptoms masquerade as relapse/recurrence; lack of association between ADM treatment and long-term outcome in observational databases. Similar problems affect psychological treatments as well, but less so. We recommend four approaches to resolve the controversy: (1) placebo-controlled trials with relevant long-term outcome assessments, (2) inventive analyses of observational databases, (3) patient cohort studies including effect moderators to improve personalized treatment, and (4) psychological treatments as universal first-line treatment step.

CONCLUSIONS

Given the public health significance of depression and increased long-term ADM usage, new approaches are needed to resolve the controversy.

May antidepressant drugs worsen the conditions they are supposed to treat? The clinical foundations of the oppositional model of tolerance

In recent years there has been a considerable debate on antidepressant drugs. Continued drug treatment with antidepressant medications may stimulate processes that run counter to the initial acute effects of a drug. The oppositional model of tolerance may explain loss of treatment efficacy during maintenance treatment and the fact that some side effects tend to occur only after a certain time. These processes may also direct the illness into a treatment-unresponsive course, including manifestations of bipolar disorder or paradoxical reactions. When drug treatment ends, oppositional processes no longer encounter resistance, resulting in potential onset of new withdrawal symptoms, persistent post-withdrawal disorders, hypomania, and resistance to treatment if it is reinstituted. In all these cases, antidepressant medications may constitute a form of iatrogenic comorbidity, which increases chronicity and vulnerability to depressive episodes. Antidepressant medications are essential drugs for the treatment of major depressive episodes. They are less likely, however, to provide protection for relapse prevention. Current prescription practices need to be reformulated in light of consideration of vulnerabilities and adverse effects of treatment. The oppositional model of tolerance provides a conceptual framework for weighing all these elements in the individual case. The model does not appear to apply to all patients who undergo treatment with AD, but only to a part of them. Studying the variables that are associated with such occurrence in certain patients and not in others would be one of the most important tasks of current therapeutic research. Current diagnostic systems in psychiatry do not consider the iatrogenic components of psychopathology, and can be applied to only patients who are drug free. They are suited for a patient who no longer exists: most of the cases that are seen in psychiatric clinical practice receive psychotropic drugs and such treatment is likely to affect prognosis and treatment choices.

Prescribing for moderate or severe unipolar depression in patients under the long-term care of UK adult mental health services

BACKGROUND

A quality improvement programme addressing prescribing practice for depression was initiated by the Prescribing Observatory for Mental Health.

METHODS

A baseline clinical audit against evidence-based practice standards was conducted in UK adult mental health services.

RESULTS

A total of 55 mental health services submitted data for 2082 patients, under the care of a community psychiatric team (CMHT) for at least a year, with a diagnosis of moderate or severe unipolar depression, 54% of whom had a comorbid psychiatric diagnosis. Selective serotonin reuptake inhibitors were prescribed for 35% of the patients, other newer generation antidepressants for 60%, tricyclic antidepressants for 6% and monoamine oxidase inhibitors for <1%. The most commonly prescribed individual antidepressants were mirtazapine (33%, usually in combination with another antidepressant), venlafaxine (25%) and sertraline (21%). Patients with severe depression were more likely (p < 0.001) to be co-prescribed an antipsychotic medication, lithium, or to have received electroconvulsive therapy. There was a documented clinical review in the last year in 85%, with a symptom rating scale used in 11%. A documented comprehensive treatment history was accessible for 50% of those prescribed antidepressant medication.

CONCLUSION

Patients with moderate or severe depression remaining under the care of a CMHT for longer than a year are clinically complex. The failure to achieve a level of wellness allowing discharge from mental health services may be partly related to the finding that not all patients had the benefit of a systematic approach to clinical assessment and sequential testing of available evidence-based pharmacological interventions.

Withdrawal effects confounding in clinical trials: another sign of a needed paradigm shift in psychopharmacology research

Randomized controlled trials' ability to produce evidence useful for people to decide whether to take, continue taking, or stop taking psychotropic drugs has been intensely critiqued, along with the trials' commercial, ideological, and regulatory contexts. This article applies the critique to the topic of withdrawal effects confounding the outcomes of relapse-prevention trials where prescribed psychotropic drugs are discontinued. Until recently, the complexity and reach of withdrawal and post-withdrawal effects were neglected by mainstream psychiatry, but not by lay users of prescribed psychotropics. This article discusses withdrawal effects as part of the pharmacology of psychotropic drugs but shaped by psychosocial factors, and possibly shaping the presentation of psychological distress generally. It outlines biases and misconceptions in assumptions, design, and reporting of general efficacy trials and findings from a recent review of 80 discontinuation trials. In theory, relapse-prevention trials are tautological and exaggerate efficacy. In publications, they pay little attention to the central feature of their design, favor abrupt or rapid discontinuations, do not attend to environmental factors, and provide insufficient data to allow re-analyses. Thus, relapse-prevention RCTs likely confound the detection of their main outcome of interest: "relapse." Using slower tapers, active placebo controls, and specific covariates in analyses would reduce the risk of withdrawal confounding, and better reporting would reduce the opaqueness of trials. The crisis in psychopharmacology is fueled partly by the disconnect between claims of therapeutic efficacy from so-called best-evidence methods despite unchanging population-level indicators of psychiatric sickness. Only by "stacking the deck" against trial sponsors' hoped-for outcomes can psychopharmacology trials regain scientific credibility.

Embedding existential psychology within psychedelic science: reduced death anxiety as a mediator of the therapeutic effects of psychedelics

Psychedelic therapies can engender enduring improvements in psychological well-being. However, relatively little is known about the psychological mechanisms through which the salutary effects of psychedelics emerge. Through integrating extant research on psychedelics with contemporary existential psychology, we present a novel hypothesis that reduced death anxiety may be a key mechanism underpinning the therapeutic effects of psychedelics. In developing this hypothesis, we also provide a complementary review of mechanisms through which psychedelics may reduce death anxiety. We conclude that an awareness of the role of death anxiety in psychopathology has the potential to guide future research into psychedelic therapies.

Development of Obsessive-Compulsive Symptoms Following Abrupt Discontinuation of Venlafaxine

Withdrawal symptoms after discontinuation of antidepressants are common and have long been known. Typical symptoms after dose reduction or discontinuation of antidepressants are dizziness, drowsiness, headache, flu-like symptoms, hyperarousal, imbalance, insomnia, irritability, and nausea. Rebound, relapse, or recurrence associated with the underlying mental disorder may also occur. The occurrence of obsessive-compulsive symptoms (OCS) following abrupt discontinuation of antidepressants have not yet been reported. Here we report the development of OCS (obsessional suicidal thoughts) in a patient with major depressive disorder and absence of a previous obsessive-compulsive disorder following abrupt discontinuation of venlafaxine. Treatment with escitalopram facilitated remission of OCS. We discuss a possible causal link between abrupt discontinuation of venlafaxine and development of OCS under consideration of pathophysiologic aspects regarding obsessive compulsive disorders, the chronological sequence of symptoms in the present case, and pharmacodynamic and -kinetic aspects. Our case report suggests the possibility of the occurrence of obsessive-compulsive symptoms following abrupt discontinuation of venlafaxine.

Protracted withdrawal syndrome after stopping antidepressants: a descriptive quantitative analysis of consumer narratives from a large internet forum

BACKGROUND

Protracted withdrawal syndrome (PWS) after stopping antidepressants (frequently also referred to as post-acute withdrawal syndrome or PAWS) has been described in a few case reports. However, a detailed quantitative analysis of specific symptom manifestations in antidepressant PWS is still lacking.

METHODS

We extracted patient narratives from a large English-language internet forum SurvivingAntidepressants.org, a peer support site concerned about withdrawal from antidepressants. PWS was ascertained based on diagnostic criteria proposed by Chouinard and Chouinard, specifically ⩾6 months of continuous antidepressant use, with emergence of new and/or more intense symptoms after discontinuation that last beyond the initial 6 weeks of acute withdrawal. We assessed medication history, outcome of PWS, and the prevalence of specific symptoms.

RESULTS

In total, n = 69 individual reports of protracted withdrawal were selected for analysis. At time of the subjects' most recent reports, duration of PWS ranged from 5 to 166 months, mean = 37 months, median = 26 months. Length of time on the antidepressant causing protracted withdrawal ranged from 6 to 278 months, mean = 96 months, and median = 79 months. Throughout the withdrawal experience, affective symptoms, mostly anxiety, depression, emerging suicidality and agitation, were reported by 81%. Somatic symptoms, mostly headache, fatigue, dizziness, brain zaps, visual changes, muscle aches, tremor, diarrhea, and nausea were reported by 75%. Sleep problems (44%) and cognitive impairments (32%) were mentioned less frequently. These broad symptom domains were largely uncorrelated.

CONCLUSION

PWS or PAWS from antidepressants can be severe and long-lasting, and its manifestations clinically heterogeneous. Long-term antidepressant exposure may cause multiple body system impairments. Although both somatic and affective symptoms are frequent, they are mostly unrelated in terms of occurrence. Proper recognition and detection of PWS thus requires a comprehensive assessment of medication history, duration of the withdrawal syndrome, and its various somatic, affective, sleep, and cognitive symptoms.

A survey of UK general practitioners about depression, antidepressants and withdrawal: implementing the 2019 Public Health England report

BACKGROUND

In 2019, a literature review indicated that more than half of people who try to come off antidepressants experience withdrawal effects. Both the National Institute of Health and Care Excellence and the Royal College of Psychiatrists updated their positions in line with that review, and Public Health England published a 152-page report called Dependence and withdrawal associated with some prescribed medicines: an evidence review. The report made several recommendations relevant to general practice.

METHOD

In order to facilitate implementation of these recommendations, an online survey was designed to explore United Kingdom general practitioner (GP) experiences, opinions, knowledge and needs in relation to depression, ADs and withdrawal. A total of 66 GPs had completed the survey when COVID-19 occurred.

RESULTS

In keeping with previous findings, this small sample of GPs had a predominantly psycho-social perspective on the causes of, and treatments for, depression. They broadly considered ADs effective for moderate/severe depression and ineffective for minimal/mild depression, for which they preferred psychological therapies and social prescribing. There was a marked lack of consistency in GPs' knowledge about the incidence and duration of withdrawal effects. Only a minority (29%) felt their knowledge about withdrawal was 'adequate' and fewer (17%) believed this about their 'Ability to distinguish between withdrawal effects and return of the original problem (e.g. depression)'. Two-thirds (68%) would like more training on these matters.

CONCLUSION

It is hoped that even this small sample will be helpful when designing, and seeking funding for, GP training programmes, and when implementing the PHE recommendations for support services, based in the primary care system, for the millions of people contemplating or initiating withdrawal from ADs every year in the UK.

How user knowledge of psychotropic drug withdrawal resulted in the development of person-specific tapering medication

Coming off psychotropic drugs can cause physical as well as mental withdrawal, resulting in failed withdrawal attempts and unnecessary long-term drug use. The first reports about withdrawal appeared in the 1950s, but although patients have been complaining about psychotropic withdrawal problems for decades, the first tentative acknowledgement by psychiatry only came in 1997 with the introduction of the 'antidepressant-discontinuation syndrome'. It was not until 2019 that the UK Royal College of Psychiatrists, for the first time, acknowledged that withdrawal can be severe and persistent. Given the lack of a systematic professional response, over the years, patients who were experiencing withdrawal started to work out practical ways to safely come off medications themselves. This resulted in an experience-based knowledge base about withdrawal which ultimately, in The Netherlands, gave rise to the development of person-specific tapering medication (so-called tapering strips). Tapering medication enables doctors, for the first time, to flexibly prescribe and adapt the medication required for responsible and person-specific tapering, based on shared decision making and in full agreement with recommendations in existing guidelines. Looking back, it is obvious that the simple practical solution of tapering strips could have been introduced much earlier, and that the traditional academic strategy of comparisons from randomised trials is not the logical first step to help individual patients. While randomised controlled trials (RCTs) are the gold standard for evaluating interventions, they are unable to accommodate the heterogeneity of individual responses. Thus, a more individualised approach, building on RCT knowledge, is required. We propose a roadmap for a more productive way forward, in which patients and academic psychiatry work together to improve the recognition and person-specific management of psychotropic drug withdrawal.

Barriers to discontinuing antidepressants in patients with depressive and anxiety disorders: a review of the literature and clinical recommendations

Use of antidepressants has recently increased, mainly caused by the increase of long-term users. Although evidence-based indications for long-term use are lacking, it is assumed that long-term use is unnecessary or undesirable in some patients. Perceived barriers to discontinuing antidepressants contribute to unnecessary or undesirable long-term use. Identifying barriers prior to, during and following discontinuation may enable strategies to overcome them. This narrative review summarises relevant qualitative and quantitative articles on perceived barriers to discontinuing antidepressants and provides recommendations for clinical practice. We can conclude that implications for clinical practice are diverse and the most important barriers experienced by patients and physicians include the fear of relapse or recurrence, insufficient evaluation and monitoring, withdrawal symptoms, and actual relapse or recurrence.

Results from a long-term open-label extension study of adjunctive buprenorphine/samidorphan combination in patients with major depressive disorder

Buprenorphine/samidorphan (BUP/SAM; ALKS 5461) is an investigational opioid system modulator for the adjunctive treatment of patients with major depressive disorder (MDD), who did not respond adequately to prior antidepressant therapy (ADT). FORWARD-2, an open-label extension study, assessed long-term safety and tolerability of adjunctive BUP/SAM treatment in these patients. Patients from four short-term trials and de novo patients were enrolled; all had confirmed MDD and a current major depressive episode lasting 2-24 months. Patients were treated with an established ADT for ≥8 weeks before receiving sublingual, adjunctive BUP/SAM 2 mg/2 mg for up to 52 weeks. Safety (primary objective) was assessed via adverse events (AEs), the Columbia-Suicide Severity Rating Scale, and the Clinical Opiate Withdrawal Scale (COWS). Exploratory evaluation of efficacy was done using the Montgomery-Åsberg Depression Rating Scale (MADRS). Of 1485 patients, 50% completed the study and 11% discontinued due to AEs. AEs of nausea, headache, constipation, dizziness, and somnolence, each occurred in ≥10% of patients. There was no evidence of increased suicidal ideation or behavior. Euphoria-related AEs were uncommon (1.2%). Following abrupt BUP/SAM discontinuation, "drug withdrawal" AEs were infrequent (0.4%), and the incidence of COWS categorical worsening after abrupt drug discontinuation was low (6.5%). Improvements in mean MADRS scores were maintained until study end, suggesting durability of antidepressant effect in patients continuing treatment. BUP/SAM was generally well tolerated, with a low risk of abuse and an AE profile consistent with those seen in placebo-controlled studies. Withdrawal reports were uncommon and of limited clinical impact.

Common CYP2D6, CYP2C9, and CYP2C19 Gene Variants, Health Anxiety, and Neuroticism Are Not Associated With Self-Reported Antidepressant Side Effects

Many patients prescribed an antidepressant stop taking it because of side effects. Genetic factors and psychological factors including state or trait anxiety, may explain variation in side effect outcomes. Our aim was to examine the relative contribution of genetic and psychological factors in people with self-reported antidepressant side effects. We undertook a case control study (n = 194) of people who took a selective serotonin reuptake inhibitor (SSRI) or serotonin/noradrenaline reuptake inhibitor (SNRI) in the past 2 years, recruited via social media advertising. Cases had previously not tolerated at least one trial of an SSRI or SNRI, evidenced by stopping the drug or reducing the dose by at least 50% because of a side effect. Control participants had taken an SSRI or SNRI but did not meet case criteria. Variation in the genes CYP2D6, CYP2C19, and CYP2C9 was analyzed by Sanger sequencing on DNA extracted from blood or saliva. Participants completed the Short Health Anxiety Inventory-18, K10, and NEO-FFI-3 personality questionnaire. Participants were 87.1% female. 70.8% had a current K10 score of 22 or more. There was no consistent evidence that cases had higher psychological distress, health anxiety, or neuroticism. There was low correspondence between participants' CYP2D6, CYP2C19, and CYP2C9 phenotypes and their history of antidepressant tolerability. For this cohort of patients a history of not tolerating SSRI or SNRI therapy was not associated with variation in the pharmacogenes we tested, nor was it associated with health anxiety or neuroticism.

Men's views of antidepressant treatment for depression, and their implications for community pharmacy practice

BACKGROUND

Men with depression can express and navigate their condition differently to women. Understanding this population's needs, and experiences, can help healthcare professionals better support these patients. There is a lack of knowledge in this area, and no studies have explored men's depression in the context of community pharmacy.

OBJECTIVES

Explore views of men around their medication for the treatment of depression and the role of community pharmacy in their treatment.

SETTING

United Kingdom (UK) primary care.

METHOD

Semi-structured in-depth interviews were conducted. Eligible participants were male, aged 18-65 years, and treating depression with antidepressants. Participants were recruited through 5 UK pharmacies (via the pharmacist or poster recruitment) and a UK University (poster recruitment). A thematic approach was used for analysis.

RESULTS

14 men aged 26-61 years, predominantly of white ethnicity were interviewed. Key themes were found. The theme 'Antidepressant's attributions to benefits' highlighted all men noticed benefits when taking antidepressants, but held uncertainty on what extent their antidepressants caused this. The themes 'Views of pharmacist's role influences engagement', and 'Influence of cognitive state upon healthcare interactions' demonstrated men were not inclined to discuss concerns with the community pharmacist. These men didn't see this as the pharmacist's role, nor had these men given cognitive space to evaluate their treatment beliefs or information needs. Yet the theme 'Reflection of support and information needs' shows men did have unmet information and support needs. This also links into the 'Hegemonic Masculinity and taking antidepressants' theme, where taking antidepressants could challenge ones masculinity.

CONCLUSION

Community pharmacists should create opportunities for men to engage in conversations around their antidepressants and wider support. Men, as a requisite for engagement, will need to see such interactions as within the community pharmacists' remit, and as part of a collaborative healthcare system.

Selective serotonin reuptake inhibitors and benzodiazepines in panic disorder: A meta-analysis of common side effects in acute treatment

BACKGROUND

Benzodiazepines (BZs) and selective serotonin reuptake inhibitors (SSRIs) are effective in the pharmacologic treatment of panic disorder (PD). However, treatment guidelines favor SSRIs over BZs based on the belief that BZs are associated with more adverse effects than SSRIs. This belief, however, is currently supported only by opinion and anecdotes.

AIM

The aim of this review and meta-analysis was to determine if there truly is evidence that BZs cause more adverse effects than SSRIs in acute PD treatment.

METHODS

We systematically searched Web of Science, PubMed, Cochrane Central Register of Controlled Trials, and clinical trials register databases. Short randomized clinical trials of a minimum of four weeks and a maximum of 12 weeks that studied SSRIs or BZs compared to placebo in acute PD treatment were included in a meta-analysis. The primary outcome was all-cause adverse event rate in participants who received SSRIs, BZs, or placebo.

RESULTS

Overall, the meta-analysis showed that SSRIs cause more adverse events than BZs in short-term PD treatment. Specifically, SSRI treatment was a risk factor for diaphoresis, fatigue, nausea, diarrhea, and insomnia, whereas BZ treatment was a risk factor for memory problems, constipation, and dry mouth. Both classes of drugs were associated with somnolence. SSRIs were associated with abnormal ejaculation, while BZs were associated with libido reduction. BZs were protective against tachycardia, diaphoresis, fatigue, and insomnia.

CONCLUSION

Randomized, blinded studies comparing SSRIs and BZs for the short-term treatment of PD should be performed. Clinical guidelines based on incontrovertible evidence are needed.

Enhancing shared decision making about discontinuation of antidepressant medication: a concept-mapping study in primary and secondary mental health care

BACKGROUND

The apparent rise of antidepressant use seems to be explained to a large extent by an increase in long-term use. Both professionals and patients appear reluctant to discontinue antidepressant medication (ADM). It is not known what factors determine this reluctance.

AIM

This study aimed to identify factors that enable the shared decision-making process about discontinuation of ADM between long-term users and their GPs.

DESIGN AND SETTING

Concept-mapping study of a purposive sample of both patients and professionals from primary and secondary mental health care in the Netherlands.

METHOD

Concept mapping was used to conceptualise and structure the topics relevant to the discontinuation process from the perspective of both patients and professionals. Participants generated topics in brainstorming sessions and subsequently prioritised and sorted them. Multidimensional scaling and hierarchical cluster analyses were used for the cluster topics.

RESULTS

Thirty-seven patients and 27 professionals generated 50 separate topics. Hierarchical cluster analysis revealed six clusters of topics: 'Process of discontinuation', 'Expectations', 'Professional guidance', 'Current use', 'Environment', and 'Side effects'. Patients and professionals came up with largely similar topics. Nevertheless, a difference was found between these groups regarding the perceived importance of professional guidance.

CONCLUSION

This study yielded an informed selection of the topics that seem most important to discuss when considering whether to discontinue ADM. As perspectives of both patients and professionals were combined, the topics may provide patients and GPs with a broader and more balanced scope of factors to consider, and thus facilitate a better shared decision-making process.

Dependence, withdrawal and rebound of CNS drugs: an update and regulatory considerations for new drugs development

The purpose of this article is to describe dependence and withdrawal phenomena related to CNS drugs discontinuation and to clarify issues related to the evaluation of clinical drug withdrawal and rebound as they relate to safety in new drug development. The article presents current understanding and definitions of drug dependence and withdrawal which are also relevant and important features of addiction, though not the same. Addiction, called substance use disorder in DSM-5, affects an individual’s brain and behaviour, represents uncontrollable drug abuse and inability to stop taking a drug regardless of the harm it causes. Characteristic withdrawal syndromes following abrupt discontinuation of CNS-active drugs from numerous drug classes are described. These include drugs both scheduled and non-scheduled in the Controlled Substances Act, which categorizes drugs in five schedules based on their relative abuse potentials and dependence liabilities and for regulatory purposes. Schedules 1 and 2 contain drugs identified as those with the highest abuse potential and strictest regulations. Less recognized aspects of drug withdrawal, such as rebound and protracted withdrawal syndromes for several drug classes are also addressed. Part I presents relevant definitions and describes clinical withdrawal and dependence phenomena. Part II reviews known withdrawal syndromes for the different drug classes, Part III describes rebound and Part IV describes protracted withdrawal syndromes. To our knowledge, this is the first compilation of withdrawal syndromes for CNS drugs. Part V provides details of evaluation of dependence and withdrawal in the clinical trials for CNS drugs, which includes general design recommendations, and several tools, such as withdrawal questionnaires and multiple scales that are helpful in the systematic evaluation of withdrawal. The limitations of different aspects of this method of dependence and withdrawal evaluation are also discussed.

A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based?

INTRODUCTION

The U.K.'s current National Institute for Health and Care Excellence and the American Psychiatric Association's depression guidelines state that withdrawal reactions from antidepressants are 'self-limiting' (i.e. typically resolving between 1 and 2weeks). This systematic review assesses that claim.

METHODS

A systematic literature review was undertaken to ascertain the incidence, severity and duration of antidepressant withdrawal reactions. We identified 24 relevant studies, with diverse methodologies and sample sizes.

RESULTS

Withdrawal incidence rates from 14 studies ranged from 27% to 86% with a weighted average of 56%. Four large studies of severity produced a weighted average of 46% of those experiencing antidepressant withdrawal effects endorsing the most extreme severity rating on offer. Seven of the ten very diverse studies providing data on duration contradict the U.K. and U.S.A. withdrawal guidelines in that they found that a significant proportion of people who experience withdrawal do so for more than two weeks, and that it is not uncommon for people to experience withdrawal for several months. The findings of the only four studies calculating mean duration were, for quite heterogeneous populations, 5days, 10days, 43days and 79weeks.

CONCLUSIONS

We recommend that U.K. and U.S.A. guidelines on antidepressant withdrawal be urgently updated as they are clearly at variance with the evidence on the incidence, severity and duration of antidepressant withdrawal, and are probably leading to the widespread misdiagnosing of withdrawal, the consequent lengthening of antidepressant use, much unnecessary antidepressant prescribing and higher rates of antidepressant prescriptions overall. We also recommend that prescribers fully inform patients about the possibility of withdrawal effects.

Long-term outcomes of trials in the National Institute for Health and Care Excellence depression guideline

The forthcoming National Institute for Health and Care Excellence depression guideline reviews short-term outcomes for long-term depression. We present effect sizes for long-term outcomes in trials that report these data. Psychological therapies become more effective, whereas antidepressants become less effective over the long term. We review other forms of longitudinal research that support these findings.

Benzodiazepines in anxiety disorders: Reassessment of usefulness and safety

Importance: Benzodiazepines (BZs) are still widely prescribed for the treatment of anxiety disorders despite many publications in the literature which favour antidepressants (ADs) instead. What is the evidence?Observations: Treatment guidelines favour ADs over BZs for treatment of anxiety disorders without any head-to-head comparison of both drug groups with placebo. BZs are claimed to cause less efficacy and more safety issues than ADs, yet ADs also cause disturbing adverse events and, similar to BZs, discontinuation symptoms. Until evidence-based data become available, a look at two 6-month generalized anxiety disorder trials conducted by the same research group, one with a BZ and the other with an AD, might provide some guidance for the clinician. Most improvement with a BZ was obtained by 4 weeks, suggesting that BZ treatment longer than 4 weeks should only be offered to patients maximally improved at 4 weeks. In contrast, ADs may have to be prescribed for 3-6 months to obtain maximal benefits.Conclusion: Results of a controlled trial as proposed will go a long way in providing clinicians missing information to guide them in the appropriate use of both BZs and ADs in anxiety disorders.

Overprescribed Medications for US Adults: Four Major Examples

To understand possible medication overprescribing, it would be important to know which classes are the most prescribed, for which indications, for what duration, and for which age groups. Among the 10 most frequently prescribed medication classes for US adults, four were evaluated for overprescribing, and systematically assessed in relation to their primary indication. The assessment included usage patterns, trends, age of recipients, treatment duration, and benefits versus adverse consequences. The findings in this selective review are supported by an extensive search of the medical literature. The four selected medication categories and their most common indication included opioids for chronic pain, proton pump inhibitors for indigestion, levothyroxine for subclinical hypothyroidism, and antidepressants for subsyndromal levels of depression. These medications, grouped by their most frequent indication along with polypharmacy, have experienced major prescription increases in recent years, particularly among older patients. Most concerning is that they have been frequently prescribed for extended periods, usually with inadequate evidence of benefit. High drug usage patterns can aid in quantifying overprescribing within polypharmacy by age group.

Antidepressant withdrawal - the tide is finally turning

Withdrawal reactions when coming off antidepressants have long been neglected or minimised. It took almost two decades after the selective serotonin reuptake inhibitors (SSRIs) entered the market for the first systematic review to be published. More reviews have followed, demonstrating that the dominant and long-held view that withdrawal is mostly mild, affects only a small minority and resolves spontaneously within 1-2 weeks, was at odd with the sparse but growing evidence base. What the scientific literature reveals is in close agreement with the thousands of service user testimonies available online in large forums. It suggests that withdrawal reactions are quite common, that they may last from a few weeks to several months or even longer, and that they are often severe. These findings are now increasingly acknowledged by official professional bodies and societies.

Complementary therapies for clinical depression: an overview of systematic reviews

OBJECTIVES

As clinical practice guidelines vary widely in their search strategies and recommendations of complementary and alternative medicine (CAM) for depression, this overview aimed at systematically summarising the level 1 evidence on CAM for patients with a clinical diagnosis of depression.

METHODS

PubMed, PsycInfo and Central were searched for meta-analyses of randomised controlled clinical trials (RCTs) until 30 June 2018. Outcomes included depression severity, response, remission, relapse and adverse events. The quality of evidence was assessed according to Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) considering the methodological quality of the RCTs and meta-analyses, inconsistency, indirectness, imprecision of the evidence and the potential risk of publication bias.

RESULTS

The literature search revealed 26 meta-analyses conducted between 2002 and 2018 on 1-49 RCTs in major, minor and seasonal depression. In patients with mild to moderate major depression, moderate quality evidence suggested the efficacy of St. John's wort towards placebo and its comparative effectiveness towards standard antidepressants for the treatment for depression severity and response rates, while St. John's wort caused significant less adverse events. In patients with recurrent major depression, moderate quality evidence showed that mindfulness-based cognitive therapy was superior to standard antidepressant drug treatment for the prevention of depression relapse. Other CAM evidence was considered as having low or very low quality.

CONCLUSIONS

The effects of all but two CAM treatments found in studies on clinical depressed patients based on low to very low quality of evidence. The evidence has to be downgraded mostly due to avoidable methodological flaws of both the original RCTs and meta-analyses not following the Consolidated Standards of Reporting Trials and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Further research is needed.

Emergent Antidepressant Discontinuation Syndrome Misdiagnosed as Delirium in the ICU

We present a case of serious antidepressant discontinuation syndrome (ADDS) in a 72- year-old woman in the intensive care unit (ICU). Although this syndrome may be mild under ambulatory conditions, ICU patients can experience serious neurocognitive symptoms that are difficult to differentiate from delirium. We report delayed recognition of the ADDS in a patient in the ICU who was initially diagnosed with severe hyperactive delirium. Subsequent to hiatal hernia surgery, the patient was admitted to the ICU for aspiration and was intubated. Due to increasing agitation the patient received high doses of dexmedetomidine, fentanyl, midazolam, and propofol. The patient was treated with high doses of a serotonin norepinephrine reuptake inhibitor (SNRI) antidepressant, duloxetine, for 2 years. However, the antidepressant was not effectively administered postsurgically due to gastroparesis. The signs and symptoms of ADDS can occur cryptogenically if they are partially masked by sedating agents. Due to concern for the discontinuation syndrome and the inability to administer duloxetine via a nasogastric tube, another SNRI, venlafaxine, was administered. Venlafaxine administration allowed unexpectedly prompt dose reduction and then total discontinuation of all sedating agents, allowing liberation from mechanical ventilation and ICU discharge. This case illustrates the importance of avoiding antidepressant discontinuation in the ICU.

Discontinuation of antidepressant medication in primary care supported by monitoring plus mindfulness-based cognitive therapy versus monitoring alone: design and protocol of a cluster randomized controlled trial

Background

Antidepressant use continues to rise, mainly explained by an increase in the proportion of patients receiving long term treatment. Although treatment guidelines recommend discontinuation after sustained remission, discontinuing antidepressants appears to be challenging for both patients and general practitioners (GPs). Mindfulness-Based Cognitive Therapy (MBCT) is an effective intervention that reduces the risk of relapse in recurrent depression and might facilitate discontinuation by teaching patients to cope with withdrawal symptoms and fear of relapse. The current study aims to investigate the effectiveness of the combination of Supported Protocolized Discontinuation (SPD) and MBCT in comparison with SPD alone in successful discontinuation of long-term use of antidepressants in primary care.

Methods

This study involves a cluster-randomized controlled trial conducted in primary care patients with long-term use antidepressants with baseline and 6, 9 and 12 months follow-up assessments. Patients choosing to discontinue their medication will be offered a combination of SPD and MBCT or SPD alone. Our primary outcome will be full discontinuation of antidepressant medication (= 0 mg) within 6 months after baseline assessment. Secondary outcome measures will be the severity of withdrawal symptoms, symptoms of depression and anxiety, psychological well-being, quality of life and medical and societal costs.

Discussion

In theory, stopping antidepressant medication seems straightforward. In practice however, patients and their GPs appear reluctant to initiate and accomplish this process. Both patients and professionals are in need of appropriate tools and information to better support the process of discontinuing antidepressant medication.

Trial registration

ClinicalTrials.gov PRS ID: NCT03361514 retrospectively registered October 2017.

Depression: more treatment but no drop in prevalence: how effective is treatment? And can we do better?

PURPOSE OF REVIEW

Since the 70s, treatment of depression, especially pharmacologically, has expanded enormously. However, epidemiological studies show that 12-month population prevalence rates have not dropped. This observation raises multiple questions. How good are treatments of depression actually? Do they improve long-term outcomes? Have the treatment gaps narrowed? And how can we make mental healthcare more effective at the population level?

RECENT FINDINGS

Recent publications suggest some answers. Controlled treatment trials show that effectiveness of specific treatments (pharmacological, psychological) is modest and probably overestimated owing to substantial spontaneous recovery and nonspecific therapeutic effects. Treatment gaps are still substantial and prevention has unclear long-term effects and is not structurally embedded. Future relevance of genetic information for better personalized treatment is potentially high but uncertain. Increasingly, the potential of treatment to improve long-term outcome is being questioned.

SUMMARY

To reduce prevalence, it is essential to narrow the treatment gaps, provide timely interventions and high-quality treatment, eradicate waiting lists, prescribe antidepressants more cautiously and better managed, consider psychological alternatives, and provide more psychosocial treatment in primary care with physician-assistants. In addition, research is needed on long-term outcome of different treatment modalities, and least but not last the value of structurally socially embedded preventive interventions.

Considering the methodological limitations in the evidence base of antidepressants for depression: a reanalysis of a network meta-analysis

OBJECTIVES

To investigate whether the conclusion of a recent systematic review and network meta-analysis (Cipriani et al) that antidepressants are more efficacious than placebo for adult depression was supported by the evidence.

DESIGN

Reanalysis of a systematic review, with meta-analyses.

DATA SOURCES

522 trials (116 477 participants) as reported in the systematic review by Cipriani et al and clinical study reports for 19 of these trials.

ANALYSIS

We used the Cochrane Handbook's risk of bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the risk of bias and the certainty of evidence, respectively. The impact of several study characteristics and publication status was estimated using pairwise subgroup meta-analyses.

RESULTS

Several methodological limitations in the evidence base of antidepressants were either unrecognised or underestimated in the systematic review by Cipriani et al. The effect size for antidepressants versus placebo on investigator-rated depression symptom scales was higher in trials with a 'placebo run-in' study design compared with trials without a placebo run-in design (p=0.05). The effect size of antidepressants was higher in published trials compared with unpublished trials (p<0.0001). The outcome data reported by Cipriani et al differed from the clinical study reports in 12 (63%) of 19 trials. The certainty of the evidence for the placebo-controlled comparisons should be very low according to GRADE due to a high risk of bias, indirectness of the evidence and publication bias. The mean difference between antidepressants and placebo on the 17-item Hamilton depression rating scale (range 0-52 points) was 1.97 points (95% CI 1.74 to 2.21).

CONCLUSIONS

The evidence does not support definitive conclusions regarding the benefits of antidepressants for depression in adults. It is unclear whether antidepressants are more efficacious than placebo.

Discontinuing Psychotropic Drugs from Participants in Randomized Controlled Trials: A Systematic Review

BACKGROUND AND OBJECTIVE

Methods and justifications for discontinuing psychotropic drugs in randomized controlled trials (RCTs), and RCTs' acknowledgement of possible withdrawal symptoms following discontinuation, have not been examined systematically, which this review aims to do. Study Eligibility, Data Extraction, and Synthesis: Publications in MEDLINE, EMBASE, and PsycINFO (2000-2017) randomly assigning participants diagnosed with mental disorders to discontinue antipsychotic, antidepressant, anticonvulsant, antimanic, mood-stabilizing, benzodiazepine, or stimulant drugs. Authors independently extracted data, devised a typology of trials, and assessed trials' recognition of with-drawal symptoms.

RESULTS

Eighty RCTs (70% with industry participation) discontinued drugs from 5,757 participants to investigate relapse prevention (44%), successful dis-continuation (26%), architecture of withdrawal (14%), and practicality of discontinuation (10%). RCTs of stimulants, antidepressants, and antipsychotics mostly aimed to reach conclusions about relapse prevention by testing abrupt or rapid discontinuations; RCTs of benzodiazepines mostly aimed to reduce drug use by testing longer-lasting, supportive discontinuations. In 67% of RCTs, no justification was given for the specific discontinuation strategy, which lasted under 2 weeks in 60% of RCTs. Possible withdrawal confounding of trial outcomes was addressed in 14% of eligible RCTs.

LIMITATIONS

Only the published literature was searched.

CONCLUSIONS AND IMPLICATIONS

RCTs use drug discontinuation to study several key issues in psychopharmacology but infrequently justify how they implement it or acknowledge that possible withdrawal symptoms may threaten internal validity. Reappraising the use of drug discontinuation and the recognition of withdrawal symptoms in RCTs is required.

Depression in the Primary Care Setting

A 45-year-old woman with hypothyroidism that has been treated with a stable dose of levothyroxine presents to her primary care provider with depressed mood, negative feelings about herself, poor sleep, low appetite, poor concentration, and lack of energy. These symptoms began several months ago during a conflict with her partner. Although she has been able to continue work and life responsibilities, she feels sadness most days and occasionally thinks that she would be better off dead. How would you evaluate and treat this patient?

Tapering of SSRI treatment to mitigate withdrawal symptoms

All classes of drug that are prescribed to treat depression are associated with withdrawal syndromes. SSRI withdrawal syndrome occurs often and can be severe, and might compel patients to recommence their medication. Although the withdrawal syndrome can be differentiated from recurrence of the underlying disorder, it might also be mistaken for recurrence, leading to long-term unnecessary medication. Guidelines recommend short tapers, of between 2 weeks and 4 weeks, down to therapeutic minimum doses, or half-minimum doses, before complete cessation. Studies have shown that these tapers show minimal benefits over abrupt discontinuation, and are often not tolerated by patients. Tapers over a period of months and down to doses much lower than minimum therapeutic doses have shown greater success in reducing withdrawal symptoms. Other types of medication associated with withdrawal, such as benzodiazepenes, are tapered to reduce their biological effect at receptors by fixed amounts to minimise withdrawal symptoms. These dose reductions are done with exponential tapering programmes that reach very small doses. This method could have relevance for tapering of SSRIs. We examined the PET imaging data of serotonin transporter occupancy by SSRIs and found that hyperbolically reducing doses of SSRIs reduces their effect on serotonin transporter inhibition in a linear manner. We therefore suggest that SSRIs should be tapered hyperbolically and slowly to doses much lower than those of therapeutic minimums, in line with tapering regimens for other medications associated with withdrawal symptoms. Withdrawal symptoms will then be minimised.

Prioritization and comprehensive analysis of genes related to major depressive disorder

Background

Major depressive disorder (MDD) is a serious mental health problem in modern society, which is difficult to identify and diagnose in the early stages. Despite strong evidence supporting the heritability of MDD, progresses in large‐scale and individual genetic studies remain preliminary.

Methods

In this study, a multi‐data source‐based prioritization (MDSP) method was proposed, and an appropriate threshold was determined for the optimization of depression‐related genes (DEPgenes). Analyses on Gene Ontology biological processes, KEGG pathway and the specific pathway crosstalk network were further proposed.

Results

A total of 143 DEPgenes were identified and the MDD‐specific network was constructed for the pathogenesis investigation and therapeutic methods development of MDD. Comparing with existing research strategies, the genetic optimization and analysis results were confirmed to be reliable. Finally, the pathway enrichment and crosstalk analyses revealed two unique pathway interaction modules that were significantly enriched with MDD genes. The related core pathways of neuroactive ligand‐receptor interaction and dopaminergic synapse supported the neuropathology hypothesis of MDD. And the pathways of serotonergic synapse and morphine addiction indicated the mechanism of drug addiction caused by serotonin used in the treatment.

Conclusions

This work provided a reference for the study of MDD, although future validation by extensive experimentation is still required.

Benefits of Sequentially Adding Cognitive-Behavioral Therapy or Antidepressant Medication for Adults With Nonremitting Depression

OBJECTIVE

Adults with major depressive disorder frequently do not achieve remission with an initial treatment. Addition of psychotherapy for patients who do not achieve remission with antidepressant medication alone can target residual symptoms and protect against recurrence, but the utility of adding antidepressant medication after nonremission with cognitive-behavioral therapy (CBT) has received little study. The authors aimed to evaluate the acute and long-term outcomes resulting from both sequences of combination treatments.

METHODS

Previously untreated adults with major depression who were randomly assigned to receive escitalopram, duloxetine, or CBT monotherapy and completed 12 weeks of treatment without achieving remission entered an additional 12 weeks of combination treatment. For patients who did not achieve remission with CBT, escitalopram was added (CBT plus medication group) to their treatment, and for those who did not achieve remission with an antidepressant, CBT was added (medication plus CBT group) to their treatment. Patients who responded to the combination treatment entered an 18-month follow-up phase to assess risk of recurrence.

RESULTS

A total of 112 patients who did not achieve remission with a monotherapy entered combination treatment (41 who responded to monotherapy but did not achieve remission and 71 who did not respond to monotherapy). Overall, remission rates after subsequent combination therapy were significantly higher among patients who responded to monotherapy but did not achieve remission (61%) than among patients who did not respond to monotherapy (41%). Among patients who responded to monotherapy but did not achieve remission, the remission rate in the CBT plus medication group (89%) was higher than in the medication plus CBT group (53%). However, among patients whose depression did not respond to monotherapy, rates of response and remission were similar between the treatment arms. Higher levels of anxiety, both prior to monotherapy and prior to beginning combination treatment, predicted poorer outcomes for both treatment groups.

CONCLUSIONS

The order in which CBT and antidepressant medication were sequentially combined did not appear to affect outcomes. Addition of an antidepressant is an effective approach to treating residual symptoms for patients who do not achieve remission with CBT, as is adding CBT after antidepressant monotherapy. Patients who do not respond to one treatment modality warrant consideration for addition of the alternative modality.

Antidepressant Use During Acute Inpatient Care Is Associated With an Increased Risk of Psychiatric Rehospitalisation Over a 12-Month Follow-Up After Discharge

Background: Some evidence suggests that antidepressants may relate to poor outcomes in depression. The aim of this study was, therefore, to examine, whether antidepressant use may worsen the long-term outcome in real-world psychiatric patients with both primarily affective and non-affective mental disorders. Methods: Based on a total of n = 151 inpatients with a mixed range of diagnoses enrolled at two psychiatric hospitals in Zurich, Switzerland, matched pairs of n = 45 antidepressant users and n = 45 non-users were selected via nearest neighbor propensity score matching. Pairs were matched according to 14 clinically relevant covariates assessing psychosocial impairments, functioning deficits and illness severity. The two outcomes of interest were the number and total duration of all rehospitalisations over a 12-month follow-up after discharge from the hospital based on the official clinical registry. Results: Altogether 35.6% of antidepressant users were rehospitalised at least once, as compared to 22.2% in matched non-users. Two or more rehospitalisations occurred in 22.2% of antidepressant users but only in 2.2% of non-users. In antidepressant users, the mean total duration of rehospitalisations was 22.22 days, as compared to 8.51 in matched non-users. According to Poisson regression analyses, antidepressant use during acute inpatient care prospectively relates to both a higher risk (incidence rate ratio [IRR] = 3.64, 95% confidence interval [95%-CI] = 1.71-7.75, p = 0.001) and a longer duration (IRR = 2.61, 95%-CI = 1.01-6.79, p = 0.049) of subsequent rehospitalisations. These findings were consistently replicated when traditional multivariable regression analysis was applied to the full sample. Findings also replicated when patients with affective and non-affective disorders were analyzed separately. Conclusions: Our findings raise the possibility that, in the long-term, antidepressants may impair recovery and increase the risk of rehospitalisation in patients with both primarily affective and non-affective disorders. More work is required to explore possible aetiopathological pathways leading to psychiatric rehospitalisation.