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Fava GA. Clinical Use of Staging in Psychiatry. PSYCHOTHERAPY AND PSYCHOSOMATICS 2024; 93:143-150. [PMID: 38636469 DOI: 10.1159/000538526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 03/18/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Giovanni A Fava
- Department of Psychiatry, University at Buffalo, State University of New York, Buffalo, New York, USA
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2
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John R, Stevie L, Mark H, Joanna M. The need for antidepressant withdrawal support services: Recommendations from 708 patients. Psychiatry Res 2023; 326:115303. [PMID: 37364505 DOI: 10.1016/j.psychres.2023.115303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/09/2023] [Accepted: 06/10/2023] [Indexed: 06/28/2023]
Abstract
Approximately half of the tens of millions of people currently taking antidepressants will experience withdrawal symptoms when they try to reduce or come off them. Nearly half of these describe their symptoms as severe in surveys. Many prescribing doctors seem ill-informed and unprepared to provide effective discontinuation advice and support, often misdiagnosing withdrawal as a relapse of depression or anxiety. 708 members of online support groups for people on antidepressants, from 31 countries, completed a sentence in an online survey: 'A public health service to help people come off antidepressants should include ................'. Two independent researchers categorised their responses into themes, and then reached consensus via discussion. Seven themes emerged: 'Prescriber Role', 'Information', 'Other Supports/Services', 'Strong Negative Feelings re Doctors/Services etc.', Informed Consent When Prescribed', 'Drug Companies' and: 'Public Health Campaign'. The most frequently mentioned requirements of the Prescriber Role were that prescribers be properly informed, provide small doses/liquid/tapering strips, develop a withdrawal plan and believe patients about their withdrawal experiences. The most frequently recommended other services were psychotherapy/counselling, support groups, patient led/informed services, nutrition advice, 24-hour crisis support and 'holistic/lifestyle' approaches. Many respondents were angry about how uninformed their doctors were and how they had been treated.
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Affiliation(s)
- Read John
- School of Psychology, University of East London, London, UK.
| | - Lewis Stevie
- Unaffiliated Researcher, Lived Experience of Prescribed Drug Dependence, Cardiff, UK
| | - Horowitz Mark
- Mental Health Sciences Unit, University College London, London, UK
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Abstract
Individual attitudes and behavior related to health and disease are major components of clinical encounters. These factors shape lifestyle, presentation of symptoms, access to patient care, interactions between patients and physicians, adherence to medical advice, and response to treatment. Health attitudes and behavior may range from anxiety and worry about illness to various forms of denial, such as delay of seeking care and lack of adherence to treatment. When attitudes result in health-damaging behavior, they may be particularly difficult to understand and become a source of frustration to both physicians and patients. Devising appropriate responses by health care providers may contribute to improving final outcomes and decrease health care costs. In particular, health behavior is likely to play a major role in the process of convalescence, in self-management of chronic conditions, in determining a state of recovery, and whenever a rehabilitation process is involved. Understanding the spectrum of health attitudes and behavior is also crucial for motivating people to make beneficial changes (lifestyle medicine), as well as for implementing safety procedures in the community.
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Arjmand S, Grassi-Oliveira R, Wegener G. Rethinking treatment-resistant depression to quasi-tenacious depression. Eur Psychiatry 2023; 66:e14. [PMID: 36632817 PMCID: PMC9970145 DOI: 10.1192/j.eurpsy.2022.2353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
With almost one-third of patients with major depression not adequately responsive to treatments, the management of treatment-resistant depression (TRD) has continued to be challenging. Recently, an essential step was taken to replace TRD with difficult-to-treat depression (DTD), pointing to some drawbacks associated with this terminology and identifying addressable barriers. In line with the DTD concept, we discuss why terming this population of patients as TRD could be semantically and clinically misleading. We then suggest replacing TRD with quasi-tenacious depression (QTD), a model and terminology that are derived from a potentially measurable outcome, the tenacity index (TI). QTD predicts that in theory remission is achievable by providing suitable treatments at hand. QTD states that every patient with major depression (even those who respond well) has some degree of tenacity that needs to be overcome by the use of proper treatment modalities. Ergo, in patients with a higher TI, due to the dearth of available armamentaria, one might suffice to achieve a partial resolution of symptoms balanced with an optimal quality of life. However, QTD calls for an incessant pursuit of novel treatments and the identification of contributing factors leading to high TI. On a track toward personalized psychiatry, and in harmony with DTD, QTD embraces all key barriers leading to a failure to treatment response and tries to provide a measurable entity for a better clinical decision while conveying a dynamic positive outlook of the disorder for both patients and health care providers.
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Affiliation(s)
- Shokouh Arjmand
- Translational Neuropsychiatry Unit, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Rodrigo Grassi-Oliveira
- Translational Neuropsychiatry Unit, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Gregers Wegener
- Translational Neuropsychiatry Unit, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Crowe M, Manuel J, Carlyle D, Thwaites B, Lacey C. The experience of 'treatment-resistant' depression: A qualitative meta-synthesis. Int J Ment Health Nurs 2023; 32:662-672. [PMID: 36635921 DOI: 10.1111/inm.13107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2022] [Indexed: 01/14/2023]
Abstract
While antidepressants may be effective in treating depression for some people, a third of people do not have an improvement in mood after a trial of two different antidepressants for an adequate duration. These people are diagnosed as having 'treatment-resistant' depression which situates the problem as part of their biological or psychological makeup. We conducted a search of studies that examined this problem from the perspective of people whose depression did not improve on antidepressants. Nine studies were included in a qualitative meta-synthesis that identified four themes across these studies: feeling trapped, disconnection, loss of self, and questioning. The participants experienced considerable distress associated with the constant presence of depression in their lives. While antidepressants may help some people, there is a need for more innovative approaches to the treatment of depression. There is a strong argument for trialling appropriate evidence-based psychotherapy before a person is categorized as having treatment-resistant depression. It is perhaps better to describe the issue as inadequate efficacy of antidepressants to situate the problem with the treatment provided rather than with the person.
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Affiliation(s)
- Marie Crowe
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Jenni Manuel
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Dave Carlyle
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Bridgette Thwaites
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Cameron Lacey
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
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Pope E, Muthukrishnan S, Phillips J, Phillips S. A case of treatment-resistant depression in an older adult and a discussion of treatment options. BJPsych Bull 2022; 46:331-336. [PMID: 34782028 PMCID: PMC9813956 DOI: 10.1192/bjb.2021.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Treatment-resistant depression is a complex condition often requiring specialist psychiatric care. Many different psychiatric, physical and social factors can lead to a poor response to initial treatment of depression, and a careful assessment is required to determine the most appropriate management option. This can be particularly complex in the older population, who often have multiple physical and social comorbidities. We have used a fictional case to illustrate this, alongside an anonymised vignette of someone with personal experience of this condition. We have also provided an overview of the current evidence for treatment options, as well as a discussion of potential aetiological factors. By the end of this article, readers should understand the ambiguity of this diagnostic term, the aetiological factors that need to be assessed and the rationale for the treatment options available. They should be able to recognise how these ideas apply to the geriatric population.
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Affiliation(s)
| | - Sabari Muthukrishnan
- Avon and Wiltshire Mental Health Partnership NHS Trust, UK.,Kingshill Research Centre, UK
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Abstract
Staging has been increasingly used in unipolar depression since its introduction in the nineties. Several models are available, but their differential features and implications are not completely clear. We systematically reviewed: (a) staging models of longitudinal development of unipolar depression; (b) staging models of treatment-resistant unipolar depression; (c) their applications. MEDLINE, PsycINFO, EMBASE, and Web of Science were examined according to PRISMA guidelines from inception to December 2021. Search terms were: 'stage/staging', combined using the Boolean 'AND' operator with 'psychiatric disorder/mental disorder/depressive/mood disorder'. A total of 169 studies were identified for inclusion: 18 described staging models or applications, 151 described treatment-resistant staging models or applications. Staging models of longitudinal development were found to play a key role in formulating sequential treatment, with particular reference to the use of psychotherapy after pharmacotherapy. Staging methods based on treatment resistance played a crucial role in setting entry criteria for randomized clinical trials and neurobiological investigations. Staging is part of clinimetrics, the science of clinical measurements, and its role can be enhanced by its association with other clinimetric strategies, such as repeated assessments, organization of problematic areas, and evaluation of phenomena that may affect responsiveness. In research, it may allow to identify more homogeneous populations in terms of treatment history that may diminish the likelihood of spurious results in comparisons. In clinical practice, the use of staging in a clinimetric perspective allows clinicians to make full use of the information that is available for an individual patient at a specific time.
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Affiliation(s)
- Fiammetta Cosci
- Department of Health Sciences, University of Florence, Florence, Italy
- Clinical Pharmacopsychology Laboratory, University of Florence, Florence, Italy
- Department of Psychiatry & Neuropsychology, Maastricht University, Maastricht, The Netherlands
| | - Giovanni A Fava
- Department of Psychiatry, University at Buffalo, State University of New York, New York, USA
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Munder T, Geisshüsler A, Krieger T, Zimmermann J, Wolf M, Berger T, Watzke B. Intensity of Treatment as Usual and Its Impact on the Effects of Face-to-Face and Internet-Based Psychotherapy for Depression: A Preregistered Meta-Analysis of Randomized Controlled Trials. PSYCHOTHERAPY AND PSYCHOSOMATICS 2022; 91:200-209. [PMID: 35158363 DOI: 10.1159/000521951] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/06/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Treatment as usual (TAU) is the most frequently used control group in randomized trials of psychotherapy for depression. Concerns have been raised that the heterogeneity of treatments in TAU leads to biased estimates of psychotherapy efficacy and to an unclear difference between TAU and control groups like waiting list (WL). OBJECTIVE We investigated the impact of control group intensity (i.e., amount and degree to which elements of common depression treatments are provided) on the effects of face-to-face and internet-based psychotherapy for depression. METHODS We conducted a preregistered meta-analysis (www.osf.io/4mzyd). We included trials comparing psychotherapy with TAU or WL in patients with symptoms of unipolar depression. Six indicators were used to assess control group intensity. PRIMARY OUTCOME Standardized mean difference (SMD) of psychotherapy and control in depressive symptoms at treatment termination. RESULTS We included 89 trials randomizing 14,474 patients to 113 psychotherapy conditions and 89 control groups (TAU in 42 trials, WL in 47 trials). Control group intensity predicted trial results in preregistered (one-sided ps < 0.042) and exploratory analyses. Psychotherapy effects were significantly smaller (one-sided p = 0.002) in trials with higher intensity TAU (SMD = 0.324, CI 0.209 to 0.439) than in trials with lower intensity TAU (SMD = 0.628, CI 0.455 to 0.801). Psychotherapy effects against lower intensity TAU did not differ from effects against WL (two-sided p = 0.663). CONCLUSIONS Our results suggest that variation in TAU intensity impacts the outcome of trials. More scrutiny in the design of control groups for clinical trials is recommended.
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Affiliation(s)
- Thomas Munder
- Department of Psychology, University of Zurich, Zurich, Switzerland
| | | | - Tobias Krieger
- Institute of Psychology, University of Bern, Bern, Switzerland
| | | | - Markus Wolf
- Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Thomas Berger
- Institute of Psychology, University of Bern, Bern, Switzerland
| | - Birgit Watzke
- Department of Psychology, University of Zurich, Zurich, Switzerland
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9
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Rink L, Adams A, Braun C, Bschor T, Kuhr K, Baethge C. Dose-Response Relationship in Selective Serotonin and Norepinephrine Reuptake Inhibitors in the Treatment of Major Depressive Disorder: A Meta-Analysis and Network Meta-Analysis of Randomized Controlled Trials. PSYCHOTHERAPY AND PSYCHOSOMATICS 2022; 91:84-93. [PMID: 34965534 DOI: 10.1159/000520554] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 10/25/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Selective serotonin and norepinephrine reuptake inhibitors (SNRI) are among the most prescribed antidepressants, and dose escalation is a frequently applied strategy after non-response to an initially prescribed dose. OBJECTIVE This meta-analysis aimed to find evidence of a dose-response relationship or to the contrary in direct comparisons of different SNRI doses in patients with major depressive disorder. METHODS A systematic literature search for RCTs comparing at least two doses of SNRIs was carried out in CENTRAL, PubMed, PsycINFO, and EMBASE. Doses were classified as high, medium, and low according to manufacturers' product monographs and analyses at the level of SNRIs as a group and for single substances, accompanied by sensitivity network meta-analyses (Prospero CRD42018081031). RESULTS From 2,070 studies screened, we included 26 studies with a total of 10,242 patients. Comparisons of medium versus low and high versus medium doses resulted in clinically and statistically non-significant standardized mean differences of -0.06 (-0.16 to 0.04) and -0.06 (-0.16 to 0.03) in favor of higher doses. In the analyses of single substances, no statistically significant results emerged, and many contrasts yielded very small effect sizes. Dropouts due to side effects tended to be more frequent with higher doses. Heterogeneity was low. Network meta-analyses of direct comparisons supported the findings, as did a risk of bias analysis. CONCLUSION Based on the lack of positive evidence for a dose-response relationship in SNRIs as a group and in single SNRIs, we recommend prescribing medium doses. In case of insufficient response, we do not recommend increasing the dose of SNRIs.
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Affiliation(s)
- Lena Rink
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Cologne, Cologne, Germany, .,Red Cross Children's Hospital Siegen, Siegen, Germany,
| | - Anne Adams
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Cora Braun
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Tom Bschor
- Department of Psychiatry and Psychotherapy, Technical University of Dresden, Dresden, Germany
| | - Kathrin Kuhr
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Christopher Baethge
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Cologne, Cologne, Germany
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Malhi GS, Bell E, Mannie Z, Boyce P, Hopwood M, Bassett D, Mulder R, Porter RJ, Lyndon B. rTMS and treatment-resistant depression: The need to consider class action! Aust N Z J Psychiatry 2022; 56:323-327. [PMID: 34250832 DOI: 10.1177/00048674211025094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Gin S Malhi
- Academic Department of Psychiatry, Kolling Institute, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Erica Bell
- Academic Department of Psychiatry, Kolling Institute, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia
| | - Zola Mannie
- Academic Department of Psychiatry, Kolling Institute, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia.,Royal North Shore Hospital, NSW Health, Northern Sydney Local Health District, St Leonards, NSW Australia
| | - Phil Boyce
- Discipline of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, The University of Melbourne and Professorial Psychiatry Unit, Albert Road Clinic, Melbourne, VIC, Australia
| | - Darryl Bassett
- Discipline of Psychiatry, University of Western Australian Medical School, Perth, WA, Australia
| | - Roger Mulder
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Richard J Porter
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Bill Lyndon
- Discipline of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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11
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Benasi G, Fava GA, Guidi J. Prodromal Symptoms in Depression: A Systematic Review. PSYCHOTHERAPY AND PSYCHOSOMATICS 2022; 90:365-372. [PMID: 34350890 DOI: 10.1159/000517953] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 06/18/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Appraisal of prodromal symptoms of unipolar depression may complement the traditional cross-sectional approach and provide a longitudinal perspective, according to a staging model of the illness. OBJECTIVE To provide an updated systematic review of clinical studies concerned with prodromal symptoms of unipolar depression, according to PRISMA guidelines. METHODS Keyword searches were conducted in PubMed, Scopus, and Web of Science. Longitudinal studies on prodromal symptoms and signs in adult patients primarily diagnosed with unipolar depression were selected. Findings were examined separately according to study design (i.e., retrospective or prospective). RESULTS Twenty-five studies met the criteria for inclusion in this systematic review. Findings indicate that a distinct prodromal symptomatology - commonly characterized by anxiety, tension, irritability, and somatic complaints - exists before the onset of unipolar depression. The duration of the prodromal phase was highly variable across studies, ranging from less than a month to several years. Prodromal symptoms profile and duration were consistent within individuals across depressive episodes. There was a close relationship between prodromal and residual symptoms of the same depressive episode. CONCLUSIONS The present systematic review addresses an important, and yet relatively neglected, clinical issue that deserves further investigation and may be of immediate practical value. The findings provide challenging insights into the pathogenesis and course of unipolar depression, which may result in more timely and effective treatment of recurrences. The definition of a prodromal phase in depression would benefit from the joint use of symptom identification, biomarkers, and neuroimaging.
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Affiliation(s)
- Giada Benasi
- Department of Psychology "Renzo Canestrari," University of Bologna, Bologna, Italy
| | - Giovanni A Fava
- Department of Psychiatry, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Jenny Guidi
- Department of Psychology "Renzo Canestrari," University of Bologna, Bologna, Italy
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Gastaldon C, Laurenzi PF, Schoretsanitis G, Papola D, Cristea IA, Naudet F, Ostuzzi G, Barbui C. Esketamine for treatment-resistant depression in adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2022. [DOI: 10.1002/14651858.cd015071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Chiara Gastaldon
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry; University of Verona; Verona Italy
- Cochrane Global Mental Health; University of Verona; Verona Italy
| | | | - Georgios Schoretsanitis
- Department of Psychiatry; The Zucker Hillside Hospital; Northwell Health, Glen Oaks New York USA
- Department of Psychiatry; Zucker School of Medicine at Northwell/Hofstra; Hempstead New York USA
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry; University of Zurich; Zurich Switzerland
| | - Davide Papola
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry; University of Verona; Verona Italy
- Cochrane Global Mental Health; University of Verona; Verona Italy
| | - Ioana Alina Cristea
- Department of Brain and Behavioral Sciences; University of Pavia; Pavia Italy
| | - Florian Naudet
- University Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes); Rennes France
| | - Giovanni Ostuzzi
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry; University of Verona; Verona Italy
| | - Corrado Barbui
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry; University of Verona; Verona Italy
- Cochrane Global Mental Health; University of Verona; Verona Italy
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Clinical Utility of Semistructured Interview and Scales to Assess Withdrawal Syndromes With Dose Reduction or Discontinuation of Selective Serotonin Reuptake Inhibitors or Serotonin Norepinephrine Reuptake Inhibitors. J Clin Psychopharmacol 2022; 42:17-22. [PMID: 34928557 PMCID: PMC9907690 DOI: 10.1097/jcp.0000000000001491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Withdrawal syndromes can occur after dose reduction or discontinuation of selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). Few measurement instruments are available to assess them: Diagnostic Clinical Interview for Drug Withdrawal 1-New Symptoms of SSRI and SNRI (DID-W1) and Discontinuation Emergent Signs and Symptoms (DESS) checklist. We assessed their interrater reliability, verified the percent agreement between the two, and tested DESS sensitivity and specificity on the basis of the diagnoses formulated via the DID-W1. METHODS One-hundred thirty-four subjects who referred for withdrawal at 3 outpatient facilities were enrolled and assessed via the DESS and the DID-W1. Percent agreement and Cohen κ were calculated to measure DID-W1 and DESS interrater reliability, as well as the agreement between DID-W1 and DESS items. Sensitivity and specificity of DESS were derived from the identification of true-positive, false-negative, true-negative, and false-positive on the DID-W1. RESULTS Both tools showed excellent interrater reliability (DID-W1 Cohen κ = 0.958; DESS Cohen κ = 0.81-1). The degree of agreement between DID-W1 and DESS items was poor or fair (Cohen κ < 0.40) for some items and moderate (Cohen κ = 0.41-0.60) for others. Sensitivity and specificity of DESS were 0.937 (true-positive = 60, false-negative = 4) and 0.285 (true-negative = 20, false-positive = 50), respectively. CONCLUSIONS DID-W1 was a reliable method to identify and diagnose withdrawal syndromes. The DESS checklist showed to be a useful tool for detecting withdrawal SSRI/SNRI symptoms when the aim is to achieve high sensitivity to identify true positives.
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14
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Cosci F, Fava GA. When Anxiety and Depression Coexist: The Role of Differential Diagnosis Using Clinimetric Criteria. PSYCHOTHERAPY AND PSYCHOSOMATICS 2021; 90:308-317. [PMID: 34344013 DOI: 10.1159/000517518] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 05/31/2021] [Indexed: 11/19/2022]
Abstract
Depressive and anxiety disorders are frequently associated. Depression may be a complication of anxiety and anxiety can complicate depression. The nature of their relationship has been a source of controversy. Reviews generally base their conclusions on randomized controlled trials and meta-analyses that refer to the average patient and often clash with the variety of clinical presentations that may occur when anxiety and depression coexist. The aim of this review was to examine the literature according to profiling of subgroups of patients based on clinimetric criteria, in line with the recently developed concept of medicine-based evidence. We critically reviewed the literature pertaining to the specific presentations of anxiety and depression, outlining the advantages and disadvantages of each treatment approach. The following prototypic cases were presented: depression secondary to an active anxiety disorder, depression in patients with anxiety disorders under treatment, anxious depression, anxiety as a residual component of depression, and demoralization secondary to anxiety disorder. We argue that the selection of treatment when anxiety and depression coexist should take into account the modalities of presentation and be filtered by clinical judgment. Very different indications may ensue when the literature is examined according to this perspective.
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Affiliation(s)
- Fiammetta Cosci
- Department of Health Sciences, University of Florence, Florence, Italy.,Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands
| | - Giovanni A Fava
- Department of Psychiatry, University at Buffalo, State University of New York, New York, New York, USA
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15
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Marchant NL, Barnhofer T, Coueron R, Wirth M, Lutz A, Arenaza-Urquijo EM, Collette F, Poisnel G, Demnitz-King H, Schild AK, Coll-Padros N, Delphin-Combe F, Whitfield T, Schlosser M, Gonneaud J, Asselineau J, Walker Z, Krolak-Salmon P, Molinuevo JL, Frison E, Chételat G, Jessen F, Klimecki OM. Effects of a Mindfulness-Based Intervention versus Health Self-Management on Subclinical Anxiety in Older Adults with Subjective Cognitive Decline: The SCD-Well Randomized Superiority Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2021; 90:341-350. [PMID: 33873195 DOI: 10.1159/000515669] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/02/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Older adults experiencing subjective cognitive decline (SCD) have a heightened risk of developing dementia and frequently experience subclinical anxiety, which is itself associated with dementia risk. OBJECTIVE To understand whether subclinical anxiety symptoms in SCD can be reduced through behavioral interventions. METHODS SCD-Well is a randomized controlled trial designed to determine whether an 8-week mindfulness-based intervention (caring mindfulness-based approach for seniors; CMBAS) is superior to a structurally matched health self-management program (HSMP) in reducing subclinical anxiety. Participants were recruited from memory clinics at 4 European sites. The primary outcome was change in anxiety symptoms (trait subscale of the State-Trait Anxiety Inventory; trait-STAI) from pre- to postintervention. Secondary outcomes included a change in state anxiety and depression symptoms postintervention and 6 months postrandomization (follow-up). RESULTS One hundred forty-seven participants (mean [SD] age: 72.7 [6.9] years; 64.6% women; CMBAS, n = 73; HSMP, n = 74) were included in the intention-to-treat analysis. There was no difference in trait-STAI between groups postintervention (adjusted change difference: -1.25 points; 95% CI -4.76 to 2.25) or at follow-up (adjusted change difference: -0.43 points; 95% CI -2.92 to 2.07). Trait-STAI decreased postintervention in both groups (CMBAS: -3.43 points; 95% CI -5.27 to -1.59; HSMP: -2.29 points; 95% CI -4.14 to -0.44) and reductions were maintained at follow-up. No between-group differences were observed for change in state anxiety or depression symptoms. CONCLUSIONS A time-limited mindfulness intervention is not superior to health self-management in reducing subclinical anxiety symptoms in SCD. The sustained reduction observed across both groups suggests that subclinical anxiety symptoms in SCD are modifiable. ClinicalTrials.gov identifier: NCT03005652.
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Affiliation(s)
- Natalie L Marchant
- Division of Psychiatry, University College London, London, United Kingdom
| | - Thorsten Barnhofer
- Mood Disorders Centre, University of Exeter, Exeter, United Kingdom.,School of Psychology, University of Surrey, Guildford, United Kingdom
| | - Roxane Coueron
- EUCLID/F-CRIN Clinical Trials Platform, University of Bordeaux, Inserm, Bordeaux Population Health Center, Bordeaux, France.,CHU Bordeaux, Service d' Information Médicale, Bordeaux, France
| | - Miranka Wirth
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humbold-Universität zu Berlin and Berlin Institute of Health, NeuroCure Clinical Research Center, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Dresden, Germany
| | - Antoine Lutz
- Lyon Neuroscience Research Center Inserm U1028, CNRS UMR5292, Lyon 1 University, Lyon, France
| | - Eider M Arenaza-Urquijo
- Inserm, Inserm UMR-S U1237, Université de Caen-Normandie, GIP Cyceron, Caen, France.,Barcelonaβeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain.,Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBER FES), Madrid, Spain
| | - Fabienne Collette
- GIGA-CRC In Vivo Imaging, Université de Liège, National Fund for Scientific Research (F.R.S.-FNRS), Liège, Belgium
| | - Géraldine Poisnel
- Inserm, Inserm UMR-S U1237, Université de Caen-Normandie, GIP Cyceron, Caen, France
| | | | - Ann-Katrin Schild
- Department of Psychiatry, Medical Faculty, University of Cologne, Cologne, Germany
| | - Nina Coll-Padros
- Alzheimer's Disease and Other Cognitive Disorders Unit, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - Floriane Delphin-Combe
- Hospices Civils de Lyon, Institut du Vieillissement, CRC Vieillissement-Cerveau-Fragilité, Lyon, France
| | - Tim Whitfield
- Division of Psychiatry, University College London, London, United Kingdom
| | - Marco Schlosser
- Division of Psychiatry, University College London, London, United Kingdom
| | - Julie Gonneaud
- Inserm, Inserm UMR-S U1237, Université de Caen-Normandie, GIP Cyceron, Caen, France
| | - Julien Asselineau
- EUCLID/F-CRIN Clinical Trials Platform, University of Bordeaux, Inserm, Bordeaux Population Health Center, Bordeaux, France.,CHU Bordeaux, Service d' Information Médicale, Bordeaux, France
| | - Zuzana Walker
- Division of Psychiatry, University College London, London, United Kingdom.,Essex Partnership University NHS Foundation Trust, Essex, United Kingdom
| | - Pierre Krolak-Salmon
- Hospices Civils de Lyon, Institut du Vieillissement, CRC Vieillissement-Cerveau-Fragilité, Lyon, France
| | - José Luis Molinuevo
- Barcelonaβeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain.,Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBER FES), Madrid, Spain.,Alzheimer's Disease and Other Cognitive Disorders Unit, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - Eric Frison
- EUCLID/F-CRIN Clinical Trials Platform, University of Bordeaux, Inserm, Bordeaux Population Health Center, Bordeaux, France.,CHU Bordeaux, Service d' Information Médicale, Bordeaux, France
| | - Gael Chételat
- Inserm, Inserm UMR-S U1237, Université de Caen-Normandie, GIP Cyceron, Caen, France
| | - Frank Jessen
- Department of Psychiatry, Medical Faculty, University of Cologne, Cologne, Germany.,German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.,Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Olga M Klimecki
- Swiss Center for Affective Sciences, Department of Medicine and Department of Psychology, Department of Political Science and International Relations, University of Geneva, Geneva, Switzerland.,Clinical Psychology and Behavioral Neuroscience, Faculty of Psychology, Technische Universität Dresden, Dresden, Germany
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16
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Predictors of relapse following a stepwise psychopharmacotherapy regime in patients with depressive disorders. J Affect Disord 2021; 293:109-116. [PMID: 34175592 DOI: 10.1016/j.jad.2021.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 06/08/2021] [Accepted: 06/13/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Real world predictors of relapse following routine treatment for depression remain under-researched. We sought to investigate this in an outpatient clinical sample with depressive disorders receiving stepwise pharmacotherapy based on early clinical decision-making, applying a naturalistic 24-month prospective design. METHODS Patients were recruited at a University hospital in South Korea from March 2012 to April 2017. After 3-week antidepressant monotherapy (N = 1262), next treatment steps (1, 2, 3, and 4 or over) with alternative strategies (switching, augmentation, combination, and mixtures of these approaches) were administered based on measurements and patient preference at 3-week points in the acute treatment phase (3, 6, 9, and 12 weeks) (N = 1246). For those who responded [Hamilton Depression Rating Scale (HAMD) score of≤14] (N = 937), relapse (HAMD>14) was identified every 3 months from 6 to 24 months (N = 816). Predictors of relapse were evaluated using multi-variate Cox proportional hazards models. RESULTS Four independent relapse predictors were identified: higher number of previous depressive episodes, higher anxiety at baseline, higher number of treatment steps, and poor medication adherence. In particular, treatment Step 4 was significantly associated with relapse compared to treatment Step 1, 2, and 3 after adjustment for relevant covariates. LIMITATION Withdrawal syndromes after discontinuing psychotropic drugs, known to confound the determination of relapse, were not evaluated. The study was conducted at a single site, which maximised consistency but may limit generalizability. CONCLUSIONS Predictors of relapse reported from more restricted trial or cohort samples were replicated in this long-term naturalistic prospective design.
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17
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Framer A. What I have learnt from helping thousands of people taper off antidepressants and other psychotropic medications. Ther Adv Psychopharmacol 2021; 11:2045125321991274. [PMID: 33796265 PMCID: PMC7970174 DOI: 10.1177/2045125321991274] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 01/08/2021] [Indexed: 12/22/2022] Open
Abstract
Although psychiatric drug withdrawal syndromes have been recognized since the 1950s - recent studies confirm antidepressant withdrawal syndrome incidence upwards of 40% - medical information about how to safely go off the drugs has been lacking. To fill this gap, over the last 25 years, patients have developed a robust Internet-based subculture of peer support for tapering off psychiatric drugs and recovering from withdrawal syndrome. This account from the founder of such an online community covers lessons learned from thousands of patients regarding common experiences with medical providers, identification of adverse drug reactions, risk factors for withdrawal, tapering techniques, withdrawal symptoms, protracted withdrawal syndrome, and strategies to cope with symptoms, in the context of the existing scientific literature.
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Affiliation(s)
- Adele Framer
- SurvivingAntidepressants.org, San Francisco,
California, USA
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18
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Ralovska S, Koychev I, De Crescenzo F, Marinov P, Cipriani A. Brexpiprazole versus placebo or other antidepressive agents for treating depression. Hippokratia 2021. [DOI: 10.1002/14651858.cd013866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Silviya Ralovska
- Department of Neurology, Psychiatry, Physiotherapy and Rehabilitation, Preventive Medicine, and Public Health; Sofia University “St. Kliment Ohridski”; Sofia Bulgaria
| | - Ivan Koychev
- Department of Psychiatry; University of Oxford; Oxford UK
| | | | - Petar Marinov
- Department of Neurology, Psychiatry, Physiotherapy and Rehabilitation, Preventive Medicine, and Public Health; Sofia University “St. Kliment Ohridski”; Sofia Bulgaria
| | - Andrea Cipriani
- Department of Psychiatry; University of Oxford; Oxford UK
- Oxford Health NHS Foundation Trust; Warneford Hospital; Oxford UK
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19
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20
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Cosci F, Guidi J. The Role of Illness Behavior in the COVID-19 Pandemic. PSYCHOTHERAPY AND PSYCHOSOMATICS 2021; 90:156-159. [PMID: 33517335 PMCID: PMC7900455 DOI: 10.1159/000513968] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 12/20/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Fiammetta Cosci
- Department of Health Sciences, University of Florence, Florence, Italy, .,Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands,
| | - Jenny Guidi
- Department of Psychology “Renzo Canestrari,” Alma Mater Studiorum University of Bologna, Bologna, Italy
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21
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Guidi J, Fava GA. The emerging role of euthymia in psychotherapy research and practice. Clin Psychol Rev 2020; 82:101941. [DOI: 10.1016/j.cpr.2020.101941] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/26/2020] [Accepted: 10/20/2020] [Indexed: 12/13/2022]
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22
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Fava GA. May antidepressant drugs worsen the conditions they are supposed to treat? The clinical foundations of the oppositional model of tolerance. Ther Adv Psychopharmacol 2020; 10:2045125320970325. [PMID: 33224471 PMCID: PMC7649913 DOI: 10.1177/2045125320970325] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 10/02/2020] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Giovanni A Fava
- Department of Psychiatry, University at Buffalo, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA
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23
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Hengartner MP, Schulthess L, Sorensen A, Framer A. Protracted withdrawal syndrome after stopping antidepressants: a descriptive quantitative analysis of consumer narratives from a large internet forum. Ther Adv Psychopharmacol 2020; 10:2045125320980573. [PMID: 33489088 PMCID: PMC7768871 DOI: 10.1177/2045125320980573] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/23/2020] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Michael P Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences (ZHAW), PO Box 707, Zurich, 8037, Switzerland
| | - Lukas Schulthess
- Department of Applied Psychology, Zurich University of Applied Sciences, Switzerland
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