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Hu Y, Xue H, Ni X, Guo Z, Fan L, Du W. Association between duration of antidepressant treatment for major depressive disorder and relapse rate after discontinuation: A meta-analysis. Psychiatry Res 2024; 337:115926. [PMID: 38733930 DOI: 10.1016/j.psychres.2024.115926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024]
Abstract
The optimal duration of antidepressant treatment for patients with major depressive disorder to reduce the risk of relapse after discontinuation remains uncertain. Medline, Cochrane Central Register of Controlled Trials, and Embase were systematically searched for randomized controlled trials (RCTs) with a discontinuation design. A single-group summary meta-analysis was performed to calculate 6-month relapse rates after discontinuation. Meta-regression with restricted cubic splines was performed to model the non-linear relationship between treatment duration and relapse rate after discontinuation. Thirty-five RCTs were included. The relapse rate after discontinuation was approximately 34.81 % at 6 months and 45.12 % at 12 months. After controlling for covariates, the meta-analysis shows that the duration of treatment is associated with the risk of relapse after discontinuation in a non-linear curve, with a relatively higher risk of relapse observed for a duration of less than three months. There appears to be no further reduction in the risk of relapse when treatment is continued for over six months. Our results indicate the importance of at least three months of treatment to avoid the relatively high risk of relapse after discontinuation. The additional benefit of longer treatment remains to be proven.
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Affiliation(s)
- Yuhua Hu
- School of Public Health, Southeast University, 87 Ding Jiaqiao Rd., Nanjing, Jiangsu 210009, China
| | - Hui Xue
- School of Public Health, Southeast University, 87 Ding Jiaqiao Rd., Nanjing, Jiangsu 210009, China
| | - Xiaoyan Ni
- School of Public Health, Southeast University, 87 Ding Jiaqiao Rd., Nanjing, Jiangsu 210009, China
| | - Zhen Guo
- School of Public Health, Southeast University, 87 Ding Jiaqiao Rd., Nanjing, Jiangsu 210009, China
| | - Lijun Fan
- School of Public Health, Southeast University, 87 Ding Jiaqiao Rd., Nanjing, Jiangsu 210009, China
| | - Wei Du
- School of Public Health, Southeast University, 87 Ding Jiaqiao Rd., Nanjing, Jiangsu 210009, China.
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Zhou D, Lv Z, Shi L, Zhou X, Lin Q, Chen X, Wan L, Li Y, Ran L, Huang Y, Wang G, Li D, Wang W, Liu C, Kuang L. Effects of antidepressant medicines on preventing relapse of unipolar depression: a pooled analysis of parametric survival curves. Psychol Med 2022; 52:48-56. [PMID: 32501194 DOI: 10.1017/s0033291720001610] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Major depressive disorder is characterized by a high risk of relapse. We aimed to compare the prophylactic effects of different antidepressant medicines (ADMs). METHODS PubMed, Cochrane Central Register of Controlled Trials, Embase and the Web of Science were searched on 4 July 2019. A pooled analysis of parametric survival curves was performed using a Bayesian framework. The main outcomes were hazard ratios (HRs), relapse-free survival and mean relapse-free months. RESULTS Forty randomized controlled trials were included. The 1-year relapse-free survival for ADM (76%) was significantly better than that for placebo (56%). Most of the relapse difference (86.5%) occurred in the first 6 months. Most HRs were not constant over time. Proof of benefit after 6 months of follow-up was not established partially because of small differences between the drug and placebo after 6 months. Almost all studies used an 'enriched' randomized discontinuation design, which may explain the high relapse rates in the first 6 months after randomization. CONCLUSIONS The superiority of ADM v. placebo was mainly attributed to the difference in relapse rates that occurred in the first 6 months. Our analysis provided evidence that the prophylactic efficacy was not constant over time. A beneficial effect was observed, but the prevention of new episodes after 6 months was questionable. These findings may have implications for clinical practice.
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Affiliation(s)
- Dongdong Zhou
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Zhen Lv
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Lei Shi
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoxin Zhou
- Medical Department, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Qingxia Lin
- Department of Psychiatry, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang Province, China
| | - Xiaorong Chen
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Liyang Wan
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Yao Li
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Liuyi Ran
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Yan Huang
- GCP Office, Chongqing Traditional Chinese Medicine Hospital, Chongqing, China
| | - Gaomao Wang
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Daqi Li
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Wo Wang
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Chuan Liu
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Li Kuang
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
- Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Van Leeuwen E, van Driel ML, Horowitz MA, Kendrick T, Donald M, De Sutter AI, Robertson L, Christiaens T. Approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults. Cochrane Database Syst Rev 2021; 4:CD013495. [PMID: 33886130 PMCID: PMC8092632 DOI: 10.1002/14651858.cd013495.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Depression and anxiety are the most frequent indication for which antidepressants are prescribed. Long-term antidepressant use is driving much of the internationally observed rise in antidepressant consumption. Surveys of antidepressant users suggest that 30% to 50% of long-term antidepressant prescriptions had no evidence-based indication. Unnecessary use of antidepressants puts people at risk of adverse events. However, high-certainty evidence is lacking regarding the effectiveness and safety of approaches to discontinuing long-term antidepressants. OBJECTIVES To assess the effectiveness and safety of approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults. SEARCH METHODS We searched all databases for randomised controlled trials (RCTs) until January 2020. SELECTION CRITERIA We included RCTs comparing approaches to discontinuation with continuation of antidepressants (or usual care) for people with depression or anxiety who are prescribed antidepressants for at least six months. Interventions included discontinuation alone (abrupt or taper), discontinuation with psychological therapy support, and discontinuation with minimal intervention. Primary outcomes were successful discontinuation rate, relapse (as defined by authors of the original study), withdrawal symptoms, and adverse events. Secondary outcomes were depressive symptoms, anxiety symptoms, quality of life, social and occupational functioning, and severity of illness. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. MAIN RESULTS We included 33 studies involving 4995 participants. Nearly all studies were conducted in a specialist mental healthcare service and included participants with recurrent depression (i.e. two or more episodes of depression prior to discontinuation). All included trials were at high risk of bias. The main limitation of the review is bias due to confounding withdrawal symptoms with symptoms of relapse of depression. Withdrawal symptoms (such as low mood, dizziness) may have an effect on almost every outcome including adverse events, quality of life, social functioning, and severity of illness. Abrupt discontinuation Thirteen studies reported abrupt discontinuation of antidepressant. Very low-certainty evidence suggests that abrupt discontinuation without psychological support may increase risk of relapse (hazard ratio (HR) 2.09, 95% confidence interval (CI) 1.59 to 2.74; 1373 participants, 10 studies) and there is insufficient evidence of its effect on adverse events (odds ratio (OR) 1.11, 95% CI 0.62 to 1.99; 1012 participants, 7 studies; I² = 37%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of abrupt discontinuation on withdrawal symptoms (1 study) is very uncertain. None of these studies included successful discontinuation rate as a primary endpoint. Discontinuation by "taper" Eighteen studies examined discontinuation by "tapering" (one week or longer). Most tapering regimens lasted four weeks or less. Very low-certainty evidence suggests that "tapered" discontinuation may lead to higher risk of relapse (HR 2.97, 95% CI 2.24 to 3.93; 1546 participants, 13 studies) with no or little difference in adverse events (OR 1.06, 95% CI 0.82 to 1.38; 1479 participants, 7 studies; I² = 0%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of discontinuation on withdrawal symptoms (1 study) is very uncertain. Discontinuation with psychological support Four studies reported discontinuation with psychological support. Very low-certainty evidence suggests that initiation of preventive cognitive therapy (PCT), or MBCT, combined with "tapering" may result in successful discontinuation rates of 40% to 75% in the discontinuation group (690 participants, 3 studies). Data from control groups in these studies were requested but are not yet available. Low-certainty evidence suggests that discontinuation combined with psychological intervention may result in no or little effect on relapse (HR 0.89, 95% CI 0.66 to 1.19; 690 participants, 3 studies) compared to continuation of antidepressants. Withdrawal symptoms were not measured. Pooling data on adverse events was not possible due to insufficient information (3 studies). Discontinuation with minimal intervention Low-certainty evidence from one study suggests that a letter to the general practitioner (GP) to review antidepressant treatment may result in no or little effect on successful discontinuation rate compared to usual care (6% versus 8%; 146 participants, 1 study) or on relapse (relapse rate 26% vs 13%; 146 participants, 1 study). No data on withdrawal symptoms nor adverse events were provided. None of the studies used low-intensity psychological interventions such as online support or a changed pharmaceutical formulation that allows tapering with low doses over several months. Insufficient data were available for the majority of people taking antidepressants in the community (i.e. those with only one or no prior episode of depression), for people aged 65 years and older, and for people taking antidepressants for anxiety. AUTHORS' CONCLUSIONS Currently, relatively few studies have focused on approaches to discontinuation of long-term antidepressants. We cannot make any firm conclusions about effects and safety of the approaches studied to date. The true effect and safety are likely to be substantially different from the data presented due to assessment of relapse of depression that is confounded by withdrawal symptoms. All other outcomes are confounded with withdrawal symptoms. Most tapering regimens were limited to four weeks or less. In the studies with rapid tapering schemes the risk of withdrawal symptoms may be similar to studies using abrupt discontinuation which may influence the effectiveness of the interventions. Nearly all data come from people with recurrent depression. There is an urgent need for trials that adequately address withdrawal confounding bias, and carefully distinguish relapse from withdrawal symptoms. Future studies should report key outcomes such as successful discontinuation rate and should include populations with one or no prior depression episodes in primary care, older people, and people taking antidepressants for anxiety and use tapering schemes longer than 4 weeks.
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Affiliation(s)
- Ellen Van Leeuwen
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Mieke L van Driel
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Mark A Horowitz
- Division of Psychiatry, University College London, London, UK
| | - Tony Kendrick
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - Maria Donald
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - An Im De Sutter
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Lindsay Robertson
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Thierry Christiaens
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
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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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Zhou D, Zhou X, Lin Q, Wang W, Lv Z, Chen X, Nie G, Kuang L. Nonpharmacological interventions for relapse prevention in unipolar depression: A network meta-analysis. J Affect Disord 2021; 282:1255-1262. [PMID: 33601704 DOI: 10.1016/j.jad.2021.01.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The development of prophylactic interventions for major depressive disorder (MDD) is an important issue in clinical practice. We aimed to compare the relative efficacy of nonpharmacological interventions for relapse prevention in adult patients with MDD. METHODS Randomized controlled trials investigating nonpharmachological interventions for relapse prevention were included. A Bayesian network meta-analysis was performed. Hazard ratios are reported as effect sizes with 95% credible intervals. Global inconsistency, local inconsistency, heterogeneity, and transitivity were evaluated. Confidence for the results comparing the active treatment with control conditions or antidepressant medicine (ADM) was assessed. RESULTS Thirty-six trials were included. Most nonpharmacological interventions were various forms of psychotherapy; others were noninvasive neurostimulation techniques (3 studies with electroconvulsive therapy and 1 study with transcranial magnetic stimulation). Psychotherapy as a monotherapy following ADM or psychotherapy produced significantly better outcomes than control conditions, and there was no significant difference between psychotherapy and ADM. The combination of psychotherapy and ADM was superior to either treatment alone. The results were similar for patients with at least 3 previous episodes. Neurostimulation techniques were also superior to controls, either as a monotherapy or combined with ADM. CONCLUSIONS Our study provided evidence that psychotherapy as a monotherapy following ADM or psychotherapy was effective and performed as well as ADM for relapse prevention. Neurostimulation techniques also showed promising results but more studies are needed to confirm their efficacy. These findings may be informative for clinical practice and inspire future research.
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Affiliation(s)
- Dongdong Zhou
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoxin Zhou
- Medical Department, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Qingxia Lin
- Department of Psychiatry, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang Province, China
| | - Wo Wang
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Zhen Lv
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaorong Chen
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Gang Nie
- Department of Gastroenterology, University-Town Hospital of Chongqing Medical University, Shapingba District, Chongqing, 401331, China.
| | - Li Kuang
- Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China; Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, 400016, China.
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Hengartner MP, Plöderl M. Prophylactic effects or withdrawal reactions? An analysis of time-to-event data from antidepressant relapse prevention trials submitted to the FDA. Ther Adv Psychopharmacol 2021; 11:20451253211032051. [PMID: 34394912 PMCID: PMC8361519 DOI: 10.1177/20451253211032051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/23/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Relapse prevention trials build the scientific foundation for recommendation of antidepressant continuation and maintenance therapy. However, the validity of the evidence is disputed and may be biased due to withdrawal confounding. METHODS We analysed survival curves from all antidepressant relapse prevention trials submitted to the United States (US) Food and Drug Administration (FDA) between 1987 and 2012 for 13 approved drugs. The main outcome was the percent of the drug effect (placebo-antidepressant difference in relapse events) at any week of the maintenance phase in relation to the total drug effect at the endpoint of the randomised maintenance phase. RESULTS Altogether, 14 studies with a mean observation period of 38.9 weeks (Kaplan-Meier estimators) were analysed. At week 3, a mean of 20.6% [95% confidence interval (CI) = 10.9-30.3%] of the total drug effect was achieved. At weeks 6 and 12, the corresponding figures were 50.3% (37.3-63.3%) and 69.0% (55.1-82.8%). No further antidepressant-placebo separation was observed as of week 24 [101.0% of total drug effect (94.6-107.3%)]. This means that censoring relapse events that occurred in the first 3, 6, 12 and 24 weeks would reduce the total drug effect at study endpoint by 20.6%, 50.3%, 69.0% and 101.0%, respectively. Assuming antidepressants had a constant prophylactic effect over 38.9 weeks, we further showed that, around week 6, the antidepressant-placebo separation was about three times larger than expected. CONCLUSION The placebo-antidepressant separation was disproportionally large between weeks 3 and 6 of the randomised maintenance phase. The benefits of continuing antidepressants relative to abrupt/rapid discontinuation declined sharply after week 6. This indicates an excess of relapse events in the placebo arms during the early maintenance phase that may be due to withdrawal reactions caused by abrupt/rapid discontinuation of active treatment. If these early relapse events are due to a direct pharmacological effect, then antidepressants' true prophylactic long-term effects are substantially overestimated.
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Affiliation(s)
- Michael P Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences (ZHAW), PO Box 707, Zurich, CH-8037, Switzerland
| | - Martin Plöderl
- Department of Crisis Intervention and Suicide Prevention, University Clinic for Psychiatry, Psychotherapy, and Psychosomatics, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Austria
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Henssler J, Heinz A, Brandt L, Bschor T. Antidepressant Withdrawal and Rebound Phenomena. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:355-361. [PMID: 31288917 DOI: 10.3238/arztebl.2019.0355] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 10/31/2018] [Accepted: 03/14/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Antidepressants are among the most commonly prescribed drugs worldwide. They are often discontinued, frequently without the knowledge of the prescribing physician. It is, therefore, important for physicians to be aware of the withdrawal and rebound phenomena that may arise, in order to prevent these phenomena, treat them when necessary, and counsel patients appropriately. METHODS This review is based on a comprehensive, structured literature search on antidepressant withdrawal phenomena that we carried out in the CENTRAL, PubMed (Medline), and Embase databases. We classified the relevant publications and reports by their methodological quality. RESULTS Out of a total of 2287 hits, there were 40 controlled trials, 38 cohort studies and retrospective analyses, and 271 case reports that met the inclusion criteria. Withdrawal manifestations are usually mild and self-limiting; common ones include dizziness, headache, sleep disturbances, and mood swings. More serious or pro- longed manifestations rarely arise. There is an increased risk with MAO inhibitors, tricyclic antidepressants, venlafaxine, and paroxetine; on the other hand, for agome- latine and fluoxetine, abrupt discontinuation seems to be unproblematic. There is also some evidence of rebound phenomena, i.e., of higher relapse rates or especially severe relapses of depression after the discontinuation of an anti- depressant. CONCLUSION A robust evidence base now indicates that there can be acute with- drawal phenomena when antidepressants are discontinued. Putative rebound phenomena have not been adequately studied to date. It is recommended that antidepressants should be tapered off over a period of more than four weeks.
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Affiliation(s)
- Jonathan Henssler
- Psychiatric University Hospital Charité at St. Hedwig Hospital, Campus Charité Mitte, Charité-Universitätsmedizin Berlin; Department of Psychiatry, Schlosspark-Klinik, Berlin; University Hospital Carl Gustav Carus Department of Psychiatry and Psychotherapy, Technische Universität Dresden; Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité-Universitätsmedizin Berlin
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Hengartner MP. How effective are antidepressants for depression over the long term? A critical review of relapse prevention trials and the issue of withdrawal confounding. Ther Adv Psychopharmacol 2020; 10:2045125320921694. [PMID: 32435449 PMCID: PMC7225779 DOI: 10.1177/2045125320921694] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/27/2020] [Indexed: 12/20/2022] Open
Abstract
The aim of this article is to discuss the validity of relapse prevention trials and the issue of withdrawal confounding in these trials. Recommendations for long-term antidepressant treatment are based almost exclusively on discontinuation trials. In these relapse prevention trials, participants with remitted depression are randomised either to have the antidepressant abruptly discontinued and replaced by inert placebo or to continue active treatment. The drug-placebo difference in relapse rates at the end of the maintenance phase is then interpreted as a prophylactic drug effect. These trials consistently produce remarkable benefits for maintenance treatment. However, the internal validity of this trial protocol is compromised, as research has shown that abruptly stopping antidepressants can cause severe withdrawal reactions that lead to (or manifest as) depression relapses. That is, there is substantial withdrawal confounding in discontinuation trials, which renders their findings uninterpretable. It is not clear to what degree the drug-placebo separation in relapse prevention (discontinuation) trials is due to withdrawal reactions, but various estimations suggest that it is presumably the majority. A review of findings based on other methodologies, including real-world long-term effectiveness trials like STAR*D and various naturalistic cohort studies, do not indicate that antidepressants have considerable prophylactic effects. As absence of evidence does not imply evidence of absence, no definitive conclusions can be drawn from the literature. To enable a thorough risk-benefit evaluation, real-world effectiveness trials should not only focus on relapse prevention, but also assess antidepressants' long-term effects on social functioning and quality of life. Thus far, reliable long-term data on these outcome domains are lacking.
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Affiliation(s)
- Michael P. Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences (ZHAW), PO Box 707, Zurich, CH-8037, Switzerland
- Medical Faculty, University of Zurich, Zurich, Switzerland
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McPherson S, Hengartner MP. Long-term outcomes of trials in the National Institute for Health and Care Excellence depression guideline. BJPsych Open 2019; 5:e81. [PMID: 31685073 PMCID: PMC6737515 DOI: 10.1192/bjo.2019.65] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
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.
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Affiliation(s)
- Susan McPherson
- Researcher, School of Health and Social Care, University of Essex, UK
| | - Michael P Hengartner
- Senior Lecturer and Researcher, School of Applied Psychology, Zurich University of Applied Sciences, Switzerland
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10
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Hengartner MP, Passalacqua S, Andreae A, Heinsius T, Hepp U, Rössler W, von Wyl A. Antidepressant Use During Acute Inpatient Care Is Associated With an Increased Risk of Psychiatric Rehospitalisation Over a 12-Month Follow-Up After Discharge. Front Psychiatry 2019; 10:79. [PMID: 30853919 PMCID: PMC6396716 DOI: 10.3389/fpsyt.2019.00079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 02/05/2019] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Michael P Hengartner
- Department of Applied Psychology, Zurich University of Applied Sciences, Zurich, Switzerland
| | - Silvia Passalacqua
- Department of Applied Psychology, Zurich University of Applied Sciences, Zurich, Switzerland
| | - Andreas Andreae
- Integrated Psychiatric Clinic of Winterthur and Zurich Unterland (ipw), Winterthur, Switzerland
| | - Thomas Heinsius
- Integrated Psychiatric Clinic of Winterthur and Zurich Unterland (ipw), Winterthur, Switzerland
| | - Urs Hepp
- Integrated Psychiatric Clinic of Winterthur and Zurich Unterland (ipw), Winterthur, Switzerland
| | - Wulf Rössler
- Department of Psychiatry, Psychotherapy and Psychosomatics, University of Zurich, Zurich, Switzerland.,Laboratory of Neuroscience (LIM 27), Institute of Psychiatry, University of São Paulo, São Paulo, Brazil.,Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Agnes von Wyl
- Department of Applied Psychology, Zurich University of Applied Sciences, Zurich, Switzerland
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Differing antidepressant maintenance methodologies. Contemp Clin Trials 2017; 61:87-95. [DOI: 10.1016/j.cct.2017.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 07/17/2017] [Accepted: 07/20/2017] [Indexed: 12/28/2022]
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Braun C, Bschor T, Franklin J, Baethge C. Suicides and Suicide Attempts during Long-Term Treatment with Antidepressants: A Meta-Analysis of 29 Placebo-Controlled Studies Including 6,934 Patients with Major Depressive Disorder. PSYCHOTHERAPY AND PSYCHOSOMATICS 2017; 85:171-9. [PMID: 27043848 DOI: 10.1159/000442293] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 11/06/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is unclear whether antidepressants can prevent suicides or suicide attempts, particularly during long-term use. METHODS We carried out a comprehensive review of long-term studies of antidepressants (relapse prevention). Sources were obtained from 5 review articles and by searches of MEDLINE, PubMed Central and a hand search of bibliographies. We meta-analyzed placebo-controlled antidepressant RCTs of at least 3 months' duration and calculated suicide and suicide attempt incidence rates, incidence rate ratios and Peto odds ratios (ORs). RESULTS Out of 807 studies screened 29 were included, covering 6,934 patients (5,529 patient-years). In total, 1.45 suicides and 2.76 suicide attempts per 1,000 patient-years were reported. Seven out of 8 suicides and 13 out of 14 suicide attempts occurred in antidepressant arms, resulting in incidence rate ratios of 5.03 (0.78-114.1; p = 0.102) for suicides and of 9.02 (1.58-193.6; p = 0.007) for suicide attempts. Peto ORs were 2.6 (0.6-11.2; nonsignificant) and 3.4 (1.1-11.0; p = 0.04), respectively. Dropouts due to unknown reasons were similar in the antidepressant and placebo arms (9.6 vs. 9.9%). The majority of suicides and suicide attempts originated from 1 study, accounting for a fifth of all patient-years in this meta-analysis. Leaving out this study resulted in a nonsignificant incidence rate ratio for suicide attempts of 3.83 (0.53-91.01). CONCLUSIONS Therapists should be aware of the lack of proof from RCTs that antidepressants prevent suicides and suicide attempts. We cannot conclude with certainty whether antidepressants increase the risk for suicide or suicide attempts. Researchers must report all suicides and suicide attempts in RCTs.
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Affiliation(s)
- Cora Braun
- Department of Psychiatry and Psychotherapy, University of Cologne Medical School, Cologne, Germany
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Berwian IM, Walter H, Seifritz E, Huys QJM. Predicting relapse after antidepressant withdrawal - a systematic review. Psychol Med 2017; 47:426-437. [PMID: 27786144 PMCID: PMC5244448 DOI: 10.1017/s0033291716002580] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 09/07/2016] [Accepted: 09/08/2016] [Indexed: 12/28/2022]
Abstract
A substantial proportion of the burden of depression arises from its recurrent nature. The risk of relapse after antidepressant medication (ADM) discontinuation is high but not uniform. Predictors of individual relapse risk after antidepressant discontinuation could help to guide treatment and mitigate the long-term course of depression. We conducted a systematic literature search in PubMed to identify relapse predictors using the search terms '(depress* OR MDD*) AND (relapse* OR recurren*) AND (predict* OR risk) AND (discontinu* OR withdraw* OR maintenance OR maintain or continu*) AND (antidepress* OR medication OR drug)' for published studies until November 2014. Studies investigating predictors of relapse in patients aged between 18 and 65 years with a main diagnosis of major depressive disorder (MDD), who remitted from a depressive episode while treated with ADM and were followed up for at least 6 months to assess relapse after part of the sample discontinued their ADM, were included in the review. Although relevant information is present in many studies, only 13 studies based on nine separate samples investigated predictors for relapse after ADM discontinuation. There are multiple promising predictors, including markers of true treatment response and the number of prior episodes. However, the existing evidence is weak and there are no established, validated markers of individual relapse risk after antidepressant cessation. There is little evidence to guide discontinuation decisions in an individualized manner beyond overall recurrence risk. Thus, there is a pressing need to investigate neurobiological markers of individual relapse risk, focusing on treatment discontinuation.
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Affiliation(s)
- I. M. Berwian
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Lenggstrasse 31, 8032 Zürich, Switzerland
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Wilfriedstrasse 6, 8032 Zürich, Switzerland
| | - H. Walter
- Mind and Brain, Campus Charité Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - E. Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Lenggstrasse 31, 8032 Zürich, Switzerland
| | - Q. J. M. Huys
- Department of Psychiatry, Psychotherapy and Psychosomatics, Hospital of Psychiatry, University of Zurich, Lenggstrasse 31, 8032 Zürich, Switzerland
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Wilfriedstrasse 6, 8032 Zürich, Switzerland
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14
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Singh R, Liles MA, Montagne M. Identifying and describing patient perspectives on long-term antidepressant use. COGENT PSYCHOLOGY 2016. [DOI: 10.1080/23311908.2016.1223902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Reshmi Singh
- Department of Pharmacy, University of Wyoming College of Health Sciences, 1000 E. University Ave., Dept. 3375, Laramie, WY 82071, USA
| | - Marie A. Liles
- Department of Global Patient Safety, Eli Lilly and Company, Indianapolis, IN, USA
| | - Michael Montagne
- Department of Pharmacy, Massachusetts College of Pharmacy and Health Sciences, 179 Longwood Ave., Boston, MA 02115, USA
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Kjosavik SR, Gillam MH, Roughead EE. Average duration of treatment with antidepressants among concession card holders in Australia. Aust N Z J Psychiatry 2016; 50:1180-1185. [PMID: 26671459 DOI: 10.1177/0004867415621392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To analyse the average treatment duration with antidepressants that are reimbursed for concession card holders under the Pharmaceutical Benefits Scheme in Australia. METHOD This pharmacoepidemiological study was based on a representative 10% sample of patients receiving Pharmaceutical Benefits Scheme prescriptions. Antidepressants redeemed by concession card holders in the period from 2010 to 2013 were analysed. A 5-year baseline period was used to exclude prevalent users from incident users. Estimation of treatment duration was based on the epidemiological equation: prevalence/incidence = average duration. The mean value for prevalence and incidence over the studied period was used in the equation. RESULTS The number of prevalent and incident users increased from 90,475 to 103,305 and from 25,006 to 26,289, respectively. The epidemiological average treatment duration in the period was about 4 years. When considered by age-bands, average treatment duration was 2 years in patients under 24 years, 3 years in patients 35 to 44 years and up to 5 years in the 55 to 64 year age group. Of new users of antidepressants reimbursed under the Pharmaceutical Benefits Scheme, 86% received their first prescription from general practitioners, 4.3% from psychiatrists and 9.7% from other physicians. CONCLUSION While recommendations have underlined the importance of giving antidepressants for a sufficient period of time, the results from this study show that it is as important to remind general practitioners to review patients on antidepressant treatment regularly, and try to cease drug treatment when timely.
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Affiliation(s)
- Svein Reidar Kjosavik
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute, University of South Australia, Adelaide, SA, Australia
- Centre for Age-Related Diseases, Stavanger University Hospital, Stavanger, Norway
- Research Unit for General Practice in Bergen, Uni Research Health, Bergen, Norway
| | - Marianne Hansen Gillam
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute, University of South Australia, Adelaide, SA, Australia
| | - Elisabeth E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Sansom Institute, University of South Australia, Adelaide, SA, Australia
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Ambresin G, Palmer V, Densley K, Dowrick C, Gilchrist G, Gunn JM. What factors influence long-term antidepressant use in primary care? Findings from the Australian diamond cohort study. J Affect Disord 2015; 176:125-32. [PMID: 25704565 DOI: 10.1016/j.jad.2015.01.055] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 12/11/2014] [Accepted: 01/25/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND Antidepressants are one of the most commonly prescribed drugs in primary care. The rise in use is mostly due to an increasing number of long-term users of antidepressants (LTU AD). Little is known about the factors driving increased long-term use. We examined the socio-demographic, clinical factors and health service use characteristics associated with LTU AD to extend our understanding of the factors that may be driving the increase in antidepressant use. METHODS Cross-sectional analysis of 789 participants with probable depression (CES-D≥16) recruited from 30 randomly selected Australian general practices to take part in a ten-year cohort study about depression were surveyed about their antidepressant use. RESULTS 165 (21.0%) participants reported <2 years of antidepressant use and 145 (18.4%) reported ≥2 years of antidepressant use. After adjusting for depression severity, LTU AD was associated with: single (OR 1.56, 95%CI 1.05-2.32) or recurrent episode of depression (3.44, 2.06-5.74); using SSRIs (3.85, 2.03-7.33), sedatives (2.04, 1.29-3.22), or antipsychotics (4.51, 1.67-12.17); functional limitations due to long-term illness (2.81, 1.55-5.08), poor/fair self-rated health (1.57, 1.14-2.15), inability to work (2.49, 1.37-4.53), benefits as main source of income (2.15, 1.33-3.49), GP visits longer than 20min (1.79, 1.17-2.73); rating GP visits as moderately to extremely helpful (2.71, 1.79-4.11), and more self-help practices (1.16, 1.09-1.23). LIMITATIONS All measures were self-report. Sample may not be representative of culturally different or adolescent populations. Cross-sectional design raises possibility of "confounding by indication". CONCLUSIONS Long-term antidepressant use is relatively common in primary care. It occurs within the context of complex mental, physical and social morbidities. Whilst most long-term use is associated with a history of recurrent depression there remains a significant opportunity for treatment re-evaluation and timely discontinuation.
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Affiliation(s)
- Gilles Ambresin
- General Practice and Primary Health Care Academic Centre, University of Melbourne, Carlton, Victoria, Australia; University Institute of Psychotherapy, Department of Psychiatry-CHUV, University of Lausanne, Switzerland.
| | - Victoria Palmer
- General Practice and Primary Health Care Academic Centre, University of Melbourne, Carlton, Victoria, Australia
| | - Konstancja Densley
- General Practice and Primary Health Care Academic Centre, University of Melbourne, Carlton, Victoria, Australia
| | | | - Gail Gilchrist
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, United Kingdom
| | - Jane M Gunn
- General Practice and Primary Health Care Academic Centre, University of Melbourne, Carlton, Victoria, Australia
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Coventry PA, Hudson JL, Kontopantelis E, Archer J, Richards DA, Gilbody S, Lovell K, Dickens C, Gask L, Waheed W, Bower P. Characteristics of effective collaborative care for treatment of depression: a systematic review and meta-regression of 74 randomised controlled trials. PLoS One 2014; 9:e108114. [PMID: 25264616 PMCID: PMC4180075 DOI: 10.1371/journal.pone.0108114] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 08/14/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Collaborative care is a complex intervention based on chronic disease management models and is effective in the management of depression. However, there is still uncertainty about which components of collaborative care are effective. We used meta-regression to identify factors in collaborative care associated with improvement in patient outcomes (depressive symptoms) and the process of care (use of anti-depressant medication). METHODS AND FINDINGS Systematic review with meta-regression. The Cochrane Collaboration Depression, Anxiety and Neurosis Group trials registers were searched from inception to 9th February 2012. An update was run in the CENTRAL trials database on 29th December 2013. Inclusion criteria were: randomised controlled trials of collaborative care for adults ≥18 years with a primary diagnosis of depression or mixed anxiety and depressive disorder. Random effects meta-regression was used to estimate regression coefficients with 95% confidence intervals (CIs) between study level covariates and depressive symptoms and relative risk (95% CI) and anti-depressant use. The association between anti-depressant use and improvement in depression was also explored. Seventy four trials were identified (85 comparisons, across 21,345 participants). Collaborative care that included psychological interventions predicted improvement in depression (β coefficient -0.11, 95% CI -0.20 to -0.01, p = 0.03). Systematic identification of patients (relative risk 1.43, 95% CI 1.12 to 1.81, p = 0.004) and the presence of a chronic physical condition (relative risk 1.32, 95% CI 1.05 to 1.65, p = 0.02) predicted use of anti-depressant medication. CONCLUSION Trials of collaborative care that included psychological treatment, with or without anti-depressant medication, appeared to improve depression more than those without psychological treatment. Trials that used systematic methods to identify patients with depression and also trials that included patients with a chronic physical condition reported improved use of anti-depressant medication. However, these findings are limited by the observational nature of meta-regression, incomplete data reporting, and the use of study aggregates.
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Affiliation(s)
- Peter A. Coventry
- Collaboration for Leadership in Applied Health Research and Care, Centre for Primary Care and Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- * E-mail:
| | - Joanna L. Hudson
- Health Psychology Section, Psychology Department, Institute of Psychiatry, King's College London, London, United Kingdom
| | - Evangelos Kontopantelis
- NIHR School for Primary Care Research, Centre for Primary Care and Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Janine Archer
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, United Kingdom
| | - David A. Richards
- Institute of Health Service Research, University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Simon Gilbody
- Mental Health Research Group, Department of Health Sciences and Hull York Medical School, University of York, York, United Kingdom
| | - Karina Lovell
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, United Kingdom
| | - Chris Dickens
- Institute of Health Service Research, University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Linda Gask
- Collaboration for Leadership in Applied Health Research and Care, Centre for Primary Care and Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Waquas Waheed
- Lancashire Care NHS Foundation Trust, Preston, United Kingdom
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care and Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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Weisler R, McIntyre RS. The role of extended-release quetiapine fumarate monotherapy in the treatment of patients with major depressive disorder. Expert Rev Neurother 2014; 13:1161-82. [DOI: 10.1586/14737175.2013.846520] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Richard Weisler
- Department of Psychiatry, University of North Carolina at Chapel Hill, Raleigh, NC, USA
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20
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Abstract
Data on the efficacy and safety of psychiatric medicines should form the foundation of evidence-based treatment practices. The US Food and Drug Administration (FDA) reviews such data in determining whether to approve new treatments, and the published literature serves as a repository for evidence on treatment benefits and harms. We describe the FDA review of clinical trials, examining the underlying logic and legal guidelines. Several FDA reviews provide evidence that the agency requires only minimal efficacy for psychiatric drugs. Further, in some instances, the FDA has relied on secondary rather than primary outcomes and has discounted the findings of negative studies in its review of antidepressant and antipsychotic medications. The published literature provides another lens into the safety and efficacy of treatments. We describe how treatment efficacy is systematically overstated and treatment-related harms are understated in the scientific literature. Suggestions are provided to improve public access to underlying safety and efficacy data and for the FDA to potentially improve its review process.
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Affiliation(s)
- Glen I Spielmans
- Department of Psychology, Metropolitan State University, Saint Paul, Minnesota 55108
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Fitzgerald PJ. Forbearance for fluoxetine: Do monoaminergic antidepressants require a number of years to reach maximum therapeutic effect in humans? Int J Neurosci 2013; 124:467-73. [DOI: 10.3109/00207454.2013.856010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Whedon JM, Rugo NA, Lux K. Challenges of Withdrawal From Chronic Antidepressant Medication: A Healing Odyssey. Explore (NY) 2013; 9:108-11. [DOI: 10.1016/j.explore.2012.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Indexed: 10/27/2022]
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Vaaler AE, Fasmer OB. Antidepressive legemidler – klinisk praksis må endres. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2013; 133:428-30. [DOI: 10.4045/tidsskr.12.1077] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Vaaler AE, Fasmer OB. A.E. Vaaler & O.B. Fasmer svarer:. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2013; 133:830. [DOI: 10.4045/tidsskr.13.0440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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