Gradual discontinuation is no better than cold turkey when it comes to relapse and withdrawal, according to a research review.
Tapering patients off antidepressants over a few weeks may create the same withdrawal symptoms as abruptly discontinuing the medication, a new Cochrane review has found.
The reviewers found that withdrawal symptoms could be being mistaken for a relapse of the mental illness.
Overall, there is relatively little evidence on how to safely discontinue antidepressants, the Cochrane authors said.
The review team analysed 33 studies involving a total of roughly 5000 patients, most of whom were being treated for recurrent depression.
The approaches examined in the studies included abrupt discontinuation, tapering over one week or longer, discontinuation with psychological support and discontinuation with minimal intervention from a mental health specialist.
With the exception of discontinuation with psychological support, none of the schemes had any effect on the successful discontinuation rate.
Professor Malcolm Hopwood, co-author of the Royal Australian and New Zealand College of Psychiatrists’ Mood Disorder Guidelines, told The Medical Republic that tapering was still the recommended method in Australia.
“We acknowledge that for some people, stopping antidepressants can be challenging – particularly for people who’ve been on them at higher doses for longer periods,” he said.
“As indicated in that review, the evidence about how to best taper isn’t perfect, we don’t have enough studies about how best to taper.
“But we do recommend a gradual withdrawal of those medications over a period of a few weeks.”
The Cochrane reviewers said that while it remained uncertain whether tapering helped avoid withdrawal symptoms, there was evidence that the risk of relapse of the depression after stopping the antidepressants was the same regardless of whether they were stopped abruptly or tapered.
Professor Hopwood acknowledged that withdrawal symptoms, which can include nausea and increased anxiety, can be easily confused with a re-emergence of depression – but the key distinguishing feature is duration of symptoms.
“Most withdrawal symptoms don’t last long periods of time,” he told TMR.
“There are reports of people with protracted symptoms, but usually they’re relatively brief and that can help inform us.”
Professor Hopwood said that the context of discontinuation can also play an important role.
“If you’re doing it because a person’s been well for a period of time, and it’s now appropriate to go off antidepressants, there’s not much time pressure on that, is there?” he said.
For more urgent matters, however – such as a very ill patient who is not responding to their current medication – Professor Hopwood advised a quicker, more supervised tapering.
In a situation like this, Professor Hopwood mentioned it was possible to start stepping up a different medication while tapering down the ineffective one.
The reviewers emphasised that the paucity of information around discontinuation meant that no firm conclusions could be made.
“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,” they wrote.
