SCIENTIFIC ARTICLE
Deprescribing Antidepressants : An overview with practical clinical scenarios
Gaurav Jain , MD 1 ; Sarita Singhal , MD 2 ; Aman Mahajan , MD , MRCPsych 3 ; Abhijit Ramanujam , MD 4 ; Shashank Kraleti , MD , FAAFP 5 ; Sunil Kumar , MD 6 ; Sumit Fogla , MD , FAAFP , MBA 7
1
Berkshire Medical Center , Pittsfield , MA ; 2 Baystate Medical Center , Springfield , MA ; 3 Rogers Memorial Hospital , Brown Deer , WI ;
4
Woodland Medical Center , Sacramento , CA ; 5 UAMS , Little Rock , AR ; 6 Neshoba County Hospital , Philadelphia , MS ; 7 Beaumont Hospital , Grosse Pointe , MI
Abstract
Antidepressants are used for a variety of indications and are among the most widely prescribed of all medications . Although concerns have been raised about the side effect profile and tolerability of the older antidepressants such as the tricyclic antidepressants ( TCAs ) and the Monoamine Oxidase Inhibitors ( MAOIs ), Selective Serotonin Reuptake Inhibitors ( SSRIs ) and other relatively newer antidepressants such as venlafaxine , mirtazapine , bupropion , and duloxetine are considered better tolerated and safer . As a result , prescriptions of these medications often do not undergo a periodic risk-benefit analysis . Although there is extensive literature supporting the use of antidepressants and their combinations for a variety of indications , there is insufficient literature on the chronic side-effects . Further , the duration for which combinations or even monotherapy need to be continued , has not been established . Additionally , if a clinical situation warrants the discontinuation of an antidepressant , the guidelines for how to do so and for the management of withdrawal syndromes are very sparse . This paper reviews the existing literature on chronic side effects of antidepressants and the various withdrawal syndromes and their management . We also present five clinical situations with a risk-benefit analysis of continuing antidepressant in each case and subsequent management .
Introduction
Eleven percent of Americans 12 years and older take antidepressant medication , as reported by the National Health and Nutrition Examination Surveys ( 2005 – 2008 ). 1 The same survey found that more than 60 % of Americans taking antidepressant medication had been taking it for two years or longer , with 14 % having medication for 10 years or more . 1 Antidepressants were the third most common prescription drug taken by Americans of all ages in 2005 – 2008 and were most frequently used by men and women between 18 and 44 years . 2 From 1988 – 1994 through 2005 – 2008 , the rate of antidepressant use in the United States among all ages increased nearly 400 %. 2 Further , only a minority of patients who were taking antidepressants were evaluated by a psychiatrist or psychologist during the course of one year , and a declining percentage underwent psychotherapy . 3
Decision-making Around Antidepressant Continuation
The majority of antidepressants are taken to treat depression and anxiety disorders . The goals of antidepressant therapy are twofold : to reduce and eliminate the acute symptoms , as well as to achieve and maintain full remission . A patient may want to stop antidepressants due to several reasons such as improvement in depressive symptoms , poor or no response to the prescribed antidepressant , intolerable side effects , planned or unplanned pregnancy or even an unwillingness to take pills . Often , if a patient is doing well on antidepressants and not complaining of too many side effects , many physicians renew the prescription indefinitely without regular monitoring of efficacy and tolerability due to moderate quality data that it protects against a relapse of depression or recurrence / worsening of anxiety in long term . Current recommendations suggest that treatment should continue for up to nine months after depressive symptoms have remitted to prevent relapse and for longer than nine months to help prevent a recurrence . 4 , 5 However , in making the decision to stop an antidepressant a number of factors need to be considered . These include factors that increase the risk of recurrence of a depressive episode : three or more previous episodes of major depression , long previous episodes , previous severe episodes especially associated with suicidality or psychotic features , high prior frequency of recurrence , an episode in the previous 12 months , residual symptoms during continuation treatment , and relapse after previous drug discontinuation . 6 For treatment of depression in children and adolescents , the practice parameters recommend continuation therapy for 6-12 months after patient becomes asymptomatic , with maintenance treatment depending on the clinician and discontinuation tried during summer so that if there is any relapse it is less disruptive to school function . 7 In addition , one needs to be aware that the discon-
Table 1 . Proposed diagnostic criteria for SRI discontinuation syndrome
39 , 40
( Adapted from Black et al and Berber MJ )
1 . Appearance within one to seven days after discontinuation or significant reduction of dose
2 . Occurrence after at least one month of exposure to antidepressant
3 . Duration of generally < 3 weeks after abrupt discontinuation or dose reduction
4 . Two or more of the following symptoms ( FINISH Mnemonic )
Flu-like symptoms Fatigue Lethargy General malaise Muscle aches / headaches Diarrhea Insomnia Nausea Imbalance Gait instability Dizziness / lightheadedness Vertigo Sensory disturbances Paresthesia “ Electric shock ” sensations Visual disturbance Hyperarousal Anxiety Agitation
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