Table 4 : Clinical Scenarios
Clinical Scenario
25-year-old man who has taken escitalopramfor six years , minimal depressive or anxiety sx for past three years , last suicide attempt four years ago , living in own apartment shared with roommate , no medical comorbidity , occasionally smokes marijuana , wants to D / C Lexapro .
34-year-old woman on venlafaxine who is planning on becoming pregnant , three past depressive episodes ( last one severe , one year ago ), one suicide attempt in last episode by overdosing on Benadryl ( 10 tabs ), medically healthy , wants to know what to do .
78-year-old woman who lives with her family , ambulates on a scooter due to osteoarthritis , has COPD , on many medications , was given remeron seven years ago , which was augmented with abilify 10mg three years ago and has been on the combination for three years .
37-year-old man with bipolar depression , alcohol use disorder , lithium 1500mg a day ( level 1.00mEq / L ), amitriptyline 100mg HS , continues to drink and have mild depressive symptoms .
40-year-old woman with recurrent depression , currently moderate episode , in the past has responded partially to sertraline 100mg , insists that she does not want to take AD anymore and wants to discuss alternate strategies .
Clinical Indicators of Risk
History of suicide attempt
Occasional drug use
Antidepressant started at young age and taken for six years
Three past depressive episodes
Last episode was severe
History of suicide attempt
Physical disability
Multiple medical comorbidities
Alcohol use disorder
Bipolar rather than unipolar depression
Antidepressant Continuation
Antidepressant Discontinuation
Risks |
Benefits |
Risks |
Benefits |
Side effects |
Decrease |
|
|
|
risk of |
|
|
|
recurrence |
|
|
Side effects
Potential teratogenicity
Neonatal antidepressant discontinuation
Side effects
Drug-drug interaction
Side effects
Interaction with alcohol use
Potential of antidepressant induced mania
Decrease risk of recurrence
Decrease in symptom intensity
Decrease risk of recurrence
Decrease in symptom intensity
Multiple past episodes |
Side effects |
Worsening of |
|
|
symptoms |
Recommendations
Slow taper under supervision Stop marijuana use Start psychotherapy
Slowly taper to lowest required dose under supervision
Start psychotherapy Close monitoring of the fetus
Start with slow taper of augmenting agent .
Watch for few months before recommending slow taper of the antidepressant under supervision
Start psychotherapy Stop alcohol use
Start psychotherapy for deaddiction and mood disorder
Slow taper under supervision
Start psychotherapy
Psychoeducation in regards to continuation and address issues with current antidepressant
Suggest alternative antidepressant involvement of the C ( -1019 ) G polymorphism of the serotonin 5-HT1A receptor gene in the occurrence of paroxetine discontinuation syndrome . 44 Table 3 summarizes main steps in the process of de-escalation of the antidepressant therapy .
References :
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8 . Bockting , C . L . H ., ten Doesschate , M . C ., Spijker , J ., Spinhoven , P ., Koeter , M . W . J ., and Schene , A . H . ( 2008 ). Continuation and maintenance use of antidepressants in recurrent depression . Psychother . Psychosom . 77 , 17 – 26 .
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10 . Fava GA , Ruini S , and Rafanelli C . et al . Sixyear outcome of cognitive behavior therapy for prevention of recurrent depression . Am J Psychiatry . 2004 161:1872 – 1876 .
Contact AMS for a complete list of references .
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