Stopping antidepressants may lead to relapse, study finds

This article was written by Sandee LaMotte in CNN:

More than half of people with chronic depression who tried to stop their antidepressant treatment relapsed into depression after a year, compared to those who did not stop taking their treatment, according to a clinical trial randomized double-blind published Wednesday.

The research, published in the New England Journal of Medicine, found that “measures of quality of life and symptoms of depression, anxiety and drug withdrawal were generally worse in patients who discontinued antidepressant treatment.”

Interestingly, the study found that a small percentage of people were able to quit their antidepressant without having another depressive episode.

“Some people can stop their treatment without a relapse, although at this time we cannot identify these people,” said Gemma Lewis, co-author, professor of psychiatric epidemiology at University College London.

“I think we can be very encouraged by the results,” said co-author Dr Tony Kendrick, professor of primary care at the University of Southampton in the UK.

“This is very good evidence to support a patient’s own decisions – in discussion with their doctor or other prescriber – about whether or not to continue antidepressants,” Kendrick said. “Both courses of action are reasonable.”

– Antidepressants for life?

When people first fall into depression, current practice is to continue antidepressants between four and nine months after their depression is in remission, said Dr. Jonathan Alpert, chair of the American Psychiatric Research Council. Association, which did not participate in the study. .

Remission is defined as a period of two months without signs of major depression such as sadness and reduced interest or pleasure in life.

“In my own practice, if the patient has a first episode of depression, and in particular if it was triggered by a life event – death of a loved one, bankrupt business – then I do my best to get patients into remission (and) then I treat for at least six months after their remission, ”said Dr. Jeffrey Jackson, a professor at the Medical College of Wisconsin, who studies depression.

“If they stay in remission for those six months, then we can consider gradually cutting back on antidepressants – with the person carefully monitoring their own depressive symptoms,” Jackson added. Jackson, who was not involved in the study, wrote an accompanying editorial published in the NEJM.

Unfortunately, the risk of another episode of depression later in life is high, said Alpert, who is also president of psychiatry at Montefiore Health System in the Bronx.

“If you’ve had an episode of depression, the chance of a second episode in your lifetime is 50%,” he said. “If someone has had two or more depressions, the chances of a third are even higher – over 75% of people who have had two or more depressions will have another.”

Science has long known that people with recurrent depression have the most difficulty stopping antidepressants and the most risk of relapse when they do, Alpert added.

“For patients who have had three or more depressive episodes, I generally plan to treat them for life,” Jackson said.

– Deal with obsolete searches

Much of the research done on the long-term effectiveness of antidepressants is old and limited, so the study was designed to fill this knowledge gap, the study’s authors said.

“A lot of people take long-term antidepressants, and the evidence to advise them to continue maintenance or to stop is weak,” Lewis said.

The study recruited 478 people from 150 primary care practices in the UK. Each person had had at least two episodes of depression or had taken antidepressants for two years or more. Everyone felt well enough to stop taking their medication.

“This is the largest study ever done in a real world primary care setting,” Alpert said.

“This is important because most patients with depression are in the care of their primary care provider,” Jackson said. “Most primary care providers only refer to psychiatrists if patients are suicidal, murderous, psychotic, bipolar, or not responding to treatment.”

Only people taking maintenance doses of four antidepressants were included in the study: citalopram (Celexa), fluoxetine (Prozac), sertraline (Zoloft) and mirtazapine (Remeron). Other popular antidepressants, such as escitalopram (Lexapro), were not included due to the greater likelihood of severe withdrawal symptoms, the authors said.

All of the drugs and the lactose placebo in the study were identically packaged in unmarked bottles so patients and researchers were not aware of the contents.

Half of the group received reduced doses of their antidepressant over a two-month period; by the start of the third month, all were taking a placebo. The other half of the group continued to take their normal dose of antidepressant.

After 52 weeks of follow-up, 56% of people who had been withdrawn from their antidepressants had relapsed into depression, compared with 39% of people who continued their medication.

“Patients who stopped their antidepressants relapsed sooner than patients who stayed on their antidepressants,” Lewis said.

Symptoms of depression and anxiety were higher in the group who also stopped their medication, she added. But is it more about withdrawal symptoms?

“It’s not always easy to say,” Kendrick said. “If someone starts to get anxious, if they start to have trouble sleeping or start to feel weak. Does this depression come back? Or is it withdrawal symptoms?”

Regardless of the source of the symptoms, a number of people left the trial even though they were unsure whether they were taking medication or a placebo.

“It was clear that they were voting with their feet,” Alpert said. “When they weren’t doing as well, they were more likely to drop out of the trial and more likely to go back to the medication.”

– Long term use

The results of the study provided insight into the benefits of long-term use of antidepressants, Kendrick said.

“It’s reassuring to know that the antidepressants that people take long term seem to be of benefit to them, and it’s not something they take unnecessarily,” he said.

There are side effects to many drugs, such as weight gain and sexual dysfunction, “so we try to choose antidepressants and adjust the dose for a particular person that they tolerate the best and have the least. side effects, ”Alpert said.

“However, as far as we know, there are no long term consequences, such as an increased risk of cancer, stroke, heart disease, or liver problems from taking it. ‘antidepressants,’ he added.

If you do decide to taper off, take it slowly and add psychological therapy, which studies show “may help prevent the risk of relapse,” Kendrick added.

“The latest guidelines suggest that you should take a few weeks to quit the antidepressants,” he said. “If you have withdrawal symptoms and it is difficult, you may need to take months to resolve them.”

– What else can we do?

Antidepressants are of course not the only treatment for depression. There are a lot of things people can do to improve their depressive symptoms while taking medication, or to reduce the likelihood of a relapse after weaning from an antidepressant, Alpert said.

Physical activity is the key. “It appears that even relatively moderate amounts of activity, such as brisk walking several times a week, can help in the treatment of depression and also in the prevention of relapses,” he said.

Social ties are also important. Making an effort not to be isolated, reaching out to others for social support, makes a difference, as do activities that are meaningful and rewarding, Alpert said.

“Community activities, volunteer activities seem to be important in helping to fight depression,” he said. “When people are pursuing goals that are meaningful to them, that also helps.”

Evidence-based psychotherapy works. “People who choose to gradually cut back on their medications are more likely to stay healthy if they pursue certain forms of psychotherapy that have been shown to be effective in studies,” Alpert said.

Cognitive behavioral therapy, or CBT, has been widely studied and considered to be comparable in effectiveness to antidepressants for depression. It is often used in combination with medicines for people whose symptoms do not improve only with antidepressants.

Therapy focuses on a person’s thought process, trying to interrupt false or negative thoughts about yourself and others that can lead to a depressed mood. Instead, people are encouraged to substitute healthier, more positive thoughts, which can improve self-image and behavior.

“It’s not quite like lying on the couch and associating freely,” Alpert said. “There are specifics like homework and skills that people acquire.”

Acceptance and Commitment Therapy, or ACT, uses a similar approach, Alpert said, with more emphasis on accepting negative thoughts and rejecting them.

“Rather than changing your thoughts, you accept the idea that they are just thoughts, that they are not the same as reality, and that they are not who I am,” Alpert explained. “Realize that thoughts like ‘I’m not good enough’ and so on are just thoughts, and learn to push those thoughts away.”

Interpersonal psychotherapy or IPT focuses on changes in a person’s life related to interpersonal relationships, Alpert said.

“Interpersonal therapy has a lot to do with relationships like losses or transitions in one’s role with others…,” he said.

Therapists will often talk to patients about the different approaches, as one may be “a better match with where they are in their life and the things they are facing,” he added. “There are a lot of things people can do besides medication.”

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