Stop Antidepressants Slowly

People commonly decide to stop taking an antidepressant. Does it matter how this is done? If a patient is pregnant, isn’t it best to stop the medication immediately? If you or your patient is taking one of the antidepressants that is rarely associated with the SSRI withdrawal syndrome, it doesn’t matter whether the medication is stopped quickly or slowly, does it? What about the patient who has been stable for a year, or two years; if they are asymptomatic, happy, and at a good place in their life, surely it doesn’t matter if they stop citalopram 20mg without tapering.

An article published in the American Journal of Psychiatry in 2010 indicates it does matter. Though this article is three years old, its significance leads me to write about it now. It is my impression that many clinicians are unaware of the risk of not tapering antidepressants, or neglect to educate their patients about the importance of going off medication gradually in almost all situations.

It is well known in psychiatry that rapid cessation of mood stabilizers increases the risk of a mood episode. In fact, previous studies of maintenance treatment have been criticized for including a treatment arm randomizing patients to abruptly stopping their medication. This is because it is widely understood that by stopping the drug suddenly, the group randomized to placebo is going to have an increased rate of relapse. This unnecessarily puts patients at higher risk for an episode of their illness and makes the drug being studied look more effective at preventing relapse than it really is. It is no longer considered ethical or valid to stop medication suddenly in trials involving bipolar disorder.

Ross Baldessarini and his colleagues have been publishing studies for many years involving the inhabitants of the island of Sardinia. They have previously documented the risks of rapidly stopping mood stabilizers and antipsychotics. The Sardinian studies have focused on mood, anxiety and psychotic disorders, particularly the longitudinal course of these illnesses, using a naturalistic design.  In the current study they looked at the consequences of the abrupt withdrawal of antidepressants in patients with major depression, bipolar 1 and bipolar 2 disorder, and panic disorder.

One of the strengths of this study, and of the other studies from this group, is the comprehensive nature and duration of follow up. Meticulous records have been kept for over forty years. There may not be a comparable database of such a large number of individuals, followed so closely and for so long, anywhere else in the world. The studies published have been of great interest and usefulness to psychiatry.

The principal finding of this study was that “the abrupt or rapid discontinuation of clinically effective antidepressant treatment was associated with a significantly shorter time to a first new episode of major depression or panic.” The patients were clinically well at the time the medication was stopped, without even mild degrees of depression or panic. In other words, there was no evidence that these patients were experiencing a relapse or recurrence prior to going off medication. The decision to stop medication rapidly was made by the patient in a large majority of cases. The increased risk of recurrence was found with both newer and older antidepressants, though the benefits of a slow taper of the medication was more pronounced with older medications.

Based on the findings, the authors made the following recommendations:

1) Gradual dose tapering should be done in all situations unless a patient is experiencing a severe adverse medical effect or a severe manic reaction.

2) Patients should be warned that abrupt discontinuation of an antidepressant can lead to early withdrawal reactions and, over a period of several months, a return of the illness being treated.

3) Primary care clinicians, who prescribe most of the antidepressants in the US, should be aware that it is the rate of dose tapering and discontinuation that plays an important role in determining the risk of stopping medication.

Though they do not say this unequivocally, the authors imply that even in the case of pregnancy the risks of stopping antidepressant medication outweigh any potential benefits. Based on the current data available to clinicians, I agree. There is a very high risk of recurrence of illness if a woman stops medication for schizophrenia, bipolar disorder or depression while pregnant. The evidence does not indicate any benefit from suddenly or abruptly stopping medication during pregnancy. The fetus has already been exposed to the medication, and rapidly discontinuing it puts the woman and her baby at the added risk of an episode of the illness she suffers from. The more appropriate course of action is to get an expert in mental illness and an obstetrician involved, so that the risks and benefits of continuing or stopping pharmacological treatment can be examined and discussed with the patient. The knee jerk reaction of stopping the antidepressant right away can create a much more severe situation and cause more harm.

Summing up: Stopping antidepressants suddenly increases the risk that symptoms will return. This applies to depression (both in unipolar and bipolar disorders) and panic disorder. Slowly tapering medication rather than stopping it rapidly is almost always the right thing to do. If treating patients with antidepressants, educate them about this. Many of them will choose to stop medication on their own in the future, and it will decrease the risk of recurrence if they do so slowly.

Illness Risk Following Rapid Versus Gradual Discontinuation of Antidepressants                                                                 Ross J. Baldessarini, M.D.; Leonardo Tondo, M.D., M.S.; Carmen Ghiani, M.D.; Beatrice Lepri, Psy.D.                           Am J Psychiatry 2010;167:934-941. 

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Group Psychoeducation for Bipolar Disorder

Medication is only 1 way to decrease the likelihood of  having another episode for people with bipolar disorder. In a study of 120 patients with bipolar disorder who were currently euthymic (back to baseline), the addition of group psychoeducation significantly reduced the chances of having another episode compared to participating in a support group.

The psycho-education group emphasized

1) early detection of symptoms of an impending mood episode

2) sticking with treatment (such as taking medication regularly, attending appointments, etc.)

3) lifestyle regularity (having a routine or schedule for physical activity, bedtime, social activity)

Though more people in the support group completed the study, those in the psycho-education group

1) fewer mood episodes

2) fewer days hospitalized

3) a longer time to the next episode

Though this is not a new study, being published 10 years ago, subsequent studies have backed up it’s central finding: there are ways to decrease the chances of having another episode in bipolar disorder in addition to taking medication.

The take away message is that learning about bipolar disorder, sticking with the treatment plan and leading a regular lifestyle can help to stay better.

A Randomized Trial on the Efficacy of Group Psychoeducation in the Prophylaxis of Recurrences in Bipolar Patients Whose Disease Is in Remission 

Francesco Colom, PhD; et. al.
Arch Gen Psychiatry. 2003;60(4):402-407. doi:10.1001/archpsyc.60.4.402.