Addressing Clinical Challenges of Antidepressant Discontinuation

Predictors of relapse following a stepwise psychopharmacotherapy regime in patients with depressive disorders

BACKGROUND

Real world predictors of relapse following routine treatment for depression remain under-researched. We sought to investigate this in an outpatient clinical sample with depressive disorders receiving stepwise pharmacotherapy based on early clinical decision-making, applying a naturalistic 24-month prospective design.

METHODS

Patients were recruited at a University hospital in South Korea from March 2012 to April 2017. After 3-week antidepressant monotherapy (N = 1262), next treatment steps (1, 2, 3, and 4 or over) with alternative strategies (switching, augmentation, combination, and mixtures of these approaches) were administered based on measurements and patient preference at 3-week points in the acute treatment phase (3, 6, 9, and 12 weeks) (N = 1246). For those who responded [Hamilton Depression Rating Scale (HAMD) score of≤14] (N = 937), relapse (HAMD>14) was identified every 3 months from 6 to 24 months (N = 816). Predictors of relapse were evaluated using multi-variate Cox proportional hazards models.

RESULTS

Four independent relapse predictors were identified: higher number of previous depressive episodes, higher anxiety at baseline, higher number of treatment steps, and poor medication adherence. In particular, treatment Step 4 was significantly associated with relapse compared to treatment Step 1, 2, and 3 after adjustment for relevant covariates.

LIMITATION

Withdrawal syndromes after discontinuing psychotropic drugs, known to confound the determination of relapse, were not evaluated. The study was conducted at a single site, which maximised consistency but may limit generalizability.

CONCLUSIONS

Predictors of relapse reported from more restricted trial or cohort samples were replicated in this long-term naturalistic prospective design.

What I have learnt from helping thousands of people taper off antidepressants and other psychotropic medications

Although psychiatric drug withdrawal syndromes have been recognized since the 1950s - recent studies confirm antidepressant withdrawal syndrome incidence upwards of 40% - medical information about how to safely go off the drugs has been lacking. To fill this gap, over the last 25 years, patients have developed a robust Internet-based subculture of peer support for tapering off psychiatric drugs and recovering from withdrawal syndrome. This account from the founder of such an online community covers lessons learned from thousands of patients regarding common experiences with medical providers, identification of adverse drug reactions, risk factors for withdrawal, tapering techniques, withdrawal symptoms, protracted withdrawal syndrome, and strategies to cope with symptoms, in the context of the existing scientific literature.

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