The treatment of major psychiatric disorders includes appropriate drug selection, accurate dosing, recognition and management of side effects, and correct duration of treatment. Doctors and patients should take a number of factors into consideration when deciding why, when and how best to discontinue antidepressants.
Deciding When to Discontinue Antidepressants
There are a number of common scenarios that may lead a medical practitioner to recommend to discontinue the use of antidepressants for a patient. Less than one third of patients with major depression are able to attain remission with an initial antidepressant trial. Multiple sequential acute-phase trials of 6-8 weeks each are often needed for a patient to find a drug regimen that achieves symptomatic remission. Long term changes or discontinuation of an the antidepressant may be warranted to address residual symptoms, persistent functional impairments, or loss of initial therapeutic effect (antidepressant tachyphylaxis).
Other medical reasons that would lead to discontinuation include:
- Unwanted side effects. of ongoing treatment such as weight gain, sexual dysfunction, nausea, blurred vision, increased anxiety, agitation, and dizziness. Quality of life for the patient must always take priority.
- Relapse or recurrence of depressive symptoms.
- Comorbid medical illness that changes the risk vs. benefit profile of the drug..
- Planning for pregnancy. A patient may prefer to be off antidepressants because of potential risks.
- Affordability of the drug. Not all antidepressants have a generic, or less expensive alternative.
- Anticipated interactions with other drugs. When taken concurrently with antidepressants, some common medications, both prescription and OTC, may increase a patient’s risk for side effects such as bleeding or serotonin syndrome, which may lead to seizures and irregular heartbeat.
Perhaps the best reason for a doctor to decide when to discontinue antidepressants is after a period of sustained improvement or recovery in which the use of the drug may no longer be deemed necessary. These patients should ideally have minimal risk for relapse or recurrence, consistent with treatment guidelines of at least 9-12 months of continuation-phase treatment after symptomatic remission.
The course of action should be personalized to the individual and all factors that affect quality of life should be taken into account.
Preferred Discontinuation Strategy
Treatment guidelines and the U.S Food and Drug Administration prescribing labels recommend a gradual reduction in dosage rather than abrupt discontinuation, which may trigger new-onset symptoms. Discontinuation symptoms can be managed by both prevention and treatment strategies. Preventive strategies include steps to be taken prior to onset of discontinuation symptoms, including patient education. For example, patients should be advised that inadvertently missing SSRI doses for a few days, especially with paroxetine, can result in discontinuation symptoms.
Gradual reduction of antidepressants as opposed to abrupt discontinuation has been shown to reduce both the pervasiveness of discontinuation symptoms and the likelihood of symptomatic relapse in the year following the termination of the drug.
Discontinuation symptoms are a group of manifestations that begin soon after the discontinuation of antidepressants. The mnemonic “FINISH” may be used to describe discontinuation symptoms: “flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal (anxiety/agitation).” Discontinuation symptoms typically subside and resolve spontaneously over 2–3 weeks. However, some reports have documented persistence of symptoms for up to 1 year
If these symptoms become intolerable during gradual reduction, clinicians may employ a number of management strategies including the resumption of a previously tolerated dose or switching to a similar dose of another antidepressant, especially long-acting ones like Fluoxetine (Prozac) which are usually easier to taper and discontinue.
Mood or anxiety symptoms may occur as part of discontinuation syndrome, but they should be differentiated from those present at the baseline. Regular follow-up visits should be conducted to monitor and detect symptom changes so that they do not worsen to intolerable levels.
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