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Dr. Bob is Robert Hsiung, MD,
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Posted by SLS on May 28, 2010, at 18:00:26
Greater Clinical Risk Following Rapid Antidepressant Withdrawal
May 28, 2010 In patients with major depressive disorder, panic disorder, or bipolar disorder, the risk for illness recurrence is far greater following abrupt or rapid, vs gradual, discontinuation of clinically effective antidepressant treatment, according to a study published online May 17 in the American Journal of Psychiatry.
"Our findings of greater clinical risk following rapid versus gradual discontinuation of antidepressants is one of several similar findings that we have reported over the years," Ross J. Baldessarini, MD, from Harvard Medical School, Boston, and McLean Hospital, Belmont, Massachusetts, told Medscape Psychiatry.
"We found this phenomenon first with discontinuing lithium in bipolar disorder patients and later with antipsychotic drugs in schizophrenia patients. Similar risks also are well known in rapidly stopping sedative-anxiolytics and anticonvulsants (both of which can lead to epileptic-like seizures)," he added.
According to Dr. Baldessarini, it was not easy to obtain data on effects of discontinuing the use of antidepressants rapidly vs gradually because single studies involving both conditions had virtually been unknown. "To my knowledge, our report is the first to involve such a comparison with antidepressants of various types," he said.
The study involved 398 patients with a Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) diagnosis of recurrent major depressive disorder (n = 224), panic disorder (n = 75), bipolar II disorder (n = 62), or bipolar I disorder (n = 37).
Roughly two-thirds were women (65.6%), a little more than half were married (54.8%), and most were employed (95.6%). The mean age of study subjects was 42 years, and the mean length of antidepressant therapy was 8.5 months. The use of antidepressants was discontinued rapidly during 1 to 7 days in 188 subjects (largely at the patient's request) and gradually during 14 days or more in 210 subjects.
Patients who discontinued antidepressant use rapidly were similar to those who discontinued gradually in most demographic and clinical characteristics. All patients include in the analysis were "clinically well" at the time of discontinuing antidepressant treatment and had no clinical evidence of even mild depression or anxiety, the study authors note.
According to the investigators, during an average of 2.8 years of follow-up, the latency to first new illness with rapid discontinuation was 0.4 times that with gradual discontinuation (3.62 months [SD, 8.78] compared with 8.42 months [SD, 22.2]; P < .0001).
"Notably," they report, the 3.62-month latency period after rapid discontinuation was one-fourth the estimated average previous interepisode interval in the same patients (14.9 months [SD, 21.0]; P < .0001) and about one-fifth of the mean previous interval following gradual discontinuation (16.6 months [SD, 30.5]; P < .0001).
In patients with bipolar I disorder and panic disorder, differences in illness latency between rapid and gradual antidepressant discontinuation were larger (3.1- to 4.6-fold) than among those with bipolar II disorder or recurrent major depressive disorder (2.4- to 2.5-fold). The reasons for these differences require further study, the investigators say.
The effect was similar across antidepressant classes, although the pace of discontinuation had less effect with drugs of prolonged half-life, they note.
Clinical Implications
"The general point for clinical practice," Dr. Baldessarini said, "is that it appears that most psychotropic drugs, when discontinued abruptly or rapidly, can lead to early and severe exacerbations of the illnesses being treated.
"It is my impression that this concept has been widely accepted and that clinical practice has been modified appropriately in many cases to include gradual dose tapering and slow discontinuation when feasible clinically," he added.
Optimal dose-tapering times and protocols still need to be worked out, Dr. Baldessarini noted. However, in general, he said, it is wise to taper off most psychotropics during at least several weeks.
"Nevertheless, modern psychiatry includes a great deal of trial and error in attempting to find effective treatments for individual patients, and this process can tend to encourage rapid changes in treatment, which can be risky."
Research Implications
The findings also have important research implications, Dr. Baldessarini said. "Many modern treatment trials involve discontinuing medications at some point, often when patients are barely recovering from an acute episode of illness," he noted. On the basis of the current results and prior research, abruptly or rapidly discontinuing psychotropic medications whether by clinical decision on the part of patients or clinicians or by experimental design "can present substantial clinical and ethical problems," the investigators note in their report.
Strengths and Limitations
The study's strengths include its large sample size with a range of disorders for which antidepressants are prescribed, with consistent assessments, treatment, and follow-up and the inclusion of different antidepressant drug types. The lack of randomized assignment to precisely scheduled dose tapering options is a major limitation.
Other limitations include uncontrolled, and often patient-determined, drug therapy discontinuation pace, as well as the possibility that some patients reported inaccurate drug therapy discontinuation data or became ill after loss to follow-up.
Dr. Baldessarini and colleagues say their findings "underscore the importance of warning patients that abrupt discontinuation of antidepressant treatment can lead not only to early adverse physiological [withdrawal] responses but also, over several months, to a return of the illness being treated."
The study was supported in part by the National Institutes of Health. Dr. Baldessarini and several coauthors report being consultants or receiving research support from several pharmaceutical companies that make antidepressant medications.
Am J Psychiatry. Published online May 17, 2010.
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Authors and Disclosures
Journalist
Megan BrooksMegan Brooks is a freelance writer for Medscape.
Posted by linkadge on May 28, 2010, at 19:43:37
In reply to Relapse risk is greater for rapid drug withdrawal, posted by SLS on May 28, 2010, at 18:00:26
Posted by Phillipa on May 28, 2010, at 21:37:16
In reply to Relapse risk is greater for rapid drug withdrawal, posted by SLS on May 28, 2010, at 18:00:26
Also seems like lower starting doses of Ad's are now being prescribed. Intersting thanks Scott
Posted by manic666 on May 29, 2010, at 13:36:58
In reply to Re: Relapse risk is greater for rapid drug withdrawal, posted by Phillipa on May 28, 2010, at 21:37:16
i stopped prozac dead when young //i thought i was curred //there was no info at that time//3 months later,an relasp an boy was it bad// thought i would just cruise back on fluxertine as prozac was now called//but no way the door was closed on that med bigtime
Posted by Phillipa on May 29, 2010, at 20:18:50
In reply to Re: Relapse risk is greater for rapid drug withdrawal, posted by manic666 on May 29, 2010, at 13:36:58
Manic didn't realize your depression had occurred at a young age. Phillipa
Posted by manic666 on May 30, 2010, at 3:22:14
In reply to Re: Relapse risk is greater for rapid drug withdrawal » manic666, posted by Phillipa on May 29, 2010, at 20:18:50
all my life really /i just didnt care to except it// i new i was different //but who could you tell in the early days//my dad didnt want to no the old bastard//an i couldent hurt my dear old mum it would have killed her //so i did what most did an hid the truth//you no your ill but its not cool to be mental
Posted by Phillipa on May 30, 2010, at 19:18:41
In reply to Re: Relapse risk is greater for rapid drug withdrawal, posted by manic666 on May 30, 2010, at 3:22:14
I had no idea. How did you manage all that working, marriage, and kids? Phillipa
Posted by manic666 on May 31, 2010, at 4:18:51
In reply to Re: Relapse risk is greater for rapid drug withdrawal » manic666, posted by Phillipa on May 30, 2010, at 19:18:41
how does anyone///you have wife, kids, morgage/work through anxierty an mini breakdowns//my kids just thought i was a cool dad an a bit off the wall//well a lot off the wall, behind the smile,thats how it is //you cry when alone an be over the top in company//you get hammered when out as fast as you can to relax as much as you can ,hence the crazy things im known for///every one goes home to bed i stay up all night carnt sleep//never go abroad on holiday ,never have //flying no problem ,fear of going nuts in strange place an embarsing me an my family//you work your life round what you can do//an bluff the rest//you live two lives the real sh*t one, an the one for others//dont show you probs to people its not theres its yours//an you wont get sympathy only disbelief//i have walked into car showrooms an picked up a ?25,000 subaru a felt nothing,in my real head //you raise your kids you do crazy off the wall thinks//you drive your car a speeds for a rush an dont care if you crash an die//on my own i may add//then all the little brakedowns in your brain turn to one f*ck*ng big one that you carnt hide //an you reolise you should have got more help years ago//only there wasnt any//suddenly you carnt hide behind the smile anymore an you family reolises there is something really wrong//an there powerless to help because you wont let them //you there dad an husband i look after them they dont look after me/// it gets worse not better after all the battles you have lost the big one//your in hospital an the world has changed forever//drugs ,theropy p docs questions//i have anger that this can control me//an i have anger at the sh*t help you get//i have anger at untrained staff an stupid questions an wrong meds//NOW take what relief you get an live it,dont moan when down fight it//the only peson that can help is yourself//do what you want to do //dont agree to things you dont want to do an live your own life without hurting the ones close//me an my grand kid adian are driveing 80miles to the seaside for fish an chips//some would say your are as mad as a frog //i would call it bonding with my grandkid //wacky grandad is a cool guy
Posted by Phillipa on May 31, 2010, at 20:20:18
In reply to Re: Relapse risk is greater for rapid drug withdrawal, posted by manic666 on May 31, 2010, at 4:18:51
Manic seriously good post. Phillipa
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