Managing Antidepressant Discontinuation: A Systematic Review

Time has come to stop using the term discontinuation syndrome since it is misleading and pushes the clinician to think that this is a benign and self-limited syndrome (Fava et al., 2015; Fava et al., 2018). The most appropriate definition is withdrawal syndrome, that is the same kind of withdrawal syndrome which is widely known for benzodiazepines, antipsychotics, substances of abuse. It is important for clinicians to know that antidepressant discontinuation or reduction might trigger a withdrawal syndrome which is in need of being discussed with patients before initiating an antidepressant. Doing so will allow patients to make more informed decisions about whether they want to start an antidepressant in the first place or whether they want to start a different pharmacological or psychological intervention, if appropriate and available.

The literature is not currently rich enough to let clinicians reassure patients that relapse rates may be lower in the primary care setting and that withdrawal symptoms are reduced by tapering or slow tapering. From a clinical point of view, slow tapering seams to reduce the severity of withdrawal symptoms, although it implies a longer duration, but this clinical impression is in need of being verified via appropriate research studies. Also switching to fluoxetine was proposed since it has a longer elimination half-life than other SSRIs or SNRIs, however from a clinical point of view not all patients benefit from this strategy and, above all, this strategy has not been tested in trials, yet.

Withdrawal does not manifest only in a single syndrome, for the moment the literature suggests the existence of at least three different syndromes, called new withdrawal, rebound, and persistent post-withdrawal disorders. They must be differentiated from relapse/recurrence, fortunately diagnostic criteria for the three withdrawal syndromes are already available (Chouinard & Chouinard, 2015) as well as a diagnostic interview based on them (Cosci et al., 2018), thus it should become easier and easier to formulate the correct diagnosis.

Guidelines to treat withdrawal syndromes are not available, yet, since randomized clinical trials are still rare. Pharmacological treatment (other than SSRI or SNRI) have been proposed as well as psychological ones, although a recent study failed to show that cognitive behavioral therapy prevents the onset of withdrawal syndromes compared to treatment as usual in a randomized controlled trial (Sholten et al., 2018). Withdrawal syndromes need to be studied and known both in primary care clinician management and in specialist clinical management, this is the only option to provide adequate assessment and treatment to our patients.

References

Chouinard G, Chouinard VA. New classification of Selective Serotonin Reuptake Inhibitor withdrawal. Psychother Psychosom. 2015;84:63-71.

Cosci F, Chouinard G, Chouinard V-A, et al. The Diagnostic clinical Interview for Drug Withdrawal 1(DID-W1)-New Symptoms of Selective Serotonin Reuptake Inhibitors (SSRI) or Serotonin Noradrenaline Reuptake Inhibitors (SNRI): inter-rater reliability. Riv Psichiat. 2018;53:95-99.

Fava GA, Benasi G, Lucente M, et al. Withdrawal symptoms after Serotonin-Noradrenaline Reuptake Inhibitors discontinuation. Psychother Psychosom. 2018;87:195-203.

Fava GA, Gatti A, Belaise C, et al. Withdrawal symptoms after Selective Serotonin Reuptake Inhibitor discontinuation: a systematic review. Psychother Psychosom. 2015;84:72-81

Scholten WD, Batelaan NM, van Oppen P, et al. The efficacy of a group-CBT-relapse prevention program for remitted anxiety disorder patients who discontinue antidepressant medication: a randomized controlled trial. Psychother Psychosom. 2018;87:240-242.

Competing interests: None declared