Managing antidepressant discontinuation: a systematic review

PurposeTo determine the effectiveness of interventions to manage antidepressant discontinuation, and outcomes for patients.MethodsSystematic review with narrative synthesis and meta-analysis. Sources: MEDLINE, PubMed, Embase, PsycINFO, AMED, Health Management Information Consortium (HMIC), OpenGrey, and WHO International Clinical Trials Registry Platform (ICTRP) to March 2017. Including: randomised controlled trials (RCTs), quasi-experimental, and observational studies assessing interventions to facilitate discontinuation of antidepressants for depression in adults. Primary outcomes: antidepressant discontinuation, and discontinuation symptoms. Secondary outcomes: relapse/ recurrence, quality of life, antidepressant reduction, sexual, social, and occupational function.ResultsOf 15 studies included, 12 were in the synthesis (8 RCTs, 2 single-arm trials, 2 retrospective cohort studies). None of the studies was rated high risk for selection or detection bias. Two studies prompting primary care provider (PCP) discontinuation with antidepressant tapering guidance found 6% and 7% of patients discontinued, versus 8% for usual care. Six studies of psychological or psychiatric treatment plus tapering reported cessation rates of between 40% and 95%. Two studies reported a higher risk of discontinuation symptoms with abrupt termination. At 2 years, risk of relapse/ recurrence was lower with cognitive behaviour therapy (CBT) plus taper versus clinicalmanagement plus taper (15%-25% vs 35%-80%: RR 0.34, 95% CI 0.18 to 0.67; 2 studies).Relapse/recurrence rates were similar for mindfulness based cognitive therapy (MBCT) with tapering and maintenance antidepressants (44%-48% vs 47%-60%; 2 studies).ConclusionsCBT or MBCT can help patients discontinue antidepressants without increasing the risks of relapse/recurrence, but are resource intensive. More scalable interventions are needed, incorporating psychological support