Guidance for the Discontinuation or Switching of Antidepressant Therapies in Adults

Abstract

Antidepressants (ADs) are commonly used for the treatment of various psychological and other medical disorders. Patient response and regimen duration with individual agents varies, necessitating discontinuation (DC) and/or switching between ADs. However, withdrawal symptoms may occur upon DC of the AD, and clinical symptom control may be compromised if the change to a new AD agent is not initiated appropriately. The purpose of this evaluation was to review the available literature and resources to compile documented methods for discontinuing or changing AD regimens in the clinical setting into a single guidance document. The results of this evaluation have yielded both detailed and general recommendations for practitioners to use and consider in discontinuing an AD and making changes between AD agents. The information provided herein is intended to provide useful guidance for clinicians and other health care professionals in their management of patients discontinuing or switching between selected AD agents.

Early Switching Strategies in Antidepressant Non-Responders: Current Evidence and Future Research Directions

“…A change in management could include increasing the dose of antidepressant, switching to another antidepressant, augmenting with another agent, or adding a non-medication treatment such as psychotherapy. If the decision is made to switch antidepressants, care should be taken to avoid discontinuation syndrome by tapering (reduction or increase of regimen dose/frequency over time) or cross-tapering antidepressants (one antidepressant is tapered down while the new antidepressant is tapered up over the same period of time) [36].…”

A review of the management of antidepressant discontinuation symptoms

“…They also agree that if discontinuation symptoms are severe, the drug should be reintroduced and a slower taper initiated [Ogle and Akkerman, 2013;Lader, 2007;Zarowitz, 2006;Schatzberg et al 2006;Reid and Cameron, 2009;Warner et al 2006;Edwards, 2006]. Baldwin and colleagues argue that duration of treatment has no association with incidence of discontinuation syndrome [Baldwin et al 2007] and two of the reviewed publications suggest that the half-life of the drug plays a more pivotal role than the taper rate [Tint et al 2008;Montgomery et al 2004].…”

“…The author argues that this period is required for the body to 'normalize' during discontinuation and recommend 4 months in order to reduce relapse rates and symptoms associated with drug withdrawal [Phelps, 2011]. Many of the guidance articles reviewed state explicitly that there is conflicting opinion as to the optimum duration of gradual dose reduction [Haddad and Anderson, 2007;Ogle and Akkerman, 2013] and the evidence base for tapering antidepressants is weak. Of the five clinical studies reviewed, only two [Himei and Okamura, 2006;van Geffen et al 2005] recommend tapering the drug over time as a result of findings that abruptly withdrawing medication significantly increases the likelihood of a discontinuation syndrome.…”

“…Most articles reviewed agree that tapering is unnecessary for patients who have been taking an antidepressant for 4 weeks or less as this is insufficient time to develop a withdrawal reaction [Ogle and Akkerman, 2013;Haddad and Anderson, 2007;Edwards, 2006]. They also agree that if discontinuation symptoms are severe, the drug should be reintroduced and a slower taper initiated [Ogle and Akkerman, 2013;Lader, 2007;Zarowitz, 2006;Schatzberg et al 2006;Reid and Cameron, 2009;Warner et al 2006;Edwards, 2006].…”

“…Due to the soaring prescription rates of drugs such as these and the prevalence of depression globally, guidance on the treatment of this disorder is necessary, especially for discontinuation, as adverse effects appear to be a common phenomenon experienced during drug withdrawal. According to Ogle and Akkerman, at present the literature available as well as the package insert guidance is vague and somewhat generic [Ogle and Akkerman, 2013]. As a result, the current study reviews the literature on:.…”