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2010 American Psychiatric Association APA Practice Guideline: About discontinuation

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How tapering and discontinuation syndrome are described in the American Psychiatric Association Practice Guidelines

 

Treatment of Patients With Major Depressive Disorder, Third Edition

originally published in October 2010

http://www.psychiatryonline.com/pracGuide/pracGuideTopic_7.aspx

 

PRACTICE GUIDELINE FOR THE

Treatment of Patients With

Major Depressive Disorder Third Edition

 

[emphases mine]

 

....page 20

Section I.B.5. Discontinuation of treatment

When pharmacotherapy is being discontinued, it is best to taper the medication over the course of at least several weeks . To minimize the likelihood of discontinuation symptoms, patients should be advised not to stop medications abruptly and to take medications with them when they travel or are away from home . A slow taper or temporary change to a longer half-life antidepressant may reduce the risk of discontinuation syndrome [iI] when discontinuing antidepressants or reducing antidepressant doses. Before the discontinuation of active treatment, patients should be informed of the potential for a depressive relapse and a plan should be established for seeking treatment in the event of recurrent symptoms . After discontinuation of medications, patients should continue to be monitored over the next several months and should receive another course of adequate acute phase treatment if symptoms recur .

 

For patients receiving psychotherapy, it is important to raise the issue of treatment discontinuation well in advance of the final session , although the exact process by which this occurs will vary with the type of therapy.

 

....page 58

E. DISCONTINUATION OF TREATMENT

If maintenance-phase treatment is not indicated, stable patients may be considered for discontinuation of treatment after the continuation phase. The precise timing and method of discontinuing psychotherapy and pharmacotherapy for major depressive disorder have not been systematically studied.

 

The decision to discontinue treatment should be based on the same factors considered in the decision to initiate maintenance treatment (Table 10), including the probability of recurrence, the frequency and severity of past episodes, the persistence of depressive symptoms after recovery, the presence of co-occurring disorders, and patient preferences. The type of treatment being received may also play a role in the decision making. In general, psychotherapy has a longer lasting treatment effect and carries a lower risk of relapse following discontinuation than pharmacotherapy. In terms of timing, patients should be advised not to discontinue medications before holidays, significant events (e.g., weddings), or stressful events.

 

Patients should be carefully monitored during and immediately after treatment discontinuation to ensure that remission is stable. The highest risk for a relapse is seen in the first 2 months after discontinuation of treatment. Hence, it is important to schedule a follow-up visit during this period to ensure stability.

 

When pharmacotherapy is being discontinued, it is best to taper the medication over the course of at least several weeks. Such tapering allows for the detection of recurring symptoms at a time when patients are still partially treated and therefore more easily returned to full therapeutic treatment if needed. In addition, such tapering can help minimize the incidence of antidepressant medication discontinuation syndromes, particularly with paroxetine and venlafaxine (98, 163, 164). Discontinuation syndromes are problematic because their symptoms include disturbances of mood, energy, sleep, and appetite and can therefore be mistaken for or mask signs of relapse (517). Consequently, patients should be advised not to stop medications abruptly and to take medications with them when they travel or are away from home. Discontinuation syndromes have been found to be more frequent after discontinuation of medications with shorter half-lives, and patients maintained on short-acting agents should have their medications tapered gradually over a longer period (518, 519). Another strategy is to change to a brief course of fluoxetine, e.g., 10 mg for 1–2 weeks, and then discontinue the fluoxetine (165). The psychiatrist should closely monitor patients withdrawing from antidepressants and provide reassurance that symptoms are time-limited and can be addressed by more gradual tapering (see Section II.B.2.b.1.i).

 

How to end psychotherapy is typically dependent on the type of therapy. For time-limited approaches, termination is usually broached from the initiation of treatment and periodically revisited, as the therapist-patient dyad notes which session they are in, how many remain, and how they have progressed toward defined goals. In dynamically oriented psychotherapy, the therapist typically raises termination as an issue well in advance of the final session, using the opportunity to explore remaining and unresolved issues in transference.

 

Before the discontinuation of active treatment, patients should be informed of the potential for a depressive relapse. Early signs of major depressive disorder should be reviewed, often with a family member, and a plan established for seeking treatment in the event of recurrent symptoms. Patients should continue to be monitored over the next several months to identify early evidence of recurrent symptoms. Again, systematic assessment of symptoms, side effects, adherence, and functional status during this period of high vulnerability is strongly recommended. If a patient does suffer a recurrence after discontinuing medication, treatment should be promptly reinitiated. Usually, the previous treatment regimen to which the patient responded in the acute and continuation phases should be reinitiated (520). Patients who have a recurrence following discontinuation of antidepressant therapy should be considered to have experienced another major depressive disorder episode and should receive adequate acute-phase treatment followed by continuation-phase treatment and possibly maintenance-phase treatment.

 

....page 39

Section II.B.2.b.1.i. Discontinuation syndrome

Selective serotonin reuptake inhibitors generally should not be abruptly discontinued after extended therapy and, whenever possible, should be tapered over several weeks to minimize discontinuation-emergent symptoms. Clinical experience and a few controlled studies suggest that among the SSRIs, discontinuation-emergent symptoms are more likely with paroxetine than sertraline, citalopram, or escitalopram and least likely to occur with fluoxetine (due to the long elimination half-life of its primary metabolite, norfluoxetine) (163, 164). Discontinuation-emergent symptoms include both flu-like experiences such as nausea, headache, light-headedness, chills, and body aches, and neurological symptoms such as paresthesias, insomnia, and “electric shock-like” phenomena. These symptoms typically resolve without specific treatment over 1–2 weeks. However, some patients do experience more protracted discontinuation syndromes, particularly those treated with paroxetine, and may require a slower downward titration regimen. Another strategy is to change to a brief course of fluoxetine, e.g., 10 mg for 1–2 weeks, and then taper and discontinue the fluoxetine (165).

 

----------A Quick Reference Guide-----------

Treating Major Depressive Disorder

Based on Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition, originally published in October 2010. A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available.

 

E. DISCONTINUATION OF TREATMENT

 

For stable patients, consider discontinuation of treatment.

  • How and when to discontinue treatment has not been systematically studied. Factors to consider include the following:

    • Risk of recurrence • Frequency and severity of past episodes • Persistence of depressive symptoms after remission • Presence of co-occurring disorders • Patient preference

  • In general, psychotherapy has a longer-lasting treatment effect and carries a lower risk of relapse following discontinuation than pharmacotherapy.
  • Patients should be advised not to discontinue medications before stressful events (e.g., holidays, weddings).
If pharmacotherapy is discontinued, taper the medication over at least several weeks.

  • Tapering allows for the detection of recurring symptoms and facilitates a return to full treatment if needed.
  • In addition, tapering can minimize discontinuation syndromes, particularly with antidepressants with short half-lives, such as paroxetine and venlafaxine. Symptoms of discontinuation syndromes include both flu-like experiences such as nausea, headache, light-headedness, chills, and body aches, and neurological symptoms such as paresthesias, insomnia, and “electric shock-like” phenomena.
Continue to monitor the patient.

  • The patient should be informed about the potential for relapse, and a plan for resuming treatment if symptoms return should be established.
  • Risk of relapse is highest in the first 2 months following discontinuation of treatment. Hence, it is important to schedule a follow-up visit during this period.
  • Systematic assessment is strongly recommended.

Other sections of interest:

 

Comments on the guidelines (comments from public accepted) http://mx.psych.org/survey/reviewform.cfm

 

Dosing of Antidepressants http://www.psychiatryonline.com/popup.aspx?aID=654898

 

Antidepressant Washout Times http://www.psychiatryonline.com/popup.aspx?aID=655376

 

Side Effect Treatment http://www.psychiatryonline.com/popup.aspx?aID=655181

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