The largest study published to date is clear: The only way to stop taking antidepressants is slowly and with psychological support. In fact, it prevents relapse into depression to the same extent as staying on antidepressants. This research, published today in the journal Lancet psychiatryis relevant for several reasons: 30% of people who are prescribed antidepressants do not actually suffer from depression; 40% take them for five years or more; and 22% do it indefinitely. However, this treatment causes unwanted side effects if taken for a long time, including sexual dysfunction and a decreased ability to express feelings. Thus, this study, which reviews 76 controlled trials involving 17,000 people, underlines the importance of adapting the prescription to each individual, with a gradual and individualized cessation of treatment, accompanied by psychological support.
“Depression is often a recurring illness without ongoing treatment; up to three in four people with depression relapse at some point,” says Giovanni Ostuzzi, a researcher at the University of Verona and lead author of the work. “Clinical guidelines recommend continuing antidepressants for a certain period after remission, and then considering stopping once the person feels well. However, in daily practice, treatment is often extended much longer than the guidelines suggest,” adds Ostuzzi, during a press conference organized this week by the SMC portal.
The meta-analysis compared different antidepressant withdrawal strategies in people with depression or anxiety already in remission. The conclusion was that slow withdrawal (more than four weeks), combined with psychological support, prevented relapses the following year to the same extent as continuing antidepressant treatment. The researchers estimated that slow withdrawal combined with psychological support could prevent one relapse in every five people, compared to abrupt cessation or rapid withdrawal (four weeks or less), which were the two least effective strategies.
“One of the most consistent results of the analysis is that psychological support or complementary psychotherapy is more effective for all different pharmacological strategies,” explains Jonathan Henssler, of the Charité Hospital in Berlin, in a commentary accompanying the article. “Even if this discovery may seem trivial, it is of considerable importance,” adds the expert, who did not participate in the study.
Henssler warns that psychological treatment “is often the hardest thing for patients to obtain in the real world.” In Spain, 30% of people who report having mental health problems turn to private healthcare without even having health insurance, according to the CIS Health Barometer, published in April this year. “Internet forums illustrate how much patients rely on self-help and how professional psychiatric and psychological support remains insufficient,” adds Henssler. 22% of Spaniards seen by a public health psychologist or psychiatrist took up to two months to be seen. And data indicates that more and more people are turning to artificial intelligence to speak out and solve their psychological problems, even though chatbots carry many risks: they reinforce self-centeredness and paranoid thinking.
The 76 trials analyzed mainly included people with major depressive disorder and various anxiety disorders. The average age of participants was 45 years, 67.5% were female, and 88% were white. The average patient follow-up was 46 weeks.
A major limitation of the study is that data on withdrawal symptoms were scarce, even though they are clearly one of the main barriers to stopping treatments. “Due to the lack of data in most studies, we sought to identify adverse events likely related to withdrawal,” explain the authors. However, they also say that these problems were more common among people who continued to take antidepressants than among those who stopped them quickly, suggesting that these are likely side effects of the antidepressant rather than withdrawal symptoms.
The authors believe their findings have relevant implications for clinical practice and health policy. The guidelines, they insist, should promote periodic review of treatment. Abrupt or rapid cessation of the antidepressant (one month or less) should be “strongly” discouraged, they insist, and a more gradual and individualized withdrawal schedule should be planned. Likewise, they believe that it is essential to provide psychological support. The authors themselves are aware, in any case, of the difficulty of implementing this recommendation in public health. Gerard Anmella, a psychiatrist and researcher at the depressive and bipolar disorders unit at Hospital Clínic de Barcelona, who was not involved in the study, agrees: “Is it possible to implement this strategy in health systems? at the SMC Spain portal.
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