Current global depression guidelines offer incomplete guidance for clinicians to identify antidepressant withdrawal, says a team of specialists after studying data from a review of 21 guidelines.
They add that previous research finds that half of all patients who discontinue or decrease dosage of antidepressants experience withdrawal symptoms.
According to Dr Anders Sørensen of Copenhagen University Hospital and colleagues, withdrawal symptoms are diverse and may include flu-like symptoms, fatigue, anxiety and sensations of electric shock.
They said most withdrawal effects last for a few weeks, but some persist for months or years, sometimes described as persistent post-withdrawal disorder, reports Medscape.
“Symptoms of withdrawal and depression overlap considerably but constitute two fundamentally different clinical conditions, which makes it important to distinguish between the two,” the researchers emphasised.
In their study published in the Journal of Affective Disorders, the researchers identified 21 clinical practice guidelines (CPGs) for depression published between 1998 and 2022 in the UK, US, the Canada, Australia, Singapore, Ireland and New Zealand. They compared descriptions of withdrawal from antidepressants and calculated the proportion of CPGs with different information.
Overall, 15 of the 21 studies in the review (71%) noted that antidepressants are associated with withdrawal symptoms, but less than half (43%) used the term “withdrawal symptoms” or similar.
Of the nine guidelines mentioning withdrawal symptoms, five used the term interchangeably with “discontinuation symptoms” and six used the term “discontinuation symptoms” only when discussing antidepressant withdrawal.
In addition, six CPGs specifically stated that patients who stop antidepressants can experience withdrawal symptoms, and five stated that these symptoms also can occur in patients who are reducing or tapering their doses.
The type of withdrawal symptoms was mentioned in 10 CPGs, and the other 11 had no information on potential withdrawal symptoms, the researchers noted. Of the CPGs that mentioned symptoms specifically associated with withdrawal, the number of potential symptoms ranged from four to 39.
“None of the CPGs provided an exhaustive list of the potential withdrawal symptoms identified in the research literature,” the researchers wrote.
Only four of the guidelines (19%) mentioned the overlap in symptoms between withdrawal from antidepressants and depression relapse, and only one provided guidance on distinguishing between the two conditions.
Most of the symptoms of withdrawal, when described, were characterised as mild, brief, or self-limiting, the researchers noted.
“Being in withdrawal is a fundamentally different clinical situation from experiencing relapse, requiring two distinctly different treatment approaches,” they pointed out.
“Withdrawal reactions that are more severe and longer lasting than currently defined in the CPGs could risk getting misinterpreted as relapse, potentially leading to resumed unnecessary long-term antidepressant treatment in some patients.”
The findings were limited by several factors including the inclusion only of guidelines from English-speaking countries, which might limit generalisability, the researchers noted. Other potential limitations include the subjective judgments involved in creating different guidelines.
However, they said their results support the need for improved CPGs that help clinicians distinguish potential withdrawal reactions from depression relapse, and the need for more research on optimal dose reduction strategies for antidepressants.
Study details
Description of antidepressant withdrawal symptoms in clinical practice guidelines on depression: A systematic review
Anders Sørensen. Karsten Juhl Jørgensen, Klaus Munkholm.
Published in Journal of Affective Disorders on 1 November 2022
Abstract
Background
Antidepressant withdrawal symptoms may mimic symptoms of depression relapse and can be challenging for patients when tapering or discontinuing antidepressants. We aimed to assess how withdrawal symptoms are described in major clinical practice guidelines on depression.
Methods
Systematic review of major clinical practice guidelines on depression from the United Kingdom, the United States, Canada, Australia, Singapore, Ireland, and New Zealand. We searched PubMed, 14 guideline registries, and the websites of relevant organisations (last search 10 July 2022). The guidelines were assessed for information and descriptions of antidepressant withdrawal symptoms regarding their type, incidence, duration, severity, onset, and presumed mechanism.
Results
We included 21 guidelines, 15 (71 %) of which stated that withdrawal or discontinuation symptoms can occur. None of the guidelines provided an exhaustive list of potential withdrawal symptoms; ten (48 %) guidelines mentioned at least one specific symptom, ranging between four and 39 symptoms. The symptomatic overlap between withdrawal and relapse was mentioned in four (19 %) guidelines. Withdrawal symptoms were generally described as mild, brief, and self-limiting; and severe in a minority of cases. Estimates of the duration, incidence, or expected onset were reported in five (24 %) guidelines, and were in all cases lower than those reported in systematic reviews.
Limitations
We included clinical practice guidelines from English-speaking countries only; our findings may not be generalisable to non-English-speaking countries.
Conclusions
Clinical practice guidelines provide scarce and inadequate information on antidepressant withdrawal symptoms and limited guidance for distinguishing withdrawal symptoms from symptoms of relapse.
Medscape article – Depression Guidelines Fall Short in Characterizing Withdrawal
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