What should be done when a patient on antidepressants improves? Long neglected, the question is now seen as a major medical issue, and research is accumulating on how to stop treatment. But the answers remain uncertain and difficult to implement.
“As soon as an antidepressant is changed or reduced, it becomes a source of anxiety for the person concerned,” Christine Villelongue, co-president of the association France Dépression, told AFP. However, “there is no framework: very often, when people stop taking it, there is no follow-up.”
After several decades of use, doctors know very well under what conditions to prescribe an antidepressant, which one to favor initially, how to evaluate its success… Precise rules are taught and put into practice.
But when the patient improves, the uncertainties multiply. Should the treatment be continued as is, with side effects that can accumulate in the long term? Should it be continued at a low dose? Should it be stopped, at the risk of a relapse or a difficult withdrawal? And, if so, should it be stopped suddenly or gradually?
These questions have been making their way among psychiatrists for several years, with the emergence of a concept: "deprescribing" which embodies the importance of thinking about stopping an antidepressant, an awareness that was far from obvious for a long time.
"Throughout my internship, which I completed very recently, this subject was never addressed in the teaching," French psychiatrist Maeva Musso, president of the Association of Young Psychiatrists and Young Addiction Specialists, told AFP.
When patients "express the wish to reduce their treatments, this is still too often interpreted by the medical profession as a denial of their disorder," continues Ms. Musso, who is very committed to the issue of deprescribing.
– A large-scale study –
She notes that other countries are more advanced than France, such as Norway, where consultations dedicated to deprescribing are offered, or the Netherlands, where micro-doses of antidepressants are authorized in order to allow a very gradual reduction.
But is this really the best strategy, as many psychiatrists believe? The idea seems intuitive, but specialists still face a glaring lack of evidence on how to proceed.
In this context, a large study, published this Thursday in The Lancet Psychiatry, finally provides answers of unprecedented robustness, thanks to the extent of the data collected.
The authors, led by Italian researchers Giovanni Ostuzzi and Debora Zaccoletti, evaluated all the studies already conducted to compare the different options when a depressed patient is doing better, more than 70 clinical trials involving some 17,000 people.
The researchers highlighted that a patient whose antidepressant medication is gradually discontinued has no greater risk of relapse than if they continue treatment, provided they have access to psychological support. In all cases, the worst option remains abruptly stopping the medication.
"Even if antidepressants are effective in preventing depressive relapses, there is no obligation to make them a long-term treatment for everyone," concludes Ms. Zaccoletti, quoted in a Lancet press release.
But several specialists urge caution: they point out, for example, that a gradual reduction without psychological support does not necessarily appear safer than a sudden stop.
“Even when an antidepressant is tapered very gradually, stopping it remains associated with a risk of relapse,” warns German psychiatrist Jonathan Henssler in a commentary also published by The Lancet Psychiatry. According to him, the results primarily demonstrate “the additional benefit provided by psychotherapy.”
However, for many patients, such support is not a realistic option, as Ms. Villelongue points out, emphasizing the "shortage" of caregivers in France.
The Lancet Psychiatry's findings "represent an ideal world, but that's not the reality on the ground," she argues. "Sometimes the psychiatrist is absent; you go a month or two without seeing them. In the meantime, if the person is tapering off medication and isn't doing well, they have no one to talk to."
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