Discontinuing Antidepressants in MDD: Timing, Tapering, and Relapse

In "Discontinuing Antidepressants in MDD: Timing, Tapering, and Relapse," the panel explores the decision that gets far less attention than the prescription.

Dr. Alva notes that stopping an antidepressant is as much a clinical act as starting one, and that it is often done badly. He asks Dr. Clayton when discontinuation is warranted, how she separates discontinuation syndrome from relapse, and when a slower taper makes sense.

Dr. Clayton starts with the clearest case. If a patient has not responded at an adequate dose, has been adherent, and is tolerating the medication, it should be discontinued. She would also stop a medication that provoked something else, such as mania. She then takes on duplicative prescribing directly. Two SSRIs, or an SSRI paired with an SNRI, do not make mechanistic sense, because the receptors are already saturated. That combination should go. The same holds when two treatments work against each other or carry an interaction that is not appropriate.

On how to stop, she draws the distinction by duration of exposure. If someone has been on a medication only briefly, she moves more quickly, and discontinuation symptoms are not much of a problem. She adds a practice note about the agents most associated with discontinuation symptoms. She does not use many of those drugs to begin with, because she works with women who may become pregnant, so she avoids them from the outset. She offers a different lever that she finds useful. She asks whether anyone else in the family has had depression, and what worked for them, because that history has real value. If the current medication is not working, that family response may point to the next choice. Her summary position is that clinicians should discontinue when something is not working, and can do so earlier than they typically do. A slow taper is reasonable, particularly when a patient has been on the medication six months or longer.

Up next, in "The MDD Pipeline: New Mechanisms Beyond the Monoamine Model," Dr. DeBattista tempers the enthusiasm around a pipeline finally moving beyond the monoamine model.