Psychological interventions such as preventive cognitive therapy (PCT) or mindfulness-based cognitive therapy (MBCT) can be delivered while a patient undergoes antidepressant tapering and may be an alternative to long-term antidepressant use, researchers say. Such interventions could be effective regardless of patient characteristics or the number of previous depressive episodes, suggest Dr. Claudi Bockting of Amsterdam University Medical Center in the Netherlands and colleagues. "Many patients wish to stop their antidepressant and are interested in exploring alternatives," Dr. Bockting told Reuters Health by email. "However, they face a dilemma, as stopping antidepressants may result in a return of depression." "We set out to study whether there is an alternative to medication and for whom it is possible to taper and stop antidepressant medication," she said. "Our study shows that clinicians and patients have a choice if the patient wants to stop their antidepressant - namely, a psychological intervention during and/or after tapering, regardless of clinical characteristics." As reported in JAMA Psychiatry, Dr. Bockting and colleagues searched the literature through January 2021 and requested individual participant data from randomized clinical trials (RCTs) comparing use of a psychological intervention during and/or after antidepressant tapering versus antidepressant use alone on the risk of depression relapse. Four RCTs with individual data from 714 participants (mean age, 49.2; 73.1%, women) were included. A meta-analysis found no significant difference in time to depressive relapse between use of PCT or MBCT during antidepressant tapering versus antidepressant therapy alone (hazard ratio, 0.86). Factors associated with a higher overall risk of relapse were: younger age at onset (HR, 0.98), shorter duration of remission (HR, 0.99), and higher levels of residual depressive symptoms at baseline (HR, 1.07). None of the included moderating factors (e.g., number of previous depression episodes, comorbid psychiatric disorder, relationship status) were associated with risk of relapse. The authors state, "Current clinical guidelines recommend the continued use of antidepressant medication for patients at high risk for depressive relapse (i.e., with multiple previous episodes and residual depressive symptoms). The results of this (individual participant data meta-analysis) suggest that continued use of an antidepressant might not be needed, even for patients at high risk." Nonetheless, they add, "The results should be interpreted with caution because depressive relapse may be mistaken for the withdrawal syndrome in the tapering conditions while a patient is receiving psychological interventions, thereby underestimating the ability of these interventions to prevent depressive relapse." Dr. Bockting said, "This study is part of the International TaskForce for RelApse prevention of depression. A larger individual patient data meta-analysis is being planned, where we look at different psychological interventions versus controls. With my team, I will focus now as well on depressed patients who do respond to treatment, but do not achieve full remission. We will study multimodal interventions to promote full recovery." Dr. Mark Foote, senior medical director for Intermountain Behavioral Health in Salt Lake City, Utah, commented on the study in an email to Reuters Health. "The general recommendation is that if someone is having a first or second episode of depression and they have been asymptomatic for approximately a year, we do want to taper them off the medications. I feel that psychotherapy will definitely be supportive in preventing relapse." However, he noted, "If someone has had multiple episodes of moderate to severe depression, the general recommendation has been to continue that medication to prevent relapse." The study is "a good reminder that we need to emphasize the importance of psychotherapy in treatment of depression and during remission," he said. Nonetheless, he added, "All decisions regarding medication tapering should be made with the prescribing clinician, taking all of the patient's factors into account." —Marilynn Larkin Source
