Patients must wait longer for treatment benefit from new medication Same as moderate switch but with longer washout period (seven days for most drugs, except those with long half-lives ) More time-consuming but considered to be saferĬurrent medication is tapered down, followed by a washout period of four or five half-lives Potential for antidepressant discontinuation syndrome due to drug-free period New medication is initiated at a conservative dose, then increasedĭiscontinue for two- to three-day washout period May be difficult to determine if patient-reported adverse effects are due to the new agent or antidepressant discontinuation syndromeĬurrent medication is tapered down, followed by a washout period of two or three days Start a new medication immediately after discontinuing the current one Increased pill burden and financial strain for patients Potential for cytochrome P450– mediated drug reactions depending on drug choice Slowly decrease dose of the current medication while increasing dose of the new medicationĬitalopram (current medication, 40-mg starting dose):Įxposure to multiple serotonergic agents has inherent risks Reduce dose by 25% every four weeks or by 12.5% every two weeksĮasier to accomplish in real-world practice, but linear dose decrease may still result in antidepressant discontinuation syndrome Reduce dose every four weeks to match 10% reduction in serotonin transporter occupancyįormulated using pharmacokinetic data but difficult to precisely implement Population-based cohort study, systematic review 23, 36 Over 10 years (highest risk in first two years) Trend toward increased risk with escitalopram and paroxetine decreased risk with bupropion Weighted mean incidence = 40% (95% CI, 28.3 to 52.6) across observational studies Typically dependent on coexisting risk factorsĬross-sectional retrospective studies 31, 32 Hyponatremia (sodium 60 years, 20 mg per day) Nefazodone, bupropion, duloxetine (Cymbalta), trazodone SSRIs, especially when used with nonsteroidal anti-inflammatory drugs or antiplatelet drugs risk mitigated by acid-suppressing medications Recommended alternatives include duloxetine (Cymbalta), sertraline, and escitalopram. Systematic reviews of six clinical trials (n = 11,869) showing decrease in depressive symptoms in patients who are screened, even in the absence of follow-up measuresįluoxetine and paroxetine should be avoided in older patients. Pregnant and postpartum patients should be screened for depression. Two studies included in larger meta-analysis When discontinuing antidepressants, cognitive behavior therapy should be used to help prevent relapse and recurrence of depressive symptoms. 42 – 44ĭouble-blind randomized controlled trial, systematic reviews, meta-analyses When antidepressants are discontinued, the risk of relapse or recurrence of depressive symptoms is higher than when treatment is continued. 10, 16, 17Ĭlinical practice guidelines, systematic reviews Choice of medication should be guided by shared decision-making, with consideration of prior treatment and response, comorbidities, costs, and risk of adverse effects. Second-generation antidepressants, including selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, serotonin modulators, and atypical antidepressants, are recommended first-line medications for the treatment of depression. Network meta-analysis, systematic reviews, clinical practice guidelines In the primary care setting, antidepressant medication and psychotherapy should be offered for the treatment of depression. Depression and use of antidepressants are both associated with preterm birth. High-quality evidence on antidepressant use in pregnancy is lacking. Gradually tapering the dosage while concurrently providing cognitive behavior therapy can decrease this risk. There is an increased risk of relapse or recurrence of depressive symptoms when an antidepressant is discontinued, compared with continued use. Although many patients use antidepressants indefinitely, few studies have examined safety and effectiveness beyond two years. Treatment history, comorbidities, costs, and risk of adverse effects should be considered when choosing an antidepressant medication. The combination of medication and psychotherapy is preferred for severe depression. Psychotherapy, including cognitive behavior therapy and other types of individual and group therapy, is also a first-line treatment. Second-generation antidepressants (e.g., selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, serotonin modulators, atypical antidepressants) are first-line therapy for depression. Antidepressants are the most commonly prescribed medications for U.S. The prevalence of depression and the use of antidepressant medications have risen steadily in the United States over the past three decades.
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