Antidepressant discontinuation linked with Risk of Relapse in Anxiety Disorders, OCD , and PTSD

In a Systematic Review and Meta-analysis of relapse prevention trials , the researchers have found that upto one year of follow up discontinuation of antidepressants in Anxiety Disorders, OCD and PTSD leads to relapse of the diseases.

Anxiety disorders have high prevalence rates are chronic in course and relapses after remission are common. Most (57%) patients with anxiety disorders who are being treated use drugs.As long term studies are scarce, whether antidepressants should also be regarded a first-line treatment option for optimising long-term prognosis remains largely unknown. International guidelines are therefore consensus based and advise continuation of treatment for variable durations (six to 24 months) and subsequent tapering of the antidepressant.

Neeltje M Batelaan et al examined the risk of relapse and time to relapse after discontinuation of antidepressants in patients with anxiety disorder who responded to antidepressants, and to explore whether relapse risk is related to type of anxiety disorder, type of antidepressant, mode of discontinuation, duration of treatment and follow-up, comorbidity, and allowance of psychotherapy.

The Data sources employed were PubMed, Cochrane, Embase, and clinical trial registers (from inception to July 2016).From which eligible studies patients with anxiety disorder who responded to antidepressants, randomised patients double-blind to either continuing antidepressants or switching to placebo, and compared relapse rates or time to relapse were included.

Data extraction Two independent raters selected studies and extracted data. Random effect models were used to estimate odds ratios for relapse, hazard ratios for time to relapse, and relapse prevalence per group. The effect of various categorical and continuous variables was explored with subgroup analyses and meta-regression analyses respectively. Bias was assessed using the Cochrane tool.

The meta-analysis included 28 studies (n=5233) examining relapse with a maximum follow-up of one year. Across studies, risk of bias was considered low. Discontinuation increased the odds of relapse compared with continuing antidepressants (summary odds ratio 3.11, 95% confidence interval 2.48 to 3.89). Subgroup analyses and meta-regression analyses showed no statistical significance. Time to relapse (n=3002) was shorter when antidepressants were discontinued (summary hazard ratio 3.63, 2.58 to 5.10; n=11 studies). Summary relapse prevalences were 36.4% (30.8% to 42.1%; n=28 studies) for the placebo group and 16.4% (12.6% to 20.1%; n=28 studies) for the antidepressant group, but prevalence varied considerably across studies, most likely owing to differences in the length of follow-up. Dropout was higher in the placebo group (summary odds ratio 1.31, 1.06 to 1.63; n=27 studies).

The researchers concluded that up to one year of follow-up, discontinuation of antidepressant treatment results in higher relapse rates among responders compared with treatment continuation. The lack of evidence after a one year period should not be interpreted as explicit advice to discontinue antidepressants after one year. Given the chronicity of anxiety disorders, treatment should be directed by long-term considerations, including relapse prevalence, side effects, and patients' preferences.

For more details click on the link: doi: https://doi.org/10.1136/bmj.j4461