The value of a prospective assessment of discontinuation-emergent symptoms proximal to the termination of antidepressant treatment cannot be overstated. Though varying in frequency and intensity, nearly all classes of antidepressants have been linked with discontinuation reactions and the associated psychological, physical, and somatic discomfort. Spontaneous reports have been typically used to gauge the risks of discontinuation reactions. Judging from a number of prospective studies, spontaneous reports very likely underestimate the occurrence of discontinuation reactions. This probability suggests that systematic inquiry must urgently become a part of the assessment in antidepressant discontinuation studies. Insight into the number and type of events that may occur following antidepressant discontinuation may be gleaned from instruments such as the Discontinuation-Emergent Signs and Symptoms Scale. This article takes a comprehensive view of a number of studies dealing with discontinuation-related adverse events. It discusses key issues in the analysis of incidence rates of antidepressant discontinuation-emergent adverse events such as the obvious bias of both clinicians' and patients' being aware of the treatment discontinuation. This article also looks at early prospective studies of antidepressant discontinuation reactions based on spontaneous reports and discusses, while making the case for, prospective studies based on systematic inquiry.
"The rate of SRI-DS varies according to the agent class from 29.4% with TCAs to 32.2% with MAOIs . Within the SSRI class relatively high SRI-DS rates ranging from 42 to 86% have been reported with short acting agents such as paroxetine (T 1/2 = 18 h), fluvoxamine (T 1/2 = 15 h), and venlafaxine (T 1/2 = 5 h), whereas longer-acting agents such as fluoxetine (T 1/2 = 84 h, T 1/2 active metabolite = 4–16days) and sertralines (T 1/2 = 26 h, T 1/2 active metabolite = 62–104 h) have lower rates of SRI- DS (0–15%)  . "
[Show abstract][Hide abstract] ABSTRACT: Sudden discontinuation of serotonin reuptake inhibitors (SRI) can lead to a number of psychological (e.g., nervousness, anxiety, crying spells, psychomotor agitation, irritability, depersonalization, decreased mood, memory disturbances, confusion, decreased concentration, and/or slowed thinking) and somatic (e.g., nausea, dizziness, headache) symptoms. Recent studies have shown that withdrawal symptoms are common with paroxetine, venlafaxine and fluvoxamine, but relatively rare and mild with fluoxetine cessation, likely as a result of its longer half-life. We report an unusual case of a patient who developed delirium after abrupt discontinuation of fluoxetine.
[Show abstract][Hide abstract] ABSTRACT: Antidepressants have shown to be effective in the treatment of depression and anxiety by reducing symptoms, as well as the risk of relapse and recurrence. Yet, several obstacles have been acknowledged in the process of adequate diagnosis and treatment of patients with these diseases: underrecognition of the health problem by the patient, underconsultation among patients who need treatment, failure to recognise and diagnose the problem by the physician, failure to prescribe drug treatment for those who need so, and eventually, on the part of the patient, not taking the drug as instructed. This thesis aims to understand why patients deviate from the prescribed and advised treatment with antidepressant drugs. The studies presented are build upon the framework of the course of drug taking consisting of three phases, namely initiation, execution and discontinuation of therapy. In this thesis, we explore patients’ considerations and decisions, based on the three phases within the course of taking antidepressants. Initiation of antidepressant drug treatment has hardly been addressed in research. This thesis showed that over one in four patients who receive a first-time antidepressant prescription appeared to decline treatment; they either do not initiate drug taking or do not persist antidepressant use for longer than two weeks. Declining a first-time antidepressant prescription was more common in patients who consult their physician for a non-specific indication, in elderly and non-western immigrants. Illness perceptions and severity, treatment needs and concerns, and patients’ views on information revealed to be important factors in the initiation of antidepressant drug taking. Fundamental in exploring the execution phase of antidepressant therapy are changes in patients’ attitude towards antidepressant treatment in response to the experiences while taking them. Health beliefs and illness severity at start showed to influence patients’ decisions about antidepressant drug taking. Patients who discontinued treatment some months after start perceived the physician’s role as limited, both during initiation and execution of treatment. They seemed to be less involved in decision making, and often appeared to have little confidence in their physician. Discontinuers were often unconvinced about the necessity of using an antidepressant, and appeared to have a strong desire to discontinue treatment. Finally, assessing whether patients taper treatment as opposed to abrupt discontinuation is important to understand patients’ behaviour during discontinuation of antidepressant therapy. We showed that one in five patients abruptly discontinue their therapy. Abrupt discontinuation caused a larger increase in the number of discontinuation symptoms than tapering. Of all patients, only one-third used a physician-made tapering schedule. We recommend healthcare professionals to inform patients of the pros and cons of taking or not taking antidepressant medication, involve patients in the treatment decision, reflect progress with treatment over time, and elicit considerations as to whether continue or discontinue drug taking. In addition, we suggest that research could systematically incorporate patients’ perspectives on medicines. Evaluation of patients’ experienced advantages and disadvantages of drug taking may contribute to the understanding of why patients take certain decisions regarding their medication use.
[Show abstract][Hide abstract] ABSTRACT: Over the last few years, a number of medications have demonstrated their efficacy in the acute treatment of social anxiety disorder. At present, selective serotonin reuptake inhibitors probably constitute the first line treatment, based on their safety, tolerability, and efficacy in the treatment of social anxiety disorder and common comorbid conditions. Data from single trials suggest that clonazepam, bromazepam, and gabapentin may have efficacy similar to the serotonin reuptake inhibitors, but further studies are needed to confirm these findings. The monoamine oxidase inhibitor phenelzine appears to be at least as efficacious as these other agents, but should be reserved for cases that fail to respond to these safer medications. Among the reversible inhibitors of monoamine oxidase A, brofaromine may also be an effective drug, while moclobemide appears to be less potent. Future research directions should include delineating ways to achieve remission (as opposed to response); developing strategies for augmenting partial responders and treating nonresponders to first line approaches; studying the long-term response to medication and prevention of relapse when medication is discontinued; clarifying ways to integrate psychosocial and pharmacological treatment approaches; developing predictors of which patients do best with which treatments; and the treatment of social anxiety disorder in children and adolescents.
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