What is the recommended approach for deprescribing antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), in adults?

Deprescribing Antidepressants in Adults: A Structured Approach

Antidepressants should be tapered gradually over a period of at least 4 weeks rather than stopped abruptly to minimize withdrawal symptoms, with longer tapering periods required for medications with shorter half-lives. 1, 2

Assessment Before Deprescribing

Before initiating deprescription of antidepressants, evaluate:

1. Current clinical status and indication

   • Determine if the patient has achieved stable remission (minimum 4-9 months of stability) 1
   • Assess if the original indication was appropriate (e.g., severe depression vs. mild/reactive symptoms) 3

2. Risk factors for withdrawal

   • Longer duration of treatment increases withdrawal risk 3
   • Medications with shorter half-lives (e.g., paroxetine, venlafaxine) have more pronounced withdrawal symptoms 2
   • Patient's age and comorbidities affect withdrawal risk 4

High-Priority Candidates for Deprescribing

Prioritize deprescribing in these scenarios:

• Patients with only mild or reactive depressive symptoms 1
• Long-term use (>6-12 months) for anxiety, insomnia, or mild depression 3
• Older adults with polypharmacy or comorbidities that increase risk 4
• Presence of adverse effects:
  • QTc prolongation concerns
  • Risk of delirium
  • Gastrointestinal bleeding risk (especially with concurrent NSAID use)
  • Liver injury risk 3

Tapering Protocol

1. General approach

   • Reduce dose gradually over at least 4 weeks 1
   • For long-term use (>1 year), consider extended tapering over 2-3 months 3
   • Use small dose decrements (25% reductions) at each step 2

2. Medication-specific considerations

   • SSRIs:
     • Fluoxetine (long half-life): May require less gradual tapering
     • Paroxetine, citalopram, escitalopram (shorter half-lives): Require more gradual tapering 2
   • SNRIs:
     • Venlafaxine and duloxetine: Require particularly slow tapering due to pronounced withdrawal effects 2
   • TCAs:
     • Require gradual tapering to avoid autonomic rebound symptoms 5

3. Monitoring during tapering

   • Schedule follow-up within 1-2 weeks of each dose reduction 2
   • Use standardized measures (e.g., PHQ-9) to monitor for symptom recurrence 2
   • Watch for withdrawal symptoms: flu-like symptoms, fatigue, tremor, insomnia, anxiety, confusion 1

When Not to Deprescribe

Antidepressants should not be deprescribed or should be deprescribed with extreme caution in:

• Patients with severe depression with high risk of relapse 1
• Patients with a history of multiple depressive episodes 6
• Patients with comorbid severe psychiatric conditions 6
• Cases where previous discontinuation attempts led to relapse 6
• Patients who express a preference to continue medication after informed discussion 6

Managing Withdrawal Symptoms

If withdrawal symptoms occur:

• Return to the previous dose that was well-tolerated 2
• Consider more gradual tapering with smaller dose decrements 3
• For severe withdrawal: Temporarily substitute with fluoxetine (longer half-life) before tapering 2

Special Considerations for Older Adults

• Start with lower doses of antidepressants and taper even more gradually 4
• Be vigilant for drug interactions, especially with medications that affect QTc interval 2
• Monitor for cognitive changes, falls risk, and orthostatic hypotension during tapering 5
• Consider deprescribing SNRIs and TCAs first if multiple psychotropic medications are used 5

Pitfalls and Caveats

• Withdrawal symptoms are often misinterpreted as relapse of depression 3
• True relapse typically occurs 2-3 months after discontinuation, while withdrawal symptoms appear within days 1
• Discontinuation of antidepressants may lead to cognitive deterioration in the following 2-3 months in some patients 1
• Sudden discontinuation can cause significant withdrawal syndromes that may require medical intervention 1

By following this structured approach to deprescribing antidepressants, clinicians can minimize withdrawal symptoms and optimize outcomes for patients who are appropriate candidates for discontinuation.