54 - Practical application of tapering

Practical application of tapering

380 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 3 Practical application of tapering Before tapering All patients should be informed of the risk of withdrawal symptoms on stopping any antidepressant. Some antidepressants, such as paroxetine and SNRIs, are more commonly associated with severe withdrawal symptoms. Patients should be warned not to stop antidepressants abruptly, because this is the method thought to be most likely to give rise to severe and long-­lasting withdrawal symptoms and to an increased risk of relapse. Although stopping antidepressants can cause some unpleasant symptoms, patients should be told that if they taper gradually and carefully, withdrawal symptoms can be maintained at tolerable levels. As patients may have had negative experiences of too-­ rapid tapering in the past, reassurance may be required. It is difficult to predict the exact period required for an individual to taper off antidepressant medication but most patients who have been taking antidepressants long term take between 3 months and 3 years. This may help to set expectations. Patients’ past experiences of stopping should be explored, as they can be informative for predicting what symptoms may arise again on tapering. Careful consideration of past attempts to stop may detect withdrawal symptoms being misdiagnosed as relapse. Often, patients will require some preparation for antidepressant tapering. This might include arrangements for lightening work or family duties or increased focus on non-­ pharmacological coping skills (patients have found a wide variety of tools useful, including acceptance, breathing exercises, exercise, hobbies, diary keeping and de-­ catastrophising).21,22 Psychological interventions to support tapering demonstrated limited effectiveness, probably because physiological factors predominate, and psychological support, while potentially helpful, is not a substitute for gradual, pharmacologically informed tapering.13,23 Both clinicians and patients should be aware that patients can experience negative psychological and physical symptoms during withdrawal that need not indicate that the full dose of the drug is needed (but may indicate that the taper rate needs to be slowed). Familiarity of the patient and the doctor with the wide variety of withdrawal symptoms (Figure 3.3) may help to mitigate unnecessary anxiety when symptoms arise and prevent misdiagnosis of relapse or other physical (such as neurological or psychosomatic conditions) or mental health conditions (such as anxiety, depressive or even psychotic disorders when symptoms are extreme), as often occurs.24 Patients may require more support during the process, professional or otherwise.22 The process of tapering Patients may be broadly risk-­stratified (further details are provided in the Maudsley Deprescribing Guidelines):9 ■ ■For low-­risk patients (<6 months of use, low-­risk antidepressant, no experience of significant withdrawal symptoms in the past), a test reduction could be made (of 25–50%). ■ ■For high-­risk patients (>24 months of use, high-­risk antidepressant, past history of severe withdrawal symptoms) a test reduction of 5–10% should be recommended. ■ ■Intermediate-­risk patients could reduce by 10–20% of their original dose.