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One third of patients with anxiety disorder will relapse when SSRI/SNRI treatment stops
Clinical Question
How common is relapse in patients with anxiety disorder following the discontinuation of treatment with an antidepressant?
Bottom line
Discontinuing the antidepressant treatment of patients with anxiety disorders will cause a relapse in almost one third of them. Unfortunately, 1 in 6 patients previously treated successfully will also relapse despite continued treatment. 1a-
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Self-funded or unfunded
Setting: Various (meta-analysis)
Synopsis
The authors searched 3 databases, including Cochrane CENTRAL, as well as clinical trial registries, to identify published and unpublished studies of patients with anxiety disorders (panic disorder, agoraphobia, social phobia, generalized anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, or a specific phobia) who responded to antidepressant treatment and were subsequently randomized to either continue antidepressant treatment or be switched to placebo. Two researchers independently selected research for inclusion, abstracted data, and evaluated study quality. The 28 included studies enrolled a total of 5233 patients, and followed them up for 8 weeks to 52 weeks. Relapse occurred in 36.4% of patients who were witched to placebo, but also in 16.4% of patients who continued treatment (odds ratio 3.11; 95% CI 2.48 - 3.89). There was no significant difference in relapse rates based on type of anxiety. The rate of relapse varied across the studies, likely due to the different durations of follow-up. All but 2 of the studies were sponsored by pharmaceutical companies and 6 were previously unpublished; additional unpublished studies were identified but data could not be obtained, increasing the risk of publication bias.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
Informed consent is always good but may or may not improve outcome
This information is not helpful. There is no indication of duration of remission (or whether remission even occurred), prior to discontinuation of antidepressants, nor length if time to relapse. Also, the vastly variable follow up times (including some as short as 8 weeks) is a problem. It would also be useful to see information on the effects of combining antidepressant treatment with cognitive behavioural therapy, and the impact of the latter on duration of remission following discontinuation. I am also not clear whether the studies included in this summary involved significant psychoeducation, and CBT or other treatments. This would presumably have a big impact. Finally, the question of the unpublished studies and how that would affect the overall picture is a significant one.
Very important info, I did not know that symptoms of anxiety will worsen in 1 in 6 patients despite of continuation of therapy. I would like to know if CBT played any role in final results ?? Any data about that??
Good poem
I think that one of the major shortcomings is that there is no comparison by reception of psychotherapy. The risk of relapse of major depression increases, for example, by number of past episodes and yet reception of CBT drastically impacts upon this risk (in a favourable direction). Perhaps this is a strong argument for public funding of psychotherapy?
Appreciated the disclosure of the industry stats re: studies included. Of 28 studies only 2 we’re not funded by pharmaceutical companies, wow!
Publication bias indeed. There are good alternatives to antidepressants for anxiety (e.g., mindfulness meditation, yoga, regular exercise). At the very least we should attempt to address the underlying issues if we are serious about helping people get off pharmaceuticals. If we just write scripts then it’s no surprise a 3rd relapse when they stop.
That said it appears many do not relapse when taken off these meds. Silver linings...
The finding of this study is certainly something to bear in mind but I think the approach should still be individualized.
bad poem
need more information on treatment modalities used, to evaluate outcomes
Relapse and withdrawal symptoms are very similar. This does not look at that very important distinction, so unfortunately is not helpful. The real answer is most of these people don’t need medications, they need therapy.