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Maudsley prescribing guidelines in psychiatry 2012

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dalsaan

The Maudsley prescribing guide in psychiatry claims to be the leading clinical reference guide in the UK. It is associated with the Maudsley hospital which is described as an international leader and ground breaker in mental health care

 

On page 276 of their latest guide they give the following advice:

 

'Many people suffer symptoms despite slow withdrawal and even if they have received adequate education regarding discontinuation symptoms. For those patients, the option do abrupt withdrawal should be discussed'.

 

Why is that you may ask. The answer lies in the next piece of prescribing advice

 

'Short life antidepressants should not generally. Be stopped abruptly, although some patients may prefer to risk a short period of intense symptoms rather than a prolonged period of milder symptoms'

 

 

Can you believe that! If your having trouble on a slow taper, cease them abruptly instead. We're not pulling of bandaids here, this is our nervous system we are talking about.

 

Perhaps we should have a thread that names and shames this baseless advice

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Altostrata

This is a measure of the cluelessness out there about withdrawal.

 

Do they give any citations for this? (Link, please!)

 

I wonder what they've seen in terms of success, doing this.

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Barbarannamated

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Altostrata

Thanks, Gia. I was very interested to look at the references they have for this odd technique to get people off antidepressants with only a couple of weeks of intense suffering.

 

As I recall from the papers cited, none of them suggest "abrupt withdrawal" when patients experience difficulty tapering. It must be a Maudsley innovation.

 

From Google Books

 

The Maudsley Prescribing Guidelines in Psychiatry

edited by David Taylor, Carol Paton, Shitij Kapur

 

John Wiley & Sons, Jan 25, 2012 - 584 pages

 

http://books.google.com/books?id=KY_2Qk4LqVYC&pg=PA276&lpg=PA276&dq=Many+people+suffer+symptoms+despite+slow+withdrawal+and+even+if+they+have+received+adequate+education+regarding+discontinuation+symptoms.&source=bl&ots=um3o36_4La&sig=fI_YQtH1h9a8hYuqk1oZ3QzbTiQ&hl=en&sa=X&ei=jsSaUJH8BPKw0AHgxYHgBQ&ved=0CDwQ6AEwAQ#v=onepage&q&f=false

 

page 276

 

How to avoid (16,17,18)

Generally, antidepressant therapy should be discontinued over at least a 4-week period (this is not required with fluoxetine).(10) The shorter the half-life of the drug, the more important it is that this rule is followed. The end of the taper may need to be slower. as symptoms may not appear until the reduction in the total daily dosage of the antidepressant is (proportionately) substantial. Patients receiving MAOls may need to be tapered over a longer period. Tranylcypromine may be particularly difficult to stop. At-risk patients (see section on ‘Who is most at risk?‘ in this chapter) may need a slower taper.

 

Many people suffer symptoms despite slow withdrawal and even if they have received adequate education regarding discontinuation symptoms.(8,21) For these patients, the option of abrupt withdrawal should be discussed. Box 4.9 lists the key points about which patients should be aware. Some may prefer to face a week or two of intense symptoms rather than months of less severe discontinuation syndrome.

 

How to treat (16,17)

There are few systematic studies in this area. Treatment is pragmatic. If symptoms are mild, reassure the patient that these symptoms are common after discontinuing an antidepressant and will pass in a few days. If symptoms are severe, reintroduce the original antidepressant (or another with a longer half-life from the same class) and taper gradually while monitoring for symptoms.

 

Some evidence supports the use of anticholinergic agents in tricyclic withdrawal(25) and fluoxetine for symptoms associated with stopping clomipramine(26) or venlafaxine(27); fluoxetine, having a longer plasma half-life, seems to be associated with a lower incidence of discontinuation symptoms than other similar drugs.(28)


Box 4.9 Key points that patients should know about antidepressant discontinuation syndromes

 

  • Antidepressants are not addictive (a survey of 1946 people across the UK conducted in 1997 found that 74% thought that antidepressants were addictive(1)). Note, however, that the semantic and categorical distinctions between addiction and the withdrawal symptoms seen with antidepressants may be unimportant to patients.

  • Patients should be informed that they may experience discontinuation symptoms (and the most likely symptoms associated with the drug that they are taking) when they stop their antidepressant.

  • Short half-life antidepressants should not generally be stopped abruptly, although some patients may prefer to risk a short period of intense symptoms rather than a prolonged period of milder symptoms.

  • Discontinuation symptoms can occur after missed doses if the antidepressant prescribed has a short half-life. A very few patients experience pre-dose discontinuation symptoms which provoke the taking of the antidepressant at an earlier time each day.

From References p. 277

8. Tint A et al. The effect of rate of antidepressant tapering on the incidence of discontinuation symptoms: a randomised study. J Psychopharmacol 2008; 22:330-332.

 

9. Taylor D et al. Antidepressant withdrawal symptoms - telephone calls to a national medication helpline. J Affect Disord 2006: 95:l29-133.

 

10. Rosenhaum JF et al. Selective serotonin reuptalte inhibitor discontinuation syndrome: a randomized clinical trial. Biol Psychiatry 1998; 44:77-87.

 

11. Michelson D et al. Interruption of selective serotonin reuptalte inhibitor treatment. Double-blind, placebo-controlled trial. Br J Psychiatry 2000; l76:363-368.

 

12. Goodwin GM et al. Agornelatine prevents relapse in patients with rnaior depressive disorder without evidence of a discontinuation syndrome: a 24-week randomized, double-blind, placebo-controlled trial. J Clin Psychiatry 2009; 70:1128-ll37.

 

13. Berigan TR. Mirtazapine-associated withdrawal symptoms: a case report. Prim Care Companion J Clin Psychiatry 2001; 3:143.

 

14. Benazzi F. Mirtazapine withdrawal symptoms. Can J Psychiatry 1998;43:525.

 

15. Berigan TR et al. Bupropion-associated withdrawal symptoms: a case report. Prim Care Companion J Clin Psychiatry 1999; 1:50~5l.

 

16. Lejoyeux M et al. Antidepressant withdrawal syndrome: recognition, prevention and management. CNS Drugs 1996:5:278-292.

 

17. Haddad PM. Antidepressant discontinuation syndromes. Drug Saf 2001; 24:l83-l97.

 

18. Anon. Antidepressant discontinuation syndrome: update on serotonin reuptalre inhibitors. J Clin Psychiatry 1997; 58(Suppl 7):3-40.

 

19. Sir A et al. Randomized trial of sertraline versus venlafaxine XR in major depression: efficacy and discontinuation symptoms. J Clin Psychiatry 2005;66:1312-1320.

 

20. Baldwin DS et al. A double-blind. randomized. parallel-group. flexible-dose study to evaluate the tolerability. efficacy and effects of treatment discontinuation with escitalopram and paroxetine in patients with major depressive disorder. Int Clin Psychopharrnacol 2006;21:l59-l69.

 

21. Fava GA et al. Effects of gradual discontinuation of selective serotonin reuptake inhibitors in panic disorder with agoraphobia. Int J Neuropsychopharmacol 2007:10:835-838.

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Altostrata

From: [Altostrata]

Subject: The Maudsley Prescribing Guidelines in Psychiatry

Date: November 10, 2012 2:16:51 PM PST

To: David.Taylor at slam.nhs.uk, carol.paton at oxleas.nhs.uk, shitij.kapur at kcl.ac.uk

 

Dear Doctors Taylor, Paton, and Kapur:

 

I am writing regarding the advice in the 2012 edition of The Maudsley Prescribing Guidelines in Psychiatry regarding discontinuation of antidepressants.

 

Specifically, I am interested in the following statement:

 

Many people suffer symptoms despite slow withdrawal and even if they have received adequate education regarding discontinuation symptoms.(8,21) For these patients, the option of abrupt withdrawal should be discussed. Box 4.9 lists the key points about which patients should be aware. Some may prefer to face a week or two of intense symptoms rather than months of less severe discontinuation syndrome.

 

My question is: What is your evidence that abrupt discontinuation in the above situation leads to only a week or two of intense withdrawal symptoms? I cannot find this information in any of your references.

 

To your knowledge, has this been put into clinical practice? What have the outcomes been?

 

If it is indeed effective, it may resolve the entire issue of tapering. Why not discontinue everyone abruptly, if only a week or two of intense symptoms follow?

 

Sincerely,

 

Altostrata

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dalsaan

Well done Alto, I'll be interested to see if you get a response. I have never seen any data/references supporting this approach and it defies logic from my perspective

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dalsaan

Hi Alto

 

Did you get any response to your email?

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Altostrata

From: Altostrata

Subject: Re: The Maudsley Prescribing Guidelines in Psychiatry

Date: November 15, 2012 10:25:44 AM PST

To: David Taylor <David.Taylor at slam.nhs.uk>

Cc: carol.paton at oxleas.nhs.uk, Shitij Kapur <shitij.kapur at kcl.ac.uk>

 

How can you determine who will have only a week or two of symptoms and who will have more severe and long-lasting symptoms, i.e. who is a candidate for cold turkey?

 

On Nov 11, 2012, at 6:37 AM, Taylor, David wrote:

 

This advice is based on clinical and personal experience. I know of no studies which support abrupt withdrawal but we have observed that symptoms persist only for a week or two after sudden stopping.

 

The reason it is not recommended to all is that the symptoms can be disabling and necessitate absence form work, etc. Symptoms are better tolerated in slow withdrawal.

 

D

 

Professor David Taylor

Director of Pharmacy and Pathology

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dalsaan

Hi Alto

 

Did you get a response to your follow up email?

 

Cheers

 

Dalsaan

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Altostrata

Nope. After a while, I sent them this.

 

 

From: Altostrata

Subject: Re: The Maudsley Prescribing Guidelines in Psychiatry

Date: November 20, 2012 5:46:42 PM PST

To: David Taylor <David.Taylor at slam.nhs.uk>

Cc: carol.paton at oxleas.nhs.uk, Shitij Kapur <shitij.kapur at kcl.ac.uk>

 

Dr. Taylor, you and your colleagues may be interested in the following paper, which suggests reactions to abrupt discontinuation may be more severe and longer lasting than only two weeks:

 

J Psychiatry Neurosci 2001;26(1):44–8.

Abrupt discontinuation of psychotropic drugs during pregnancy: fear of teratogenic risk and impact of counseling.

Einarson A, Selby P, Koren G.

 

Abstract at http://www.ncbi.nlm.nih.gov/pubmed/11212593 with free full text.

 

 

Throughout the literature, there are indications abrupt discontinuation leads to more severe and longer lasting withdrawal syndrome than tapering, as well as suggestions that, if withdrawal symptoms appear during tapering, the tapering be slowed with smaller decrements, not with abrupt discontinuation.

 

This is borne out by hundreds of thousands of posts all over the Web by patients who have discontinued too rapidly and report suffering withdrawal symptoms for months or even years.

 

Here are the results of a recent informal Web survey conducted by the Royal College of Psychiatrists http://www.rcpsych.ac.uk/expertadvice/treatments/antidepressants/comingoffantidepressants.aspx :

 

"People in our survey report that the symptoms generally lasted for up to 6 weeks. A small percentage of symptoms lasted longer than this. A quarter of our group reported anxiety lasting more than 12 weeks."

 

Please reconsider revising this section of the Maudsley, as clinicians may be injuring people by too-abrupt discontinuation.

 

Sincerely,

 

Altostrata

SurvivingAntidepressants.org

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bubbles

Hi Alto - this is a really old post, but did they ever respond and/or revise their recommendations?
 

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Altostrata

The only response I received was to my November 10, 2012 note at 

The response was:

 

Quote

This advice is based on clinical and personal experience.  I know of no studies which support abrupt withdrawal but we have observed that symptoms persist only for a week or two after sudden stopping.
 
The reason it is not recommended to all is that the symptoms can be disabling and necessitate absence form work, etc.  Symptoms are better tolerated in slow withdrawal.
 
D
 
Professor David Taylor
Director of Pharmacy and Pathology

 

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bubbles

Thanks Alto.

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