Maintenance or discontinuation of antidepressants in primary care
Lewis G, Marston L, Duffy L, et al. N Engl J Med. 2021;385(14):1257-1267. doi: 10.1056/NEJMoa2106356.
This trial was asking whether patients should stop or continue their antidepressant.
This was a multicenter, randomized, double-blind trial from 150 general practices across 4 sites in the UK.
Recruitment was via letter after searching electronic medical records.
N=478 adults aged 18-74 years with a minimum of 2 previous episodes of depression or who had been on an antidepressant (citalopram, sertraline, fluoxetine, or mirtazapine) for >2 years and were considered well enough to discontinue the medication.
Participants received their usual antidepressant or tapered off to just placebo over months.
The primary outcome was the first relapse of depression within 1 year.
Mean age was mid 50s with 73% female; half were on citalopram.
Relapse within 1 year occurred in 39% of participants in the maintenance group and 56% in the discontinuation group (hazard ratio, 2.06; 95% CI: 1.56 to 2.70; P<0.001).
There was no statistical difference in adverse events.
EDITOR'S COMMENTARY - Ken Milne, MD This provides some good information when discussing whether to discontinue an antidepressant. There could be some participation bias, with 23,553 potential patients, 1,466 screened, 606 eligible, and 478 enrolled. These data lack external validity to antidepressants other than selective serotonin reuptake inhibitors (SSRIs) and mirtazapine and potentially to other countries. This trial was not funded by industry, which makes me have more confidence in the results.
BOTTOM LINE: It is reasonable to offer discontinuation of certain antidepressants with well-enough patients while cautioning them that there is a higher rate of relapse with stopping.
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