SSRI Discontinuation Linked to Poor Outcomes
In a naturalistic study, researchers identified 87 patients in an outpatient clinic who had taken SSRIs for depression and who were clinically stable for at least five years. After five years, 27 patients elected to discontinue SSRIs, and 60 elected to continue. Patients who chose to stop taking SSRIs were much more likely to experience depressive relapse over a one year period relative to patients who continued on medication (62% vs. 16%). For patients discontinuing SSRIs, the median time to relapse was 10 months, while for those who continued their meds, the median time to relapse was 38 months (three years and two months). Age, gender, number of prior depressive episodes, and SSRI type and dose were not significant predictors of relapse, but presence of residual depressive symptoms did strongly predict relapse (Pundiak TM et al., J Clin Psychiatry 2008;69(11):1811-1818).
TCPR’s Take: While the sample sizes are modest, the implications to the practicing psychiatrist are profound. Patients often ask us, “Will I have to take medication for the rest of my life?” We typically tell our patients that the longer they are in remission the safer it will be to taper their medications. But this study casts doubt on this clinical wisdom. While patients were not randomly assigned to continuation vs. discontinuation, in some ways this reinforces the results even more. Why? Because patients who naturalistically decided, in consultation with their psychiatrists, to taper their SSRI after five years would be the ones you would expect to have the best prognosis.
The extent to which the advantage for medication continuation represents a true prophylactic effect as opposed to discontinuation effects of the medications is unknown, though medications were slowly tapered in this study. Though not well studied, adding psychotherapy prior to medication discontinuation may help decrease risk of relapse (see research update in this issue).
Cognitive Therapy Delays Relapse in Youth Depression
A recent trial examined the impact of adding cognitive-behavioral therapy to an existing SSRI regimen in the prevention of relapse in pediatric depression. After showing a treatment response to an open-label trial of an SSRI (usually fluoxetine), participants were then randomly assigned to either augment their medication by adding eight to 11 sessions of CBT or to continue medication at the same dosage. Over the six-month continuation treatment period, 37% of the medication group relapsed compared to 15% of patients in the CBT + medication group, a statistically significant difference. Parents reported greater satisfaction in the CBT + medication group, and a nonsignificant trend favored the combined treatment group in terms of child satisfaction with treatment and depression rating scale scores (Kennard BD et al., J Am Acad Child Adolesc Psychiatry 2008;47:1395-1404).
TCPR’s Take: This appears to be the first study of its kind with depressed youth. The roughly 40% relapse rate on medication is very similar to rates seen in an earlier study examining long-term antidepressant efficacy in children (Emslie GJ et al., Am J Psychiatry 2008;165:459-467). The current study included only 46 participants, but the significant effect seen in favor of CBT suggests that its results are not a fluke. This study’s results are consistent with findings from the psychotherapy literature which suggest that maintenance psychotherapy for psychotherapy responders reduces depressive relapse. Providing patients with CBT (or perhaps other psychotherapies) is likely an effective method to improve long-term treatment response.
The Role of Etiquette-Based Medicine
We’ve all been told from time to time that we should mind our manners. A Boston psychiatrist, Michael Kahn, suggests that manners are not limited to dinner parties; rather, he calls for “etiquette-based medicine.” Dr. Kahn is not writing about displaying empathy toward patients (though this is certainly important) – he’s talking about simply showing common courtesy and respect. He proposes that to increase patient satisfaction, physicians should seriously consider developing protocols for proper behavior, even creating checklists that remind us how to behave in the presence of patients. For example, he devised a checklist for an initial meeting with a hospitalized patient that included: asking permission to enter the room; introducing oneself; shaking hands; sitting down (smiling if appropriate); explaining one’s role; and asking how the patient feels about being in the hospital. Such checklists could be adapted to a wide variety of situations and could be used to help train students and residents (Kahn MW, N Engl J Med 2008;358:1987-1988).
TCPR’s Take: It is sad to think that physicians need to be reminded to display common courtesy; however, nearly every physician has heard patients complain of another doctor’s poor manners. Treating patients with respect is important for many reasons, one of which is that it improves adherence to treatment. Devising some simple professional routines to use during client encounters is likely a good idea; it is hard to see a downside to consistent professionalism.