Summary of findings 4. Discontinuation of long‐term antidepressant with minimal intervention compared to usual care for depressive and anxiety disorders in adults.
| Discontinuation of long‐term antidepressant with minimal intervention compared to usual care for depressive and anxiety disorders in adults | ||||||
| Patient or population: participants with long‐term antidepressants for depressive or anxiety disorders Setting: primary care (GP practices) Intervention: discontinuation with minimal intervention Comparison: usual care | ||||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect (95% CI) | №. of participants (studies) | Certainty of the evidence (GRADE) | Comments | |
| Risk with usual care | Risk with discontinuation of long‐term antidepressant with minimal intervention | |||||
| Successful discontinuation rate: proportion (%) of participants who successfully stopped use of antidepressants at the end of the trial Defined as no antidepressant use during the preceding 6 months and absence of a depressive or anxiety disorder Follow‐up: 52 weeks |
In one study, there was no evidence of an effect on the antidepressant discontinuation rate | ‐ | 146 (1 RCT) | ⊕⊕⊝⊝ LOWa |
Intervention included a patient‐specific letter to the GP with a recommendation to discontinue the antidepressant and tapering advice Successful discontinuation was defined by study authors as no antidepressant use during the preceding 6 months and absence of a depressive or anxiety disorder In the intervention group, 6% (95% CI 2 to 14) successfully stopped their antidepressant compared to 8% (95% CI 4 to 16) who spontaneously stopped in the usual care group after 1 year (P = 0.6) |
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| Relapse rate Follow‐up: 52 weeks |
In one study, there was no evidence of an effect on relapse rate | ‐ | 146 (1 RCT) | ⊕⊕⊝⊝ LOWb | In the tapering advice group, 26% participants relapsed compared to 13% in the usual care group (P = 0.05) . Study did not distinguish relapse from symptoms of withdrawal |
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| Withdrawal symptoms | One study measured withdrawal symptoms but did not analyse or report data | |||||
| Adverse events | Not measured | |||||
| Depressive symptoms Assessed with CESD scale Follow‐up: 52 weeks |
In one study, there was no effect on depressive symptoms | 106 (1 RCT) | ⊕⊝⊝⊝ LOWc | Study authors reported a higher mean CESD score in the tapering group (n = 51) (mean CESD total endpoint score 13.7 (SD 8.9)) compared to the usual care group (n = 55) (mean CESD total endpoint score 12.6 (SD 7.9)) at the end of the trial but no difference between groups (P = 0.51) (higher CES‐D score means increased intense symptom severity) | ||
| Anxiety symptoms Assessed with PAS scale Follow‐up: 52 weeks |
In one study, there was no effect on anxiety symptoms | 104 (1 RCT) | ⊕⊝⊝⊝ LOWd | Study authors measured the severity of illness in patients with panic disorder by using the Panic and Agoraphobic Scale (PAS). Study authors reported a higher mean PAS score in the tapering group (n = 50) (mean PAS 4.1 (SD 7.2)) compared to the usual care group (n = 51) (mean PAS 3.6 (SD 7.1)) at the end of the study but no differences between groups (P = 0.71) (higher PAS scores indicating greater severity) | ||
| Quality of life Assessed with QALY by using EQ‐5D Follow‐up: 52 weeks |
In one study, there was no evidence of an impact on the quality of life | ‐ | 146 (1 RCT) | ⊕⊝⊝⊝ VERY LOWe | Participants in the tapering advice (n = 70) group had a mean of 0.70 QALYs (SD 0.25) and those in the usual care group (n = 76) had a mean of 0.72 QALYs (SD 0.26). There was no difference between discontinuation with tailored recommendation and usual care in quality of life (mean difference (with multiple imputation for missing values) ‐0.02, 95% CI ‐0.05 to 0.10; higher scores indicate better quality of life)). Study authors reported 0.07 as the minimally important difference for the EQ‐5D | |
| Social and occupational functioning | Study did not report social and occupational functioning | |||||
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CESD: Center for Epidemiological Studies Depression Scale; CI: confidence interval; DESS: Discontinuation‐Emergent Signs and Symptoms; EQ‐5D: EuroQoL Group Quality of Life Questionnaire based on 5 dimensions; GP: general practitioner; PAS: Panic and Agoraphobic Scale; QALY: quality‐adjusted life‐year; RCT: randomised controlled trial. | ||||||
| GRADE Working Group grades of evidence. High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect. | ||||||
aDowngraded by one level for imprecision (single study with a small number of participants) and by one level for risk of bias (withdrawal confounding bias; withdrawal symptoms may be misclassified as relapse and may lead to restart of the antidepressant).
bDowngraded by one level for withdrawal confounding bias (study measured DESS symptoms but did not analyse data) and by one level for imprecision (single study with a small number of participants).
cDowngraded by one level due to risk of bias (withdrawal confounding bias, attrition bias) and by one level due to imprecision (a single study).
dDowngraded by one level due to risk of bias (withdrawal confounding bias, attrition bias) and by one level due to imprecision (a single study).
eDowngraded by one level for imprecision (a single study with a small number of participants) and by two levels for risk of bias (withdrawal confounding bias, high number of missing values, risk of performance bias).