PURLS / PEER REVIEWED

Antidepressant Tx for Anxiety Disorders: How Long?

Clinician Reviews. 2019 December;29(12)

Author(s):

This systematic review/meta-analysis provides long-awaited evidence about the length of time to treat to minimize relapse risk.

References

1. Batelaan NM, Bosman RC, Muntingh A, et al. Risk of relapse after antidepressant discontinuation in anxiety disorders, obsessive-compulsive disorder, and post-traumatic stress disorder: systematic review and meta-analysis of relapse prevention trials. BMJ. 2017;358:j3927. Erratum in: BMJ. 2017;358:j4461.
2. National Institute of Mental Health. Prevalence of any anxiety disorder among adults. www.nimh.nih.gov/health/statistics/any-anxiety-disorder.shtml#part_155094. Updated November 2017. Accessed November 26, 2019.
3. Kessler RC, Petukhova M, Sampson NA, et al. Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012;21:169-184.
4. Bandelow B, Sher L, Bunevicius R, et al. Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder in primary care. Int J Psychiatry Clin Pract. 2012;16:77-84.
5. Kaczkurkin AN, Foa EB. Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues Clin Neurosci. 2015;17:337-346.
6. Donovan MR, Glue P, Kolluri S, et al. Comparative efficacy of antidepressants in preventing relapse in anxiety disorders—a meta-analysis. J Affect Disord. 2010;123:9-16.
7. Mojtabai R, Olfson M. National trends in long-term use of antidepressant medications: results from the U.S. National Health and Nutrition Examination Survey. J Clin Psychiatry. 2014;75:169-177.

PRACTICE CHANGER

Keep patients on antidepressant therapy for anxiety disorders for a year or longer before considering a taper.¹

STRENGTH OF RECOMMENDATION

A: Based on a systematic review/meta-analysis of several good-quality randomized controlled trials.

A 42-year-old woman with generalized anxiety disorder (GAD) and panic attacks has been treated with sertraline (100 mg/d) for the past 8 months. She has also engaged in cognitive behavioral therapy (CBT) for 6 months. Her Generalized Anxiety Disorder-7 score has decreased from 19 prior to treatment to 5 at present. Now she would like to stop her antidepressant medication because she feels better. Would you recommend that she discontinue her medication at this point?

Anxiety disorders are common and often chronic and can cause significant morbidity and impairment.^2,3 Firstline treatments for anxiety disorders include CBT and antidepressants, particularly selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors.^4-6

There is limited evidence regarding duration of antidepressant therapy for anxiety disorders. Previous studies have shown a high risk for relapse after discontinuation of antidepressants.⁶ A review of current practice patterns regarding pharmacologic treatment of depression and anxiety indicates an uptick in longer term antidepressant use for up to 2 years.7 However, long-term studies to guide treatment decisions are lacking.

STUDY SUMMARY

Clear benefit of continuing treatment

This systematic review and meta-analysis evaluated studies that looked at relapse rates and time to relapse in patients treated for anxiety disorders.¹ The authors used PubMed, Cochrane, and Embase to identify studies involving patients treated for a variety of psychiatric disorders, including GAD, posttraumatic stress disorder (PTSD), panic disorder (PD), obsessive compulsive disorder (OCD), and social phobia. Eligible studies enrolled patients with anxiety disorders who had a positive response to an antidepressant and then randomized them in a double-blind fashion to either discontinuation of antidepressants and commencement of placebo (stopping group) or continuation of antidepressants (continuation group) for a duration of 8 to 52 weeks. The primary outcomes were relapse rate and time to relapse.

Twenty-eight studies met the inclusion criteria for the meta-analysis, with a total of 5233 patients (2625 patients in the continuation group and 2608 patients in the stopping group). A breakdown of the trials by indication included OCD (7), PD (6), GAD (6), social phobia (5), and PTSD (4). The authors graded the overall risk for bias to be low but noted that attrition bias was present in most studies.

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