Reacción a "The most effective strategy for discontinuing antidepressants is gradual reduction combined with psychological therapy, according to data from more than 17,000 adults"

The new study analysed all available scientific evidence on antidepressant discontinuation using a network meta-analysis. This method allows different discontinuation strategies to be compared even when they have not been directly evaluated against each other in clinical trials. The study includes 76 randomised clinical trials with a total of 17,379 participants with depression (79%) or anxiety disorders (21%), all of whom had previously responded to antidepressant treatment.  

The findings show significant differences in the risk of relapse depending on the strategy used. Continuing antidepressant treatment resulted in 40% fewer relapses than gradual withdrawal and 50% fewer than abrupt withdrawal. Continuing antidepressant treatment together with brief psychological support reduced relapses by 50% compared to gradual withdrawal and by 60% compared to abrupt withdrawal. Gradual withdrawal together with brief psychological support did not increase the risk of relapse compared to continuing with the same dose. In addition, it reduced relapses by 40% compared to gradual withdrawal without psychological support and by 50% compared to abrupt withdrawal.

In conclusion, the study indicates that slow withdrawal accompanied by brief psychological support to prevent relapses is as effective as continuing the antidepressant and clearly superior to rapid or abrupt withdrawal. 

Is it a high-quality study? Yes. The analysis brings together all available evidence and makes comprehensive comparisons to rule out the influence of confounding factors. The results remain consistent across all exploratory models. 

What does it add to previous evidence? Until now, it was known that discontinuing antidepressants increased the risk of relapse, but the effect of withdrawal speed and the impact of adding brief psychological support had not been systematically studied. This study is the first to synthesise the data in a comprehensive and comparative manner.

Notable limitations. Like any meta-analysis, the study presents aspects that should be interpreted with caution: 

1. Use of network analysis. Network analysis is a technique that allows treatments that have never been directly compared in a study to be compared. Therefore, some conclusions are based on these indirect comparisons, rather than on experiments. 

2. Lack of studies on psychological therapy. Only 5% of participants received additional psychological support. In contrast, 51% continued antidepressant treatment without psychological support (main comparison). The evidence is therefore much stronger for continuing medication than for the effect of adding therapy. Furthermore, in none of the trials was psychological therapy masked, which may overestimate its effect. The psychological interventions were very heterogeneous (mindfulness, cognitive-behavioural therapy, combined therapy, positive affect interventions, etc.), making it impossible to identify which modality is most effective. 

3. Arbitrary definition of 'slow withdrawal'. The definition of the speed of antidepressant withdrawal (progressive vs slow > or < 4 weeks) is arbitrary. Studies are needed that analyse the speed of withdrawal as a continuous variable in order to determine the appropriate speed for each patient. 

4. Mix of depression and anxiety. Only 20% of the sample had anxiety disorders. This limits generalisation to this group.

5. Relatively short follow-up. The mean follow-up was 46 weeks (< 1 year), sufficient to measure early relapses, but not for long-term conclusions. Even so, the differences in risk are very marked (up to 60%).

Implications for clinical practice. The high use of antidepressants is partly due to:

• The high prevalence of anxiety-depressive disorders.
• Their efficacy and availability.
• The lower accessibility and higher structural cost of offering psychological therapy. 

This study suggests that accompanying withdrawal with brief psychological support significantly reduces the risk of relapse and should be considered in clinical planning. 

Is it feasible to implement this strategy in healthcare systems? In the public system, offering brief psychological support systematically during discontinuation is challenging due to economic and staffing constraints. Even so, the results point to the need to integrate brief, protocolised psychological interventions into medication withdrawal processes, given their potential impact on reducing relapses.