Antidepressant Tapering: Cognitive Therapy Could Replace Maintenance Medication

What’s happening – Cognitive therapy during antidepressant tapering could help some people avoid long-term antidepressant use, a new study shows. Breedvelt et al found no difference in relapse risk between preventive cognitive therapy (PCT) or mindfulness-based cognitive therapy (MBCT) during and/or after tapering and antidepressant monotherapy in an individual participant data meta-analysis that included 714 participants. Younger age at onset, shorter duration of remission, and higher levels of residual depressive symptoms at baseline were associated with a higher overall risk of relapse. The authors suggest that the use of a psychological intervention while tapering antidepressants could be an  alternative to maintenance medication.

Why it’s complicated – It can be difficult to distinguish from withdrawal symptoms and relapse symptoms, which Breedvelt and colleagues noted. A review of antidepressant discontinuation approaches by Leeuwen et al found an “urgent need” for studies that will investigate this distinction.

Reports & Perspectives

  • An article by Professor David Taylor, director of pharmacy and pathology at the UK’s NHS, in The Guardian discusses the difficulties of antidepressant withdrawal, with which he has personal experience, in light of increased prescription rates during the pandemic. Dr. Taylor highlights his 2019 Lancet Psychiatry paper that advocated for slower antidepressant withdrawal regimens, making comparisons to benzodiazepine tapering schedules.
  • Is Facebook taking the place of physician advice when it comes to managing antidepressant withdrawal symptoms? This is the question behind White et al’s study that explored how people use social media to raise awareness and support each other while tapering off antidepressants and other psychiatric medications, often turning to the Internet when they feel that physician- or psychiatrist-led tapers have failed.
  • @Cyberplasm (Daniel Frankel, PhD, of Newcastle University) tweeted about the Guardian article, “There are new guidelines on how to safely come off antidepressants but most GP’s are unaware. Taper slowly!! Excellent article on how to come off AD’s.”
  • @Reduxreloaded (Dr. Ed White, lead author of the Facebook study) tweeted, “Published this morning, hopefully, a few GPs will take notice and be curious and questioning of what they see when they taper their patients off antidepressants.”
  • @LuciMahon, who reported several medication tapers in her past, replied to Dr. White, tweeting, “Some GPs already know and are understanding, quite a few need to believe and support their patients. I was told repeatedly by my former GP when reporting severe withdrawal symptoms that ‘You shouldn’t be suffering that as the medication is out of your system.’”

In Practice

Schizophrenia Drug Gets Breakthrough Designation, Phase 3 Trial Focuses on Cognition

What’s happening –FDA granted breakthrough therapy designation to BI 425809, Boehringer Ingelheim’s novel glycine transporter-1 (GlyT1) inhibitor, for the treatment of cognitive impairment associated with schizophrenia. The company announced the start of the CONNEX Phase 3 clinical trial, which will study the safety and efficacy of BI 425809 given once daily over a 26-week period for improving cognition in adults with schizophrenia. In addition to traditional outcome measures, the Phase 3 trial will use “disease-specific speech biomarker technology” from Aural Analytics and a Virtual Reality Functional Capacity Assessment Test (VRFCAT) by the clinical research company VeraSci to interpret the treatment’s effectiveness. The VRFCAT “simulates key instrumental activities of daily living in a realistic and interactive environment and demonstrates sensitivity to basic functional capacity deficits,” according to the company’s announcement.

Why it’s noteworthy – No pharmacologic treatments are available to treat cognitive impairment associated with schizophrenia, so after encouraging Phase 2 results that were published in Lancet this past March and the FDA’s breakthrough therapy decision, the journey of this compound will be closely watched.

Reports & Perspectives

  • Researchers from the Italian Network for Research on Psychoses studied 618 clinically stable participants with schizophrenia across 24 university psychiatric clinics or mental health departments over 4 years and found that social and nonsocial cognition, avolition, and positive symptoms were the main baseline factors associated with real-life functioning. Mucci et al wrote that these variables associated with real-life functioning are not routinely assessed by intervention programs, and that their importance supports the implementation of cognitive training programs and personalized interventions.
  • In related news, FDA has accepted the NDA for BioXcel Therapeutics’ BXCL501, an orally dissolving thin film formulation of dexmedetomidine, for the acute treatment of agitation associated with schizophrenia and bipolar disorders I and II. The agency will review BXCL501 in January 2022.
  • @JAMAPsych (JAMA Psychiatry) tweeted about the Mucci et al study “A longitudinal study in more than 600 people with schizophrenia documented that social and non-social cognition, avolition and positive symptoms are the main factors impacting on real-life functioning at follow-up #ItalianNetworkforResearchonPsychoses”
  • @StanfordPSY (Stanford Psychiatry) tweeted, “Researchers & colleagues study the anticholinergic medication burden on cognitive functioning for outpatients with #schizophrenia”

In Practice

Psychosis: A CBT-based Family Intervention for Caregivers

What’s happening – Training for families and caregivers of individuals with psychosis can reduce self-perceived depression, anxiety, and negative aspects of the caregiving experience, as well as increase prosocial attitudes toward psychosis, according to a study by Kopelovich et al. The team summarized the effects of their training program, Psychosis Recovery by Enabling Adult Carers at Home (REACH), which is based on CBT for psychosis (CBTp) and focuses on recovery-oriented psychosis psychoeducation, caregiver self-care, and skills training. Family members and caregivers attended either a 1-day (n=168) or 4-day (n=29) REACH training program and were surveyed before training, after, and 4 months later. Results suggest the program can help prevent caregiver burnout and emotional distress while also increasing understanding of their loved ones’ symptoms and experiences.

Why it’s complicated – Dr. Kopelovich noted that less than 2% of families receive a family intervention for psychosis (FIp) in the US, despite national recommendations for family psychoeducation and skills training. The Psychosis REACH training is now available virtually via the University of Washington School of Medicine’s Spirit Lab.  More from Dr. Kopelovich on standard caregiver training in our Psy-Q below.

Reports & Perspectives

  • A study of 15 community mental health center units in Norway found that implementation of national guidelines on FIp was low, with roughly 4% of families of patients with psychotic disorders having received psychoeducation. When provided, quality of the FIp was reported to be high and the authors concluded that more families and patients must have access to this vital treatment.
  • A qualitative study by Radley et al explored the experiences of mental health professionals who worked with parents with psychosis and their families. Two themes reported: a range of needs in parents with psychosis and communication issues both with patients and with other agencies; differing views about the appropriateness of having contact with patients’ children and families.
  • A recent SAMHSA report recommends CBTp as the standard of care for individuals with psychosis and provides evidence for its expansion in mental health systems. (More on the impact of this course correction.)
  • @ABCTpsychosis (Psychosis and Schizophrenia Spectrum Special Interest Group in the Association for Behavior and Cognitive Therapies) tweeted, “New research by @DrKope, @BryanStiles3, Maria Monroe-DeVita, @DrKateHardy, Kevin Hallgren, & @DougturkDouglas suggests that the #PsychosisREACH training in #CBTp informed skills can improve outcomes for carers of individuals with psychosis.”
  • @DrKateHardy (coauthor on the Psychosis REACH study) retweeted @ABCTpsychosis, adding, “Fortuitous timing on this publication. Released the same day @DrKope and I co-led the second P-REACH family skills live workshop. A humbling experience presenting to a passionate caregiver audience committed to learning skills to support their loved ones.”
  • @DrKope (lead author of the Psychosis REACH study Sarah L. Kopelovich, PhD) tweeted about the SAMHSA report, “Celebrating the publication of this important document—the first federally-issued declaration that CBT for psychosis should be offered as standard of care for individuals with psychotic disorders in the US. A major step forward.”
  • @DrKateHardy replied, “Great strides forward for evidence-based psychosocial interventions in the US!”

Psy-Q Challenge

Is it common for caregivers of individuals with psychosis to receive family interventions? What are the guidelines? Sarah L. Kopelovich, PhD, answers.

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In Practice

Last Updated: Aug 26, 2021