Drug Tapering and Discontinuation

Sequential treatment offers a unique opportunity for antidepressant drug tapering and discontinuation. In fact, it offers the opportunity to monitor the patient in one of the most delicate aspects of treatment. In the original studies (Fava et al., 1994, 1998) antidepressant drugs, mainly tricyclics, were decreased at the rate of 25 mg of amitriptyline or its equivalent every other week. When selective serotonin reuptake inhibitors (SSRIs) are involved, more gradual tapering is the better.

It is important to warn the patient that he/she should not perceive "steps" (as one patient defined them) in this tapering (i.e., patients should not perceive substantial differences in their sleep, energy, mood, and appetite in going from 200 mg to 175 mg of amitriptyline per day). If they do, the appropriateness of tapering the antidepressant drug should be questioned. Indeed, in the original studies, drug discontinuation did not take place in a few patients.

The sequential format offers an ideal opportunity to support the patient psychologically when withdrawal syndromes (despite slow tapering, particularly with SSRI) do occur. At times when patients are fearful of drug discontinuation, it is helpful to emphasize that a drug-free status is a step forward in therapy and may be associated with increased quality of life. Thus, it is a sign of progress. Antidepressant drugs may be prescribed again, if needed, in the event of prodromal symptoms of mood deterioration, and patients should be reassured that this option is always available.

Review of Efficacy Research

There is now extensive research evidence, based on five randomized controlled trials reviewed in detail elsewhere (Fava et al., 2005), on the long-term benefits, including a lowered relapse rate, of increasing the level of remission with cognitive-behavioral strategies. In one trial, Fava et al. (1998) used the combination of CT and WBT described in this chapter and yielded dramatic differences in relapse rate compared to clinical management. In two trials, follow-up was up to 6 years (Fava et al., 2004; Paykel et al., 2005).


The patient, a 44-year-old man who works as a county clerk, has a major depressive disorder of recent onset. He had two previous episodes 1 and 3 years earlier that were treated by his primary care physician with fluvoxa-mine (100 mg per day) for 4 months each time. Although in this case his physician has prescribed fluvoxamine (100 mg per day), he wonders whether a different treatment may be justified. Careful assessment discloses only partial remission after each episode. The psychiatrist confirms treatment with fluvoxamine, but introduces the need of a sequential approach. After 3 months of drug treatment, the patient is given the combined treatment, CT + WBT. The CT part of treatment yields important insights and modification of some of his maladaptive attitudes. WBT allows him to realize how his lack of autonomy leads his workmates consistently to take advantage of him. This results in workloads that, because of their diverse nature, undermine the patient's environmental mastery, constitute a significant stress, and increase his work hours. The patient accepts the situation by virtue of his low degree of self-acceptance: He claims that this is the way he is, but at the same time he is dissatisfied with himself and chronically irritable. When he learns to say "no" to his colleagues (assertiveness training) and to endorse this attitude consistently, a significant degree of distress ensues, linked to perceived disapproval by others. However, as time goes by, his tolerance to disapproval gradually increases, and in the last session he is able to make the following remark: "Now my workmates say that I have changed and that I have become a bastard. In a way I am sorry, since I have always tried to be helpful and kind to people. But in another way I am happy, because this means that—for the first time in my life—I have been able to protect myself." Fluvoxamine was tapered and discontinued during psychotherapy. The patient had no further relapse at an 8-year follow-up, while being drug-free. This clinical picture illustrates how an initial feeling of well-being (being helpful to others) identified in the patient's diary was likely to lead to overwhelming distress. Its appraisal and the resulting change in behavior initially led to more distress, then yielded a lasting remission.


Isaac Marks (1999) suggested that the prevailing therapeutic mechanisms for explaining therapeutic effectiveness in psychotherapy are about to change. Foa and Kozak (1997) wondered whether the slowing advance of CT might be the result of an alienation from psychopathology. The sequential model introduces a conceptual shift in psychotherapy research and practice. The target of psychotherapeutic efforts is not predetermined and therapy-driven (e.g., cognitive triad) but depends on the type and intensity of residual symptomatology (Fava et al., 1994,1998) or the specific impairments in psychological well-being (Fava et al., 1998; Fava & Ruini, 2003). Therefore, the cognitive approach in the sequential model is pragmatic and realistic instead of idealistic, based on a strictly evidence-based appraisal of its components (Fava, 2000). There is limited awareness that current techniques of treating affective disorders are geared more toward acute situations than toward residual phases of illness, and that they neglect psychological well-being (Fava, 1999). The model may be frustrating to the purist because of its blurring of clear-cut interpretive instruments. However, it is more in keeping with the complexity of the balance of positive and negative affects (Ryff & Singer, 1998) in health and disease, and the clinical needs of patients with affective disorders.


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