Expectation effects in antidepressant discontinuation: Implication for clinical practice

Abstract

Expectation effects for antidepressants have been shown in numerous randomized studies and meta-analyses. Participants in placebo groups frequently reported relevant improvements of depressive diseases (response rates 40% placebo vs. 50% verum) and occurrence of disturbing side effects in the sense of nocebo effects. These findings emphasize the influence of individual expectations on the efficacy and tolerability of antidepressants and indicate that they are also relevant in the process of discontinuation. The discontinuation of antidepressants can be associated with debilitating symptoms, such as dizziness, sleeplessness and irritability. These so-called discontinuation symptoms are usually mild and self-limiting within a few days to weeks; however, if patients are not informed about possible adverse symptoms in advance, their occurrence can result in fear of recurrence or dependence. Discontinuation symptoms can easily be mistaken for signs of relapse or recurrence of depression, especially when the discontinuation is carried out without medical or psychological support. Clinical reports of failed discontinuation attempts and resulting negative expectations have become more frequent. Opportunities to optimize expectations include patient-physician interactions and treatment information. This article discusses therapeutic strategies to manage discontinuation symptoms with the aim to optimize expectations adapted to individual prior experiences. Strategies, such as psychoeducation, framing, informing about placebo and nocebo effects and the development of coping skills can be used to shape realistic expectations and positively impact the discontinuation process through accompaniment of therapy.