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Antidepressant Discontinuation — MRCPsych Paper B MCQ

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EasyMood DisordersAntidepressant DiscontinuationMRCPsych Paper B

A 45-year-old man with a history of chronic depression has taken fluoxetine 40 mg daily for 5 years and is now in sustained remission. After discussing his risk of relapse and the benefits and risks of continued treatment, he and his prescriber make a shared decision to stop fluoxetine. According to NICE NG222, which is the most appropriate approach?

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Correct answer: E — Reduce fluoxetine stepwise, reviewing after each reduction and monitoring symptoms

The correct answer is E. NICE recommends reducing antidepressants to zero in a stepwise, individualised schedule, with the pace agreed with the patient. Each reduction should be followed by review for withdrawal symptoms and recurrence of depression; withdrawal may take weeks or months. Although fluoxetine has a long duration of action and generally causes fewer withdrawal problems than shorter-acting antidepressants, NICE specifically recommends gradual withdrawal at doses of 40–60 mg daily and allowing 1–2 weeks to assess the effect of a reduction. Immediate cessation is therefore inappropriate at 40 mg. A fixed 1-week taper does not account for the patient's response or long treatment duration. Switching SSRIs is unnecessary solely to facilitate stopping, and antidepressant treatment is not automatically lifelong; continuation should reflect relapse risk and informed preference.

Reference: National Institute for Health and Care Excellence. Depression in adults: treatment and management (NG222), recommendations 1.4.12–1.4.18: Stopping antidepressant medication. 2022. https://www.nice.org.uk/guidance/ng222/chapter/Recommendations