431 - Stopping Antidepressants, Best Diets 2022, We All Need Somebody
Take 3 – Practical Practice Pointers©
From the Literature
1) Discontinuing Antidepressants
We treat a lot of depression in primary care. The studies that informed the US Preventive Services Task Force recommendation to screen for depression stressed the need for “adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.” Part of the reason for the emphasis on these systems was that with an active approach to the management of depression (by monitoring treatment with serial PHQ-9 scores and treating to remission - a PHQ-9 < 5), we can avoid undertreating patients for depression and having them never quite feeling like they could get off medication. The research suggested that if patients were treated to remission for a first depressive episode and kept there with medication for at least 6 months, they had a greater chance of getting and staying off medication. Patients who have had previous episodes of depression are at greater risk for needing to continue long-term antidepressants.
A study was recently published in the New England Journal of Medicine that appeared to challenge these points with its title, “Maintenance or Discontinuation of Antidepressants in Primary Care.” In this study, patients who had been on antidepressant (AD) therapy for at least 2 years, did not have bipolar disorder, and who “felt well enough to come off ADs” were randomized (and blinded) to continued AD or a two-month tapering dose of AD to placebo. The patients were followed for 52 weeks. The doses of the AD they were on were reasonable doses for primary care management of depression. Depression relapse occurred in 39% of the maintenance group and 56% of the discontinuation group (NNH for discontinuation ~ 6). More patients in the discontinuation group stopped the study medication and went back to their primary care doctors to get their old antidepressant back (20% in maintenance group and 39% in the discontinuation group, NNH ~ 5). The other secondary outcomes trended in a similar fashion as the primary outcome. Adverse events were similar between groups and there were no deaths or suicide attempts during the study.
Here’s the kicker, though. To be included in the study, the patients must have had 2 episodes of depression prior to the current treatment. In addition, the authors initially had defined a PHQ-9 score < 12 as an eligibility criterion, but jettisoned that requirement early in the study, because they found a number of people with higher scores who still wanted to get off their medication. This latter information was found only in the study protocol which was an online attachment to the study. These two issues made the population they studied at high risk for relapse, and while I would always be open to considering a trial of discontinuation, I would not push it for such high-risk patients.
The authors, troublingly, do not refer to these patients as having a higher risk for relapse in their study report, which is misleading. I tell our residents (and recommend to you) that I don’t suggest that they critically appraise every study that comes across their desks, but when a study purports to challenge existing practice, that’s the time to dig into it a little. Once I dug in, this study seemed to be practice affirming, rather than practice changing.
Lewis G, Marston L, Duffy L, et al. Maintenance or Discontinuation of Antidepressants in Primary Care. New England Journal of Medicine. 2021;385(14):1257-1267. doi:10.1056/NEJMoa2106356 Link
From the US News and World Report
2) “Best Diet” Rankings for 2022
U.S. News recently released its annual assessment of the best diets, offering extensive data and information on 40 popular diet plans. The rankings were established by a reputable panel of experts, including physicians, nutritionists, dieticians who rated each diet in seven categories: how easy it is to follow, its ability to produce short-term and long-term weight loss, its nutritional completeness, its safety and its potential for preventing and managing diabetes and heart disease. To ward off possible bias, each panelist provided information indicating clear or apparent conflicts of interest. In such cases, panelists did not rate the diet where a potential conflict existed.
For the 5th consecutive year, the Mediterranean Diet ranks as the No. 1 Best Diet Overall and was rated the best diet in 6 out of the 9 categories, including best plant-based diet, easiest diet to follow, best diet for healthy eating, best diet for diabetes, and for best diet for heart health (tie). The DASH Diet and the Flexitarian Diet (a plant-based plan with meat in moderation) were tied for 2nd best overall diet. The MIND diet (Mediterranean-DASH Intervention for Neurodegenerative Delay), designed to help prevent dementia, was 4th.
WW (Weight Watchers), the Flexitarian Diet, and the Volumetrics diet (diving foods by “energy density”) were tied for the top-rated Best Weight-Loss Diet and WW and the Mayo Clinic Diet were tied for the Best Commercial Diet.
It is important to note that there isn't "a" Mediterranean diet. The cultural lifestyle of people in countries bordering the Mediterranean Sea shares common principles, including an active lifestyle, weight control, and a diet high in produce, nuts and healthy oils and low in red meat, sugar, and saturated fat. A Mediterranean diet pyramid has been developed to help guide those desiring to follow this nutritional approach (see References).
The DASH Diet (Dietary Approaches to Stop Hypertension) is promoted by the NHLBI to stop or prevent HTN. It emphasizes vegetables, fruits, whole grains, lean protein and low-fat dairy. DASH also discourages foods that are high in saturated fat, such as fatty meats, full-fat dairy foods and tropical oils, as well as sugar-sweetened beverages and sweets and sodium. The NHLBI publishes free guides on the plan (See references).
Mark’s Comments (With Guest Commentary):
The word “diet” is really more of a misnomer. The most highly rated “diets” are really about healthy, structured, intentional approaches of eating. It is also important to note that many of these plans don’t consider cultural and demographic differences, including how to approach eating when there isn’t an abundance of healthy choices. It is therefore important to help patients customize their approach to include foods they are already familiar with and can afford, as well one that can reliably be sustained.
To that end, I reached out to colleague, “Lifestyle Medicine guru,” and regular Take 3 contributor Beth Polk, MD, for her insights. In addition to regularly speaking nationally on this topic, Beth served as one of 4 national faculty on an AAFP Advisory Committee for Lifestyle Medicine. Beth replied: “Despite the large body of evidence that it can prevent chronic disease, I have heard criticism of the Mediterranean diet as unaffordable and that it is not translatable to other cultures. However, if we think about the diet in terms of the general principles of increasing fruits, vegetables, beans, nuts and seeds, and eliminating processed foods and decreasing meat intake, the top 5 diets meet these criteria, and they can be easily adapted to regional and cultural differences. There are many alternative pyramids available to help make it more accessible and thinking creatively about using local produce, farmer’s markets and staples such as beans and rice makes it more affordable. And remember, the best advice we are able to give our patients is still ‘eat food (unprocessed), mostly plants, and not too much.’”
It is notable that diet plans that ranked the lowest included Whole 30, Keto, Modified Keto, Dukan, and GAPS diets. Most of these include a limitation of carbs and an emphasis on protein and the long-term maintenance of ketosis. While these diets have become quite popular (and have been shown to be potentially effective with short-term weight loss), their long-term health impact continues to be concerning.
· U.S. News Best Diets Rankings for 2022. January 4, 2021. Link
· DASH Eating Plan: Link
From PeerRxMed (www.PeerRxMed.org)
3) We All Need Somebody …
“We all need somebody to lean on.” Bill Withers
We gathered together in the small church this past Saturday to commemorate the ‘unthinkable.” There in the front of the church was a casket containing the body of our physician colleague and friend, Corey Sayers, who at 28 years of age died well before what we wanted to believe was “his time.” And from a cancer, sclerosing epithelioid sarcoma, that one year ago none of us had even heard of.
This was the same man who lit up a room with his presence, who was admired by his friends and adored by his patients, and who had been blessed with the “superpower” of being a gatherer of people. And he continued to use this superpower as much as his strength would allow to his last days with us, bringing people together not only to help and support him, but more importantly to him, to connect with each other.
During the service, a heartwarming video overflowing with smiles attempted to capture the essence of the life of this radiant soul, followed by the playing of the classic Bill Wither’s song, “Lean on Me, “ chosen because it represented so much of what Corey stood for, and a truth he had to live out more than ever in the last year of his life … “Sometimes in our lives, we all have pain, we all have sorrow … Lean on me, when you’re not strong …. We all need somebody to lean on.” Even as we celebrated this all too brief and beautiful life, there was no way to hide our collective broken heart.
And all this was happening as we approach the peak of not just “another surge,” but one that is stretching both resources and emotions to the breaking point. In connecting with colleagues from across the country over the past few days, it’s quite obvious that we’re all carrying an individual and collective load of pain and sorrow right now that is becoming too much to bear for many. So if you’re feeling this, please know you are not alone. If you’re not feeling that burden right now, you can bet that someone around you is, and even if they’re not saying so, they could sure use a hand.
It is more important now than ever to not try and “soldier” through this alone. None of us has ever been here before. So asking for help to try and process these surreal times is not weakness, but rather wisdom and sanity. That’s the entire purpose of PeerRxMed – for us to explicitly and deliberately connect with each other in good times and bad. To share the journey and ensure no one is trying to care alone.
Bill Withers ended his song with this invitation: “If there is a load you have to bear that you can't carry, I'm right up the road, I'll share your load, if you just call me (call me) ….” Our colleague Corey Sayers lived this out daily and leaves it for us as a legacy. His life was a living demonstration that sharing the load together makes for a much more fulfilling and meaningful life, and also one that’s a whole lot more fun. Who are the “somebodies” in your life who you can do some “leanin’ on”? Don’t wait … for their sake, and yours ….
Mark and John
Carilion Clinic Department of Family and Community Medicine
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