ABSTRACT
Interruption or abrupt discontinuation of the use of antidepressants may lead to withdrawal symptoms. These are most common with selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs).There is insufficient scientific evidence about the prevalence of antidepressant withdrawal symptoms and how to optimally discontinue antidepressants. The multidisciplinary document 'Discontinuation of SSRIs & SNRIs' offers a rationale and suggestions for the gradual tapering of these antidepressants. The following factors are consistently named as risk factors for the occurrence of withdrawal symptoms: (a) the patient experiences withdrawal symptoms in case of non-compliance or skipped doses; (b) a previous attempt to stop was unsuccessful; and (c) the patient is being treated with higher doses than the smallest effective dose of SSRIs or SNRIs. In patients with one or more risk factors, a tapering schedule with non-linear dose-reduction steps should be considered. The speed at which these steps are taken, should be adjusted depending on occurrence of withdrawal symptoms. Shared decision-making by patient and physician is the best way to select a tapering schedule.
Subject(s)
Antidepressive Agents/administration & dosage , Depressive Disorder/drug therapy , Selective Serotonin Reuptake Inhibitors/administration & dosage , Serotonin and Noradrenaline Reuptake Inhibitors/administration & dosage , Substance Withdrawal Syndrome/etiology , Humans , Norepinephrine/antagonists & inhibitors , Risk Factors , SerotoninSubject(s)
Somatoform Disorders/therapy , Attitude of Health Personnel , Communication , Evidence-Based Medicine , General Practice/methods , General Practitioners/psychology , Humans , Patient Education as Topic , Physician-Patient Relations , Practice Guidelines as Topic , Somatoform Disorders/diagnosis , Treatment OutcomeABSTRACT
The multidisciplinary guideline 'Diagnostics and treatment of irritable bowel syndrome (IBS)' provides the basis for a properly coordinated collaboration between the patient suffering from IBS and all healthcare providers involved in his or her treatment, such as the general practitioner, gastroenterologist, internist, occupational-health physician, dietitian and psychologist. The diagnosis 'IBS' is often made in accordance with diagnostic criteria, such as the Rome III criteria, but a somatic condition needs to be excluded first. If there are no indications for this, additional diagnostic tests are not necessary. Management of the condition consists primarily of advice on life-style plus non-pharmacological interventions, in addition to explaining the condition and providing information. Drug treatment is rarely indicated. If the IBS symptoms have a significant impact on quality of life and patients do not respond to the measures taken in accordance with this general policy, there are three options for psychotherapeutic treatment. When the symptoms result in absenteeism or other work-related problems, the doctor can advise the patient to contact the occupational-health physician and to search for specific solutions in consultation with the employer. When individual advice is required or if the patient's diet is not well-balanced, a referral to the dietitian will follow.
Subject(s)
Irritable Bowel Syndrome/diagnosis , Irritable Bowel Syndrome/therapy , Life Style , Practice Guidelines as Topic , Referral and Consultation , Absenteeism , Diet , HumansABSTRACT
OBJECTIVES: A high prevalence of Coeliac Disease (CD) is found among patients with a clinical diagnosis of irritable bowel syndrome (IBS) compared to the general population. Symptoms of CD are quite similar to IBS, but its treatment is different. The aim of this study was to evaluate the cost-effectiveness of screening for CD in patients with diarrhoea/mixed type IBS (IBS-D/mix) in terms of cost per quality adjusted life year (QALY) in the Netherlands. METHODS: A decision model was constructed to evaluate the costs and health benefits of serological testing followed by confirmatory endoscopy with biopsy. Probabilistic sensitivity analysis (PSA) was performed to examine the effect of parameter uncertainty. Finally, the budget impact of implementing the screening process was also computed for implementation over a 10-year time horizon. RESULTS: Screening resulted in an increase of about 0.07 quality life years (QALYs) per patient over a lifetime horizon. The incremental cost effectiveness ratio was about 6,200 euro/QALY compared to no screening. The PSA showed that the uncertainty in cost effectiveness results is not considerable. The value of information analysis confirmed the robustness of the results. Screening all current patients with diarrhea/mixed type IBS would require a total budget of about 25 million Euros over a 10 year time period. CONCLUSION: Screening patients with IBS-D or IBS-mix for CD is almost certainly cost-effective. The screening program would improve the quality of life of those patients with IBS symptoms who actually have CD at a relatively low cost.