Saturday, March 10, 2018

Minimising antidepressant discontinuation problems

Clare Gerada defended the Royal College of Psychiatrists on the Today programme this morning against a complaint (of which I was one of the signatories) that the College is minimising the significance of antidepressant discontinuation problems (see Council for Evidenced-based Psychiatry (CEP) press release). There doesn't seem to be a dispute that antidepressant discontinuation problems occur (eg. see previous post) - Clare Gerada said in about a third of patients - and can be prolonged (see another previous post), but the issue seems to be whether they resolve for the vast majority of patients within two weeks. I don't think the evidence supports that view.

There is a history of doctors thinking they know better about antidepressant discontinuation problems than the public (see my book chapter). The Defeat Depression campaign was a five-year national programme launched in January 1992 by the Royal College of Psychiatrists in association with the Royal College of General Practitioners. A door-to-door survey of public opinion was undertaken to obtain baseline data before the campaign started and most of the people questioned in the sample, that is 78%, thought that antidepressants were addictive. This finding caused some consternation amongst those running the campaign, because, as far as they were concerned, the public was misinformed on this issue. Part of the education programme, therefore, was to teach doctors that patients should be told clearly when antidepressants are first prescribed that discontinuing treatment in due course will not be a problem. Now they seem to be saying that it may be a problem but symptoms generally won't last long.

The first official recognition in the literature that SSRI antidepressants can cause discontinuation problems was in a BMJ editorial in 1998, which suggested they were preventable and simple to treat. The same authors only two years later acknowledged that discontinuation symptoms are common in a letter to the Lancet. I agree there is little evidence of physical addiction, in the sense that the body gets addicted to SSRIs, but commonsense understanding of the word also includes psychological dependence, and despite what the Defeat Depression campaign said, the public knew, even if doctors did not, that taking antidepressants can become a habit.

Doctors did not use their common sense to realise that discontinuing a drug that is thought to improve mood may cause problems - technically called a nocebo, or negative placebo, response. Antidepressants are likely to be habit forming, so however much the medical profession may declare that they are not primarily reinforcing like psychostimulants, the public has always understood that there may be difficulties in discontinuing antidepressants. The general public might reasonably have expected that psychiatrists, who are supposed to be specialists in disorders of the mind, would recognise psychological dependence, base their advice on clinical experience, and use their common sense.

I have always encouraged CEP to focus on psychological aspects of prescribed drug dependence (see eg. previous post). I was even critical of the RCPsych leaflet (see another previous post) that has caused such disquiet, not least because it's been taken down from the College website before it's been properly reviewed, even though I thought it was generally a helpful leaflet.

By the way, from the interview today, Clare Gerada, like her husband (see post), doesn't seem to believe in the placebo amplification hypothesis of apparent antidepressant efficacy, and I'm not sure why .


Anonymous said...

Well said Duncan - Could you please give a reference for the letter which was signed by you and others? many will be so thankfull that at last people are speaking out openly in public forums rather than just amongst professional groups. the more the disgraceful attempt to dupe the public is outed the more people will be spared the high possibility of suffering adverse effects of psychiatric drugs. Clare should be ashamed of herself not least for declaring that in 30 years she has not had any experience of indivividuals suffering from withdrawal or other negative symptoms. I think most people would have seen through the silliness of claiming tht a person had been through the door only yesterday claiming as a result of the study that they now can take the drugs which have been helping so much without worrying. Leave that nonsense to politicians. The claim is simply so disengenuous - statistically over a period of her time even if part time as a GP there will have been some who have had serious negative experiences as with most drugs. She is as angry about the public being informed when the publicity machine has been able to keep the truth largely under wraps. As a cliician she should be using evidence to inform rather than her biased opinion. But readers please do read the David Healy blog and the Rxisk blog to see for yourselves what the physical NOT JUST PSYCHOLOGICAL harms which which Duncan has pointed out are experienced by those who have take anti depressants (and other psychiatric drugs) often without any warning of possible side effects or help to withdraw. Again Clare was disengenuous by muddling the understanding of 'addictive' with the addiction to street drugs ...the issue is not on the same. Shame shame shame on them - why have so few been left to shoulder the burden of exposing what has been happening for many years? Paradoxically they have brought the institutions into even more disrepute and undermined public triust in the people first mantra - the idea of partnership and transparency has been shown to be a sham .Susanne Stevens

Anonymous said...

Apologies Duncan I missed the link and enormous thanks for publishing the whole letter with responses from the college. Hope you will keep followers of your blog updated. susanne

Dan Dalmonte said...

This is disturbing. Obviously psychiatrists would want to hide the dependency-forming tendencies of the drugs they provide. It would be a warning signal for people who were considering taking them. Evidence of this tendency to dependency formation would cut into the business of psychiatrists who are committed to the biomedical model of mental illness. Just pop a pill and you're cured.