Friday, November 22, 2019

The scope of psychotropic medication discontinuation problems

The stakeholder comments submission (see table) from the College of Mental Health Pharmacy about the Scope for the NICE guideline on Safe prescribing and withdrawal management of prescribed drugs associated with dependence and withdrawal is revealing about why antidepressant discontinuation problems are minimised (see eg. previous post). The College questions why antidepressants have been included within the Scope. What it's worried about is that patients might discontinue or not seek antidepressant treatment when they need it, if they know about antidepressant discontinuation problems.

Similarly, prescribers may use the chemical imbalance theory as a way of persuading patients to take antidepressants (see previous post). This is despite the fact that believing the theory may make patients more pessimistic about the prognosis of their depression and lower their perceived ability to regulate their mood (see previous post). More seriously as far as antidepressant discontinuation problems are concerned, believing the chemical imbalance theory may at least contribute to, if not cause, discontinuation problems (see previous post). Eveleigh et al (2019) found evidence from patients that the chemical imbalance theory was a prominent factor in creating fear of discontinuation.

Several stakeholders in the NICE consultation suggested including in the Scope other drugs, such as antipsychotics, which also cause discontinuation problems. NICE refused, saying that such guidance is included within the NICE guideline for psychosis and schizophrenia in adults, although I can't see any mention of discontinuation problems there. NICE only seems to have included antidepressants within the Scope because it was asked to by the Department of Health.

The Royal College of Psychiatrists usefully raises the issue of the psychological component of dependence but I'm not sure that NICE really takes this on board in its response. People who have antidepressant discontinuation problems often experience them very physically. It's good that NICE will presumably expand (although maybe by not very much) on its Depression guideline to produce more detailed advice for safe prescribing, monitoring and safe withdrawal of antidepressants. But people are being made dependent on psychotropic medication in general. The psychological element, at least, of antidepressant discontinuation problems cannot be denied (see previous post). It's understandable NICE may wish to sidestep this complex issue but these wider factors do need to be addressed.

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