GP monitoring of those on antidepressants

Tony Kendrick, who I have mentioned before (see eg. previous post) is the first author of a paper about antidepressant withdrawal in general practice. It found that more than 40% of patients could discontinue their antidepressant treatment in a clinical trial, comparing whether adding internet and telephone support to family practitioner review was more effective than practitioner review alone. The numbers that managed to withdraw under the two conditions was not significantly different, although those that had added support had small improvements in depression, antidepressant withdrawal symptoms and mental well-being.

However, only 4.9% of patients who were mailed invitations were eligible and consented to the trial. They had to be well enough to consider discontinuation, wish to do so and be at low risk of relapse. As I said in a previous post, people are generally very reluctant to take part in antidepressant discontinuation trials. There is at least a question about how much the results of the trial are generalisable to all those on antidepressants. Antidepressant discontinuation problems should not be minimised (see eg. last post). 

Nonetheless, if the paper leads to more review by general practitioners of those taking maintenance antidepressants this should be welcomed. Doctors are making far too many patients dependent on antidepressants and need to do more to prevent this happening (see eg. another previous post).

Mainstream psychiatry continues to minimise significance of antidepressant withdrawal

Mainstream psychiatry has minimised the significance of antidepressant withdrawal, as I first pointed out in a BMJ letter in 1997. My complaint then was that the Defeat Depression Campaign, launched in January 1992 by the Royal College of Psychiatrists in association with the Royal College of General Practitioners, advocated educating patients and doctors that discontinuing antidepressant treatment is not a problem. 

As I explained in my book chapter, what caused so much consternation to the Defeat Depression Campaign was that 78% of people in a door-to-door survey of public opinion thought that antidepressants are addictive. I suggested in the BMJ letter that the general public actually understood this issue better than the Royal Colleges of Psychiatrists and General Practitioners. It's common sense to believe that discontinuing taking medication that is thought to improve mood may be difficult. 

The British National Formulary (BNF), which doctors use for reference about medication, has given a warning since 1990 that symptoms may occur if an antidepressant is stopped suddenly after regular administration for 8 weeks or more. In fact, case reports of discontinuation reactions have appeared since antidepressants were first introduced. The Drugs and Therapeutic Bulletin (DTB), which publishes independent, practical, patient-orientated, evidence-based content on medicines for healthcare professionals, recommended in 1999 that if maintenance antidepressant treatment is discontinued that both the doctor and patient need to be alert to the risk of discontinuation effects and the re-emergence of depressive symptoms, which can occur on cessation of any antidepressant. It made clear that antidepressants should not be stopped abruptly, nor treatment courses interrupted, unless there is a good clinical reason, for example a serious adverse effect or patient request.

A new class of antidepressants called serotonin specific reuptake inhibitors (SSRIs) was introduced onto the UK market in 1987. Withdrawal symptoms were only acknowledged by the drug companies after SSRIs had been in widespread clinical use for several years. A consensus meeting of experts, sponsored by Eli Lilly, the manufacturers of fluoxetine, or Prozac™, as it is known by its trade name, was held in Phoenix, Arizona, at the end of 1996. This led to an editorial in the British Medical Journal in 1998 acknowledging that antidepressant  discontinuation problems existed (Haddad et al, 1998). It suggested, though, that they were both preventable and simple to treat. The same authors only two years later acknowledged that discontinuation symptoms are common (Young & Haddad, 2000). 

The National Institute for Health and Clinical Excellence, which evaluates treatments for NHS use, therefore, stated in its 2004 depression guideline the opposite of what was recommended by the Defeat Depression campaign: ie. that all patients prescribed antidepressants should be informed that discontinuation/withdrawal symptoms may occur on stopping, missing doses or, occasionally, on reducing the dose of the drug. It qualified this, though, by saying that symptoms are usually mild and self-limiting but can occasionally be severe, particularly if the drug is stopped abruptly. 

More recently in its 2022 guidance on ‘Medicines associated with dependence or withdrawal symptoms: Safe prescribing and withdrawal management for adults’, NICE clearly states that antidepressants cause withdrawal symptoms even though they have not historically been classified as dependence-forming medicines. In its updated 2022 depression guideline, it now says that withdrawal symptoms can be mild and usually go away within 1 to 2 weeks; can sometimes be more difficult, with symptoms lasting longer (in some cases several weeks, and occasionally several months); and can sometimes be severe, particularly if the antidepressant medication is stopped suddenly. At least the guideline now acknowledges that withdrawal symptoms are not as usually mild and self-limiting as the previous version of the guideline stated. 

This amendment was made after a complaint was made to the Royal College of Psychiatrists, which I signed (see eg. previous post). Although the complaint was initially wrongly dismissed, the College did eventually accept there should be greater recognition of the potential in some people for severe and long-lasting withdrawal symptoms on and after stopping antidepressants and called for NICE to update its guideline on antidepressant withdrawal (see eg. another previous post). 

I still worry, though, that the full importance of antidepressant withdrawal has, after all these years, not been understood by mainstream psychiatry (see previous post). There is in fact limited scientific evidence on this topic and recommendations are too driven by personal opinions or experiences rather than evidence as such (see another previous post). There are also methodological problems with antidepressant discontinuation studies, not least that blinding strategies are often insufficient to properly address placebo and nocebo aspects. What is commonly overlooked is that antidepressant withdrawal symptoms even occur in blinded antidepressant arms when antidepressants are continued. 

This finding has been confirmed in a new systematic review based on short-term industry studies (see Psychology Today article). One in three people were found to have at least one withdrawal symptom in the antidepressant withdrawal arm, but one in six people were still found to have withdrawal symptoms in the control arm even though antidepressants were continued. 

The problem with the new systematic review is that it minimises the frequency of antidepressant withdrawal, suggesting they occur in only 15% of people. But withdrawal symptoms may occur during and despite slow tapering and may persist for a long time (see eg. previous post). Even with the help of CBT to prevent relapse after withdrawal, only 36% of patients succeeded in discontinuing antidepressants over 16 months in a failed trial that found no difference between CBT and controls. Only 28% did not have a recurrence. 

Patients are actually, generally, very reluctant to take part in antidepressant discontinuation trials (see previous post). Fear of recurrence, relapse, or disturbing current mental equilibrium is common and prior failed attempts to discontinue antidepressants reinforce these expectations. People have also commonly been taken in by the myth of chemical imbalance in the brain as the cause of depression (see eg. another previous post) and are, therefore understandably, fearful and uncertain about stopping antidepressants, as the thought is their chemical imbalance could return. This fear overpowers the concern and uncertainty about continuing antidepressants. It's understandable if people think it’s better to be safe than sorry by continuing antidepressants (see eg. yet another previous post). 

So, even though we may have gone from the situation of antidepressant withdrawal symptoms being denied, as in the Defeat Depression campaign, to one in which they are accepted but the significance minimised (see eg. previous post), there is still insufficient understanding of the nature of antidepressant withdrawal. The situation has not really changed from what I wrote in an Openmind article nearly 25 years ago:-

People may form attachments to their medications more because of what they mean to them than what they do. Psychiatric patients often stay on medications, maybe several at once, even though their actual benefit is questionable. Any change threatens an equilibrium related to a complex set of meanings that their medications have acquired. These issues of dependence should not be minimised, yet commonly treatment is reinforced by emphasising that antidepressants, for example, are not addictive.

Even though psychiatrists may want to justify antidepressant treatment, this does not excuse minimising problems caused by taking it. Doctors are advocates of antidepressant treatment and this has led to them overlooking what should have been obvious about the risk of discontinuation problems. Perhaps we shouldn't be too surprised that doctors have been slow to recognise antidepressant discontinuation reactions and continue to minimise their significance, as they focus on short-term fixes of emotional problems (see eg. previous post), they are not properly psychologically minded and they are too quick to peddle medication and oversimplistic psychological interventions (see eg. another previous post). I’m not saying this to polarise debate about modern psychiatry, but the biomedical model that mental illness is due to brain disease has became too dominant and should not be buttressed by denying or minimising the significance of antidepressant withdrawal and other medication side effects.

To keep you in good humour

History of Psychiatry has an interesting article on ‘Cheerfulness in the history of psychiatry’. As the article says, “the notion of the French gaité tends to couple mood with an innate configuration, both procuring laughter, fun and vivacity". It goes on to mention Louis-Antoine Marquis de Caraccioli who was “ a prolific writer of the eighteenth century, [who] dedicated a book to a psychological theme that medicine has forgotten: ‘gaité’ in French". 

The article goes on:-

At the beginning of the nineteenth century, this work inspired two doctoral theses in medicine, … In their texts, Louis Monferran (1785– ?) and Vincent Rémi Giganon (1794–1857) explored the therapeutic benefits of the medical prescription of cheerfulness. In addition to lifestyle recommendations, they focused on the psychotropic substances available to them: alcohol, coca, hemp and opiates. … Giganon [also] … recommended … inhaled nitrous oxide gas.

Well, at least they included lifestyle recommendations as well as various substances. We have learnt a lot about these substances since Montferran and Giganon and can also learn from these authors’ historical theses for the present. Of course psychedelic substances are making a comeback as prescribed medications (see previous post). But, although fighting sadness with cheerfulness may seem to make sense. we also need to be realistic. 

It may be easy to get caught up in the charms of momentary cheerfulness. To quote Giganon from the article. "Laughter, song, wordplay, and jargon may spell doubts and allay suspicions". Or, to quote Monferran, again from the article, "Momentary cheerfulness delights the soul without perturbing it, evokes laughter without ridicule, and refines pleasures without corrupting them”. By contrast, "lasting or internal cheerfulness is based on an inner contentment, a blameless conscience, and the secret applause that follows a good action; this joy is more perfect than momentary cheerfulness". Modern society has become too focused on quick fixes (see previous post) and oversimplistic psychiatric treatment (see another previous post).