Study Examines the Difficulty of Withdrawing from Antidepressant Drugs

Correcting unnecessary long-term antidepressant use is difficult and met with apprehension by providers and service users

Zenobia Morrill
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Researchers in the Netherlands, led by Dr. Rhona Eveleigh, investigated a tailored approach to withdrawing from longterm antidepressants prescribed inconsistently with clinical guidelines. Their results suggest that antidepressants are overprescribed and that once they are started it is difficult to discontinue their use.

“This study concludes that overtreatment with antidepressants is very prevalent and that a considerable proportion of long-term use has no clinical justification,” the authors write. “As such, this study aims to reduce inappropriate long-term antidepressant use in general practice.”

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Research has demonstrated that antidepressant drugs are not significantly superior to placebo at reducing depressive symptoms except in cases of severe depression. However, clinical practice has failed to reflect this research and antidepressants continue to be prescribed as a first-line treatment for mild to moderate depression. The question of how to withdraw from antidepressants when they have been prescribed inappropriately has become central to remediating overtreatment.

The researchers evaluate the effectiveness of a recommendation to cease treatment with antidepressants by implementing an approach tailored to the patient and the psychiatric diagnosis. The aim of this study is driven by the high levels of problematic long-term antidepressant use, classified as “overtreatment.”

This usage is contraindicated explicitly by research recommending the limited duration of antidepressant use. Moreover, the authors write that the effectiveness of antidepressants is “questionable,” with five out of every six users failing to experience benefits. They explain:

“It is important to discuss how patients can use their own resources to cope with their problems; providing medication might be counterproductive, as medication use may disincentivize a patient to find non-pharmacological solutions, thereby diminishing patient empowerment in a context where regaining control is essential for recovery.”

This study was conducted across 45 general practices in the Netherlands between February of 2010 and March of 2013. Patients who had been using antidepressants for over nine months were identified by general practitioners. Those who did not meet criteria for a current psychiatric diagnosis, or another reason for continued use (e.g., chronic pain or neuropathic pain) were included.

The sample consisted of 146 individuals who were randomly assigned to one of two groups: those that received a recommendation to discontinue antidepressants and those in the control group, who proceeded with their usual care. Patient characteristics were well balanced across the two groups.

Recommendations to discontinue antidepressant use were rejected by 34 out of 70 participants (49%) by the patient themselves (14 cases, 41%), the general practitioner (1 case, 3%), as a shared decision (16 cases, 47%), and in the remaining cases, data were missing. Reasons cited were fear of recurrence, relapse after a previous attempt at discontinuation, the presence of psychological symptoms, wanting a second opinion, and other, non-specified reasons. However, it was not found that those who rejected this recommendation did so because of experiencing greater or lesser distress or depressive symptoms.

Results demonstrated that 6% of individuals recommended to discontinue were able to successfully stop taking antidepressants, even given that 51% of those in this group accepted the recommendation to discontinue.

In the control group, 8% of patients successfully discontinued merely because of spontaneous discontinuation. Successful discontinuation was defined by no antidepressant use for the preceding six months and no depressive or anxiety disorder during the one-year follow-up (as assessed by the Composite International Diagnostic Interview).

Additionally, individuals who had received the recommendation to discontinue were more likely to relapse compared to individuals in the control group. Patients who were able to successfully discontinue did not differ from those who were unable to across demographic characteristics. However, they were more likely to have been taking antidepressants for a shorter duration before attempting discontinuation than their counterparts.

Overall, many patients rejected the recommendation to discontinue, general practitioners tended to agree with this rejection, and those who did attempt to discontinue were mostly unsuccessful. Eveleigh and researchers suggest that these results demonstrate not only the inconsistency between guidelines and practice but the strong apprehension to discontinue antidepressant use across providers and patients alike.

The authors cite other research which has found that patients fear to stop antidepressant treatment and lean toward a “better safe than sorry” approach. There is also evidence tying this tendency to the accompanying belief that their depression is chronic and merits life-long treatment. General practitioners similarly express fears around disturbing the “equilibrium,” by tapering antidepressant use, preferring to “take the path of least resistance.”

Eveleigh and co-authors conclude that recommendations to discontinue may be ineffective, and perhaps even counterproductive given the findings of this study. Instead, they call attention to a needed apprehension at prescribing antidepressants at the outset, particularly concerning their lack of effectiveness and the available non-pharmacological alternatives. They write:

“Notwithstanding, it is felt that the first, and possibly most important, step to prevent inappropriate long-term use of antidepressant medication in primary care is to be more restrictive in prescribing antidepressant medication in the first place and make more use of alternative, non-pharmalogical treatments.”

Additionally, in cases where discontinuation is recommended, they state that it “might be useful to forewarn patients about the difficulty of discontinuing and to encourage using antidepressants only for a limited period.”

 

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Eveleigh, R., Muskens, E., Lucassen, P., Verhaak, P., Spijker, J., van Weel, C., … & Speckens, A. (2017). Withdrawal of unnecessary antidepressant medication: a randomised controlled trial in primary care. BJGP Open, BJGP-2017. (Link)

14 COMMENTS

  1. I have slowly tapered many people off antidepressants, usually without significant problems. My approach has been to refer them to Irving Kirsch’s studies to prove to them that antidepressants only work via the placebo effect, and to explain how “chemical imbalance-ism” is merely a scam that psychiatry (with the help of the drug industry) devised, in a desperate attempt to avoid the extinction it was facing due to competition from social workers and psychologists for the psychotherapy role, by creating permanently helpless/drug-dependent customers. This is never easy (especially if they grew up in the medical model era), since the medical model is being pushed by so many in authority roles, and since it’s so ingrained in our culture’s psyche. Over time through patient psychotherapy, which is by far the main focus of our sessions and which I believe is the most crucial step needed to enable success, I also help them get in touch with, express, and address whatever real-life issues were making them sad and anxious. It’s never an easy process, but these steps often lead to their losing confidence in psychiatry’s drugs and myths, and increasing confidence in themselves. As a result, they usually become less fearful of “relapse” upon antidepressant discontinuation and become more motivated to give it a try, which often enables them to very gradually come off them without too much trouble, although this is not always the case.

  2. Doctors really do need to educate themselves regarding the common adverse effects of antidepressant discontinuation syndrome, since I know from personal experience that the doctors are largely clueless of these adverse effects, thus often misdiagnose them, which of course results in further iatrogenic harm.

    https://en.wikipedia.org/wiki/Antidepressant_discontinuation_syndrome

    Personally, I believe that prior to prescribing any of the antidepressants, for any reason including smoking cessation, doctors should be required to forewarn patients of how hard it is to get off this class of drugs. I believe this is called informed consent and should be happening, but it is not happening in practice.

    I will also mention a middle aged woman can not go into a hospital today for any reason, without the idiot doctors asking them if they’re depressed. This needs to change, too.

  3. This looks like very solid research. It remains disturbing that such articles are written so cautiously and in such arcane terms that the impact is minimized. “Overprescribing” of antidepressants should be referred to as “malpractice” or “harming patients through the harmful side effects of unneeded drug prescriptions.” Instead of saying “Providing medication may be counterproductive,” why not say, “Prescribing drugs appears to harm many patients by preventing their seeking of other approaches that are likely to be more effective.” And why not recommend that “antidepressants should not be prescribed before other less damaging approaches are fully explored?” It’s time to stop being so mealy-mouthed about this stuff. Scientist need to confidently state the conclusions of research to date: antidepressants don’t help most people (5 out of 6 in this study), and long-term use of antidepressants makes things worse for many users. Those two facts together should be enough to make doctors very, very reluctant to prescribe ADs as a first or even second-line treatment. But nobody in the mainstream seems willing to say that the emperor is, in fact, quite naked.

    • Brilliant. I love the more direct, “mince no words” approach. That being said, careers have been ended with such brutal honesty by the opposition. I know a psychologist who challenged a shrink on his prescribing practices of a 7 year old (who was already on 4 medications) and was threatened, in writing, by the shrink himself. Those in power are ruthless in defending their man made divinity. But, the tide is about to turn and I’ll be so happy to have a ring side view of their demise.

      • Thanks! I do think the wheels are starting to come off the psychiatric cart, but it’s a big cart with lots of wheels, and the psych profession isn’t averse to dragging the cart along the ground even if the wheels are gone. As long as they’re making billions of dollars off of selling psych drugs, they’ll do whatever they can to keep the cash flowing. And you’re right, I’ve been attacked and/or undermined for speaking my mind about psych drugs. You kind of learn a way of maintaining balance between honesty and protecting your job, but it’s not really safe to speak up in these settings. That’s why I got into advocacy instead of working directly in a mental health agency – the ethical conflicts were just too intense for me to feel good at the end of the day. But researchers have more latitude, and I would really like to see more of them come out and be honest about what the data suggest.

    • I can’t remember who said it, Steve, but a doctor who gives seminars here argued there could be short term benefit in limited use of neuroleptics (2-6 weeks.) In his opinion there was never a good reason to use SSRI’s since the costs out weighed the benefits.

      I went off Abilify in 10 weeks. A few headaches and some diarrhea, but nothing major. Effexor took about a year. After more than 3 months off it entirely I feel physically sick half the time. I’m a success story compared to most others.

      • The only possible useful application of psych drugs is for acute care in the vast majority of cases. I know there are a small minority of folks experiencing paranoia and voice-hearing, etc., who are willing to accept the horrific side effects because they can’t seem to find another path, but for most people, whatever benefits (if any) they experience diminish rapidly, or are pretty quickly outweighed by the increasing adverse effects. In my view, except for temporary sedation during a crisis, going to psych meds should only be an act of final desperation.

        • In my case I was paranoid and hallucinating from 3 weeks without sleep. A “side” effect of Anafranil.

          I told my parents to please let me skip classes and sleep a few days to recuperate. My doctor told Mom I should be better immediately after 24 hours since Anafranil was out of my system. I obviously had classic Schizophrenia.

          He didn’t even talk to me, just heard Mom’s concerns and told her I was hopelessly crazy and needed immediate hospitalization. Terrifying for all of us but Dr. Snake-Oil! Just another day for that quack.

  4. I would like to know how they discontinued. Is this a Cold Turkey study?

    Or was it the fast taper that the drug companies recommend (cut in half for 2 weeks then quit)?

    Was there a difference between these 2 groups?

    What about the success rate of slow tapers?

    Egads.