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.”
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.”
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)