A new review, published in the British Journal of Clinical Pharmacology, identifies several strategies that prescribers can use to assist patients with coming off of antidepressants, and explores the barriers preventing individuals from doing so. The review highlights the need for further exploration of withdrawal symptoms associated with discontinuing antidepressants as well as to test whether the available tapering strategies work. The author, Tony Kendrick, a professor of medicine at the University of Southampton, writes:
“Surveys of antidepressant users suggest 30-50% have no evidence-based indication to continue, but coming off antidepressants is often difficult due to fears of relapse, withdrawal symptoms, and a lack of psychological treatments to replace maintenance treatment and prevent relapse.”
The need for a reduction in antidepressant use is clear to see when examining the ever-increasing rates of antidepressant prescriptions across western countries over the past 30 years. This increase in antidepressant prescriptions is primarily due to increases in treatment duration, or how long an individual is on antidepressants, with treatment duration doubling every ten years over the past three decades.
“The median duration of use among patients on antidepressants is now more than two years in the UK and more than five years in the USA,” Kendrick writes.
The frequency of long-term antidepressant use is concerning, considering the risk of adverse effects, such as weight change, sleep disturbance, sexual dysfunction, impairments of autonomy and resilience, and dulled or blunted experience of emotions. For older individuals, the risks are more significant, as the side effects produced by antidepressants can worsen with age. Those 65 and older taking antidepressants are at increased risk for mortality, falls, stroke, gastrointestinal bleeding, and seizures, among other health issues.
Additionally, being on antidepressants for an extended period increases an individual’s risk of experiencing withdrawal symptoms when they attempt to stop using their medication. Common withdrawal symptoms include sensory issues, insomnia, anxiety, depression, and suicidal thoughts.
These withdrawal symptoms may mimic the original issue, like depression, that brought the individual to treatment, which may lead them to restart their medication under the assumption that their presenting symptoms have returned. These assumptions are often reinforced by their primary care physicians, rather than waiting for the withdrawal symptoms to go away on their own. This then reinforces the belief for the individual that they need to remain on antidepressants.
Moreover, the longer an individual is on antidepressants, the less likely it is that their general practitioner will reassess whether the medication is still necessary or appropriate. Individuals are typically provided with repeat prescriptions and are usually prepared to continue taking antidepressants indefinitely. Fears of relapse or becoming unstable, and lack of communication from their general practitioners about weaning off, fuel individuals’ willingness to commit to a lifetime of antidepressant use.
In addressing strategies to reduce antidepressant prescription, Kendrick urges against antidepressant prescriptions for individuals experiencing mild symptoms of depression or anxiety. He highlights how avoiding beginning antidepressant treatment during the initial meeting between practitioner and patient allows for time for the individual to improve without treatment, which occurs for a significant number of individuals.
If the symptoms remain persistent, antidepressants should be prescribed only under certain circumstances: if an individual has not benefited from or would not be a good fit for psychosocial interventions (therapy, self-help, or an exercise regimen), the individual is at risk for developing more severe depression or anxiety, or the individual has a history of recurrent depression or anxiety and is requesting to begin a new course of treatment for an antidepressant they had been prescribed in the past.
Kendrick urges general practitioners to avoid spreading misinformation about antidepressants, such as they are used to treat deficiencies of serotonin in the brain. This claim is not supported by brain research and is problematic as it can lead patients to believe that they require indefinite treatment to “fix” this imbalance.
The chemical imbalance myth, along with other misconceptions about antidepressants, is prevalent across popular websites. This is concerning, considering many patients are citing serotonin deficiency as the reason why they need antidepressants.
Other misinformation about antidepressants has been spread by pharmaceutical companies as well. This has resulted in a lack of attention to the significant impact placebo effects have on the efficacy of antidepressants (88% of short-term antidepressant efficacy is attributed to placebo effects and only 12% being attributed to the actual pharmacology of the drug) and to patient withdrawal symptoms, which are often explained away as being part of the patient’s underlying mental health issues.
Kendrick also emphasizes the need to adequately educate patients about antidepressant use by informing them from the start that they will be on antidepressants for a limited time, after which they will be assessed to determine if the medication is still necessary. Patients should be informed of withdrawal symptoms associated with antidepressant use so that they can make a fully informed decision about whether they would like to begin taking antidepressants, knowing the potential risks.
Clear, national guidelines are vital in reducing antidepressant prescriptions. Guidelines acknowledging the limited efficacy and potential side effects and withdrawal issues may have yielded positive results, with prescribing for first-time experiences of depressive episodes decreasing from 70% to 60% of episodes.
Unfortunately, national guidelines can also work counteractively. The NICE guidance indicates that antidepressants should be prescribed for two years or longer for episodes of depressive symptoms that are reoccurring, which has resulted in the overall antidepressant prescribing remaining amount the same, even though first-time episodes prescriptions decreased.
In a review of barriers to stopping antidepressant use, fear of withdrawal and relapse, lack of guidance from practitioners, and time constraints related to follow-up appointments were found to be major roadblocks. Some of these barriers, such as patient fears and lack of practitioner guidance, can be assuaged in part through increased support for the patient by the practitioner, which others, also pointing to the concern individuals have with coming off of antidepressants, have called for as well.
Kendrick points to the importance of practitioners initiating discussions about ending antidepressant treatment with their patients, rather than operating under the assumption that their patients will initiate it. Along similar lines, having regular reviews of the medication and the patient’s treatment is crucial to determine whether the drug is still needed or whether it can be discontinued.
Kendrick also identifies several different drug tapering programs that allow patients to be weaned off of the medication, and therefore avoid experiencing potentially unpleasant or distressing withdrawal symptoms. Although further research needs to be conducted to determine the best method to use to wean off of antidepressants, broadly speaking, the process should be one that is negotiated between patient and practitioner via a process of mutual decision-making.
Psychotherapy is also highlighted as an essential part of the tapering process, as it provides a space for individuals to express their fears related to withdrawal and experience a sense of support. The available literature suggests that those who receive psychological or psychiatric care as they are tapering from antidepressants have higher success rates – with between 40% and 95% of individuals discontinuing antidepressant use altogether.
However, a significant limitation to psychotherapy is access – resources are limited, and not all have the means to access therapy. In England, the program Improving Access to Psychological Therapies (IAPT) was developed to help individuals in need access therapy. As of 2016, only 15% of individuals diagnosed with depression and anxiety in primary care were referred or self-referred to psychotherapy. Although the Mental Health Taskforce hopes to increase this to 25% by 2021, the vast majority of individuals will still fall through the cracks.
Kendrick proposes an alternative: online psychological support coupled with primary care support as a way to assist patients with stopping antidepressants, which would address the gaps left behind by psychotherapy. He highlights the REDUCE program in England, which is funded by the National Institute for Health Research (NIHR).
Through qualitative research, the program identified factors that both harm and help patient’s attempts to discontinue antidepressants. Through this program, both the general practitioner and patient have access to online programs that are designed to assist with antidepressant withdrawal. The patient also has access to three phone call sessions with a psychological wellbeing practitioner.
For practitioners, the REDUCE program developed internet modules that provide practitioners with information and assistance on topics such as how to talk to patients about tapering and outlines tapering schedules for antidepressants. The reduction schedules have been adapted for all antidepressants. They are adjusted depending on the withdrawal symptoms associated with each particular antidepressant, as well as the history of the patient (such as if they have a history of distressing withdrawal symptoms or are particularly fearful of withdrawal). The plans are also adaptable themselves, in that practitioners are encouraged to slow down tapering, or return to the previous dose if withdrawal symptoms become too distressing or severe.
The REDUCE program is currently being assessed as to whether it is an effective intervention to assist with antidepressant discontinuation. There is a similar program in development in Australia. Although promising, these programs require additional research to determine whether they work.
Overall, increasing antidepressant rates driven by long-term antidepressant use points to an issue in prescribing. Resources are needed to assist practitioners to consider initiating antidepressant treatment more carefully. If they do prescribe, guidance is needed on the duration of time they are keeping patients on these medications.
A thorough review of the research literature indicates that tapering safely can be accomplished through the increased practitioner and patient education and support, tapering strategies, and psychological support, both in-person and online. The review points to the need for further research into this matter, so that clear guidelines and programs can be put into place to ensure that patients are not remaining on medications that are no longer needed.
Kendrick, T. (2020). Strategies to reduce the use of antidepressants. British Journal of Clinical Pharmacology. DOI: 10.1111/bcp.14475 (Link)