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September 24, 2020 by Council for Evidence-Based Psychiatry

Major milestone: Royal College releases new guidance on stopping antidepressants

 

Today I welcome the new patient information leaflet, entitled ‘Stopping Antidepressants’, published by the Royal College of Psychiatrists.

The leaflet distills many years of work by researchers, campaigners and the prescribed harm community, which has jointly challenged previous understandings of antidepressant withdrawal as being a relatively benign experience for most people.

Instead, the leaflet now follows the updated NICE guidelines in recognising that while withdrawal symptoms can be mild and relatively short-lived for some, for many others withdrawal can be severe and protracted, lasting for weeks, months or beyond. The leaflet also usefully acknowledges that we cannot predict at the outset of prescribing who will suffer more serious withdrawal, which of course implies that each person must be informed, before starting an antidepressant, of the potential for severe withdrawal. Offering such informed consent is especially important given, as the leaflets accepts, that ‘between a third and half of people’ who take antidepressants will experience withdrawal to some extent. This means antidepressant withdrawal in the UK is a widespread phenomenon given that 17% of the adult population was prescribed an antidepressant last year, even if we accept the lower and contested estimation of one third (contested, since the lower estimation is based on flawed company trials, methodologically designed, in my view, to minimise withdrawal).  

The leaflet also acknowledges that withdrawal can be confused with relapse, especially since withdrawal reactions (like increased anxiety or depression) can mirror the very experiences that led many people to accept an antidepressant prescription in the first place. The leaflet offers some useful ways in which withdrawal and relapse can be distinguished, but most importantly, it acknowledges that this is not an exact science, which in my view implies that doctors must listen to and respect their patients’ views on what they think their discontinuation experience denotes.

The leaflet also avoids suggesting that depression is caused by a chemical imbalance that antidepressants somehow correct. Instead, it more cautiously recognises that antidepressants increase levels of neurotransmitters (such as serotonin and noradrenaline), with the brain slowly adapting, over time, to these increased levels. If an antidepressant is stopped quickly, therefore, the brain will need time to adjust to its absence. This period of readjustment, it is ventured, is what drives the withdrawal reaction. The leaflet, therefore, suggests that tapering must occur very gradually, and at a pace in keeping with the person’s needs and experiences, which is something for which campaigners have been calling for a very long time. It also offers some generic tapering protocols as an initial guide.

In all, I believe this leaflet is a welcome development. And I congratulate its authors on its construction and publication. Its contents contrast strikingly with the view of withdrawal propounded by many establishment psychiatrists only two years ago.

I would like to believe that members of CEP have played a central role in facilitating this shift, through our research and germane publications,[i] our initiation of the recent Public Health England review into prescribed drug dependency and withdrawal (and our work as expert advisors on the review),[ii]our work with NICE in getting the withdrawal guidelines updated and our feedback to the College regarding the fraught issues pertaining antidepressant withdrawal more broadly.

Last of all, while I’d like to think that CEP must take some credit for these changes, the greatest credit goes to those service users, withdrawal charities, online support forums and members of the prescribed harm community who have tirelessly and courageously campaigned on this issue for so many years. It’s their collective voice, courage and efforts that have ultimately shifted the dial on this critical issue. It is they to whom we all owe the greatest gratitude and for them that we must all continue the fight for suitable, national withdrawal support and provision.

Dr James Davies

[i] Davies, J., Read, J. (2018). A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based? Addictive Behaviors. pii: S0306-4603(18)30834-7. doi: 10.1016/j.

Guy, A., Davies, J. & Rizq, R., (2019_ Guidance for Psychological Therapists: Enabling conversations with clients taking or withdrawing from prescribed psychiatric drugs (an all-party Parliamentary Report for Prescribed Drug Dependence publication). London: APPG PDD .

Moncrieff, J. & Stockmann, T. (2019). Introduction for therapists on how psychiatric drugs work. In: A. Guy, J. Davies, R. Rizq (Eds.) Guidance for Psychological Therapists: Enabling conversations with clients taking or withdrawing from prescribed psychiatric drugs. London: APPG for Prescribed Drug Dependence.

Davies, J. Read, J., M. P. Hengartner., Cosci, F., Fava, G., Chouinard, G., van Os, J., Nardi, A., Gøtzsche, P., Groot, P., Offidani, E., Timimi, S., Moncrieff, J., Spada, M., Guy, A. (2019) Clinical guidelines on antidepressant withdrawal urgently need updating

BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2238

Davies J, Pauli R, Montagu L (2018) Antidepressant Withdrawal: A Survey of Patients’ Experience (an APPG for PDD Report)

Guy A, Brown M, Lewis S (2018) The Patient Voice: an analysis of personal accounts of prescribed drug dependence and withdrawal submitted to petitions in Scotland and Wales (an APPG for PDD Report)

[ii] Taylor, S., Annand, F., Burkinshaw, P., Greaves, F., Kelleher, M., Knight, J., Perkins, C., Tran, A., White, M. & Marsden, J. (2019).

Dependence and withdrawal associated with some prescribed medicines: An evidence review. London: Public Health England.

 

 

 

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