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The philosopher Baltasar Gracian observed: “The art of medicine lies in knowing what not to do”. That includes not discontinuing antidepressants when it is in the patient’s best interests to recommend continuing treatment to prevent relapse, write Associate Professors Jeffrey Looi, Stephen Allison and Professor Tarun Bastiampillai …
A recent article in The Conversation asked: “Considering going off antidepressants? Here’s what to think about first”. Although we acknowledge the aims of the article were to inform the public, we wish to discuss concerns regarding the medical advice that was promulgated in that article that might prompt patients with mental ill-health to cease medication.
As practising medical practitioners, we welcome working with pharmacists as valued members of multidisciplinary health care teams, especially their expertise and skills in dispensing and providing advice on medications.
Such teamwork is essential for effective patient care. In this context, we suggest that the consideration of discontinuation of antidepressants is but one component of the holistic planning of mental health care that is led by GPs, psychiatrists, and other medical specialists, working together with psychologists and other allied health workers, including pharmacists. Without holistic planning, ceasing antidepressants can potentially cause harms and imperil remission and recovery from severe psychiatric illness.
Centring on the best interests of patients, there needs to be a holistic diagnostic assessment (see Chapter 2 of reference), biopsychosocial formulation, and ongoing collaborative discussion of the patient’s culturally grounded narrative and explanatory model of the illness, goals, and agreement on the appropriate treatments (pharmacological and non-pharmacological) for mental illness with a medical expert (ie, GP, psychiatrist and other medical specialists such as geriatricians and neurologists).
Antidepressants are prescribed for a wide range of mental health conditions, primarily by GPs and psychiatrists, including such illnesses as, but not limited to, depression, bipolar disorder, anxiety, post-traumatic stress disorder, and obsessive compulsive disorder, as well as comorbid depression in people with other mental illnesses.
Furthermore, antidepressants are considered as part of the spectrum of options for treatment, and are often combined with psychological therapy to improve outcomes for anxiety disorders and mood disorders, such as depression.
In this context, continuation or discontinuation of medication is properly situated in a broad assessment of the patient and their illness, rather than an algorithmic approach to dose reduction.
Decisions regarding mental health diagnosis and pharmacological and non-pharmacological treatment should be shared between doctors and patients working toward an agreed goal according to patients’ wishes, needs and circumstances. Prescribing or discontinuing medication is part of a range of broader treatment options; for example, psychiatrists recommend evidence-based psychological therapies such as cognitive behavioural therapy as first line treatment for many anxiety disorders. So medications are prescribed judiciously, and discontinuation is not a simple consideration, especially in areas where there is limited evidence such as psychotic depression (pp 332-333), which means the treatment options need to be carefully discussed with patients. Such collaborative plans are then led and coordinated by GPs, psychiatrists and medical specialists working together with allied health workers such as pharmacists.
We address particular assertions in the article on a point-by-point basis below.
Assertion 1
“Use of antidepressants has increased since the beginning of the [coronavirus disease 2019 (COVID-19)] pandemic at a greater rate than past decades. As we return to some semblance of normality, people may well be thinking about going off their mental health medicines, particularly antidepressants.”
Firstly, no evidence is cited for any of these statements. However, we acknowledge that there is evidence that antidepressant use may have increased during the pandemic. Secondly, although there has been evidence that transient psychological symptoms waxed and waned during the COVID-19 pandemic, it is unjustified to assert that people prescribed antidepressants during this period had transient symptoms. Furthermore, there is no evidence offered for the assumption that post-COVID-19 it is safe for people taking antidepressants to discontinue them.
Assertion 2
“Of course, there are reasons you might be thinking about discontinuing your antidepressant. They could include:
- no longer experiencing symptoms of depression or anxiety
- finding other ways of coping
- medicine seeming ineffective
- long-term use and wanting a break
- a life event such as pregnancy, divorce or job change
- media influences, such as reports about treatments or portrayals of people taking similar medications
- side effects, stigma or pressure from family and friends.”
Again, these circumstances should be discussed with the treating doctor as part of collaborative planning. This list of reasons for stopping an antidepressant is not supported by citing qualitative or any other evidence.
In contrast, a recent meta-analysis addressing the question “whether to continue the same antidepressant used to achieve remission or to discontinue in remitted patients with a major depressive disorder” found that overall, the relapse rate was significantly lower (by about 20%) in those that continued antidepressants.
Assertion 3
“4 things to think about: Once you’ve considered your reasons for wanting to stop taking an antidepressant and whether you’ve given it a fair shot to work, think about whether you feel well physically and emotionally and have supportive people in your life.
If you still want to embark on a process of stepping down or ceasing medication:
1. approach your prescriber honestly with your reasons for discontinuation and work towards a shared decision to reduce the dose
2. plan dose reduction at a rate suitable for your personal health and duration of antidepressant use (months versus years). Longer use requires a longer taper. Dose reduction can be by as little as 10% or as much as 25% every one to two weeks, followed by another two to four weeks when you can observe how you feel and manage the reduced dose. If symptoms are tolerable, continue tapering as before. But be prepared to move back to the previous or a 10% dose increase if symptoms emerge
3. monitor any symptoms and health by using a daily diary that records the drug dosage throughout the taper
4. maximise the chances of success with self-care: a healthy diet, regular exercise and sleep.
Every medicine we take should have a reassessment date. People taking antidepressants should have their medication reviewed no later than 12 months after they started.”
There is again, no evidence offered for the rather definitive assertions on dose reduction, and it continues to beg the question that a patient should consider antidepressant discontinuation as a given, nor is there consideration of the issues around comprehensive diagnostic assessment and collaborative framing of care.
We agree that discontinuation of antidepressants should be discussed with GPs, psychiatrists and other medical specialists, that is, those with expertise that encompasses a holistic medical care approach not confined to medication.
Even though it is agreed that medication should be reviewed, there is no balanced consideration whether ongoing antidepressant use may be warranted, especially in light of the evidence ongoing antidepressant use can prevent relapse of remitted depression.
GPs, psychiatrists and other medical specialists working with pharmacists can provide effective care through synergy, as distinct from a narrower focus on medication discontinuation that may arise from the viewpoint of a single professional group with expertise in dispensing medication.
Conclusions
The patient-centred, evidence-based approach to use of antidepressant medication begins with diagnostic assessment by a medical specialist, collaborative care planning with the patient, including, but not limited to medication use, psychological and other therapies. Judiciously and collaboratively used, antidepressants are a means towards the ends of improving patients’ mental health.
Discontinuation of antidepressants, as an option, must be considered comprehensively as part of the treatment approaches for a given diagnosis. In this context, antidepressant discontinuation can never be an end in itself.
Associate Professor Jeffrey Looi is Head of the Academic Unit of Psychiatry and Addiction Medicine, Australian National University School of Medicine and Psychology, and co-founder of the Consortium of Australian-Academic Psychiatrists for Independent Policy Research and Analysis.
Associate Professor Stephen Allison is Associate Professor of Psychiatry at the College of Medicine and Public Health, Flinders University, and co-founder of the Consortium of Australian-Academic Psychiatrists for Independent Policy Research and Analysis.
Professor Tarun Bastiampillai is Professor of Psychiatry at the College of Medicine and Public Health, Flinders University; Adjunct Professor at the Department of Psychiatry, Monash University Medical School; and co-founder of the Consortium of Australian-Academic Psychiatrists for Independent Policy Research and Analysis.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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If you would like to submit an article for consideration, send a Word version to mjainsight-editor@ampco.com.au.
Many patients see the ongoing costs of psychiatry as too great and wait times too long, resulting in disengagement from the psychiatrist and when/if uncertainty about their medication occurs opt to rely on more easily accessible options for making decisions. It is not optimal. Those with chronic and severe mental health conditions can struggle to work consistently enough to cover basic living costs, in which case psychiatry is often only interfaced briefly with during emergency department visits, and sometimes receiving most interactions with a registrar.
More needs to be done to give the most vulnerable access to affordable psychiatry and GPs. Perhaps a starting point could be larger Medicare rebate for those with health care cards so they can be more likely to receive bulk billing. Asking these people to find 100s of dollars for the appointment (even if much of that is refunded) is often not feasible. If the Government needs to find $ for this then reduce rebates for families over certain incomes. Society as a whole would be better if the most vulnerable got the best care.
While I appreciate the concerns, the authors have about patients stopping antidepressants suddenly, without discussing it with the GP, in my experience, patients have quite commonly stopped antidepressants without consultation, and many have not been in contact again. I also have seen many patients who have chosen stop their antidepressants and relapsed. Given that this article is for general consumption profit, then a professional paper, I would not expect an explicit solid evidence base. The list of reasons cited for ceasing antidepressants seems quite reasonable. The dose reduction schedule doesn’t seem unreasonable, although the quantities may be challenging, especially if medications are taken as capsules. Given that, whether we like it, or not, patients will use their own agency. In this matter, I can certainly see the place for an article like this. At least it doesn’t tell patients that they are poisoning themselves.
This is really an article written for the general populace than a medical audience. In my career in general practice I cannot recall any article or educational session from a psychiatrist suggesting in whom it was reasonable to withdraw antidepressants. The proportion of older patients on antidepressants is high and the potential for iatrogenesis present. Perhaps the MJA might like to commission the authors of this piece to write an MJA article on the withdrawal of antidepressants as this remains a more neglected area. Withdrawing antidepressants may harm some patients but benefit others. Not doing harm to patients remains an important medical premise.