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Antidepressants are being overprescribed, but there is limited guidance for general practitioners or their patients when it comes to stopping the medication.
A perspective published in the Medical Journal of Australia has called for a re-evaluation of antidepressant prescribing in primary care.
Antidepressant use is rising, with one in seven Australians taking antidepressants, 92% of which are prescribed by general practitioners.
Despite this, growing evidence suggests that antidepressant effects are minimal in patients with mild to moderate symptoms, with studies showing that exercise can have stronger effects.
Professor Katharine Wallis of the University of Queensland and co-authors argue that antidepressants are overprescribed.
“The evidence suggests that antidepressants are overprescribed in Australia: patients, more commonly women and older people, are both started on antidepressants when clinical guideline criteria are not met, and continued on antidepressants for longer than clinical guidelines recommend for most people, where the potential harms likely outweigh the potential benefits, and where better alternatives are available.”
Relapse vs withdrawal
The perspective authors note that the increase in antidepressant use is largely due to a rise in long term use, with around half of people on antidepressants taking them for longer than two years.
“Long term antidepressant therapy has been justified by results of relapse prevention trials showing higher rates of relapse among individuals randomly assigned to discontinue antidepressants compared with those who continue them,” the authors wrote.
“Yet, arguably these trials stop antidepressants too precipitously and misinterpret physiological withdrawal symptoms as relapse.”
Antidepressant withdrawal symptoms include anxiety, irritability, low mood and tearfulness, and can be severe and long-lasting, which makes it difficult for some people to cease antidepressants.
“Even if only 2% of users experience severe withdrawal symptoms, the scale of the problem is alarming given that nearly 2 million Australians are long term antidepressant users,” the authors wrote.
A need for deprescribing guidelines
There have been calls for better guidelines around deprescribing antidepressants.
The Royal Australian College of General Practitioners recognises the Maudsley deprescribing guidelines as an accepted resource, which recommends hyperbolic tapering of doses to cease antidepressants.
However, the Royal Australian and New Zealand College of Psychiatrists guidelines claim hyperbolic tapering is not practical or feasible.
“How best to minimise withdrawal symptoms to enable people to successfully stop antidepressants requires further research,” the authors of the perspective in the MJA wrote.
“Although slow hyperbolic tapering of drug dose can help to minimise withdrawal symptoms, we do not yet know the optimal tapering regimen. Nor do we know that this approach will work in everyone.”
Even with clearer deprescribing guidelines, it is possible that some people will never be able to stop taking antidepressants due to severe withdrawal symptoms.
“If so, then informed consent discussions about starting antidepressants need to include information that, once started, it may not be possible to stop antidepressants, and patients may have to take them for the rest of their life with associated risks,” the authors wrote.
The authors call for more practical resources for general practitioners, such as tapering plans with instructions for reducing doses, and advice for accessing mini doses for use in tapering.
“Given the sheer number of people now taking antidepressants long term and the difficulty that some people face stopping antidepressants, there needs to be better recognition (by both patients and practitioners) and management of antidepressant withdrawal symptoms and support for people to safely stop,” the authors wrote.
Read the perspective in the Medical Journal of Australia.
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Bravo! At last, recognition of the overprescription of antidepressants and the all-too-common withdrawal symptoms that are misinterpreted as “relapse” of “depression”. As a psychiatrist I see too many people on long-term antidepressants, with no good indication for their use, either acutely or long-term. The term depression has become meaningless and includes a variety of normal responses to adversity and loss. It’s understandable that GPs reach for a pill when they have so little time for taking a comprehensive history and offering counselling. Further education is needed for GPs and psychiatrists, who are also guilty of overprescribing these medications. Big Pharma’s marketing has been spectacularly successful.
For an impartial professional organisation, RANZCP gives a good impression of uncritically supporting the Pharma endorsed line of argument for continuing with the status quo of antidepressant use. The line taken seems to smack of more than traditional medical conservatism. Calling for “more studies” in well studied areas of practice, rather than at least calling for and actively endorsing pilot studies in our community, seems to be the standard deflection. Maybe there’s a point I am missing here? Perhaps communication is the issue?
As a long term GP I find it difficult to believe the one in seven of the population taking anti-depressants- where does this figure come from-it is not stated in the extract above..
Basic clinical guidelines must be followed. Only prescribe a drug if there is no alternative, and for a confirmed diagnosis of a disorder. All too often antidepressants are prescribed for situational stressors and then continued for life. Set treatment goals and with-plans for medication discontinuation. Manage patient expectations. Drugs should not be first line treatment nor should it be the only modality. It is easier to have a brief few sessions of counselling. The money saved from unncessary antidepressant use will help other treatable conditions.