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The practice of prescribing antidepressants on top of other medications without a clear rationale. Also giving patients more than they need.

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An ethical requirement that patients are required to know the potential benefits, side effects, and risks of the medication before being prescribed.

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Physical or psychological symptoms that occur after becoming independent of a drug. All symptoms are typically harmful to the patient.

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Results of Routine Prescription of Antidepressants

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Results of Routine Prescription of Antidepressants

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This article explores the effects felt by people trying to come off the use of antidepressants. The results highlight the fact that many people struggle with things like addiction, anxiety, and withdrawal symptoms. On top of these issues, they also begin to feel the side effects of the drugs like nausea, dizziness, and even brain zaps. This

This raises concerns for how antidepressants are prescribed. Continued practice of our routine prescription method could cause a variety of issues including overprescribing, and a lack of informed consent.

Source: https://www.sciencedirect.com/science/article/pii/S0306460319309001

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Abstract

Introduction

The incidence and severity of withdrawal effects when coming off antidepressants (ADs) have recently received considerable attention. National guidelines on the topic have proven to be inaccurate. This paper reports the largest direct-to-patient international survey on these issues.

Methods

Data generated by an online survey from 867 people from 31 countries, who had taken ADs continuously for at least one month, and had tried to come off (successfully or not) was analysed.

Results

The majority (59%) had taken ADs for more than three years. Of those who were still taking them, 29% had been doing so for at least 20 years. 61% reported some degree of withdrawal effects, and 44% of these described the effects as 'severe'. The most common of six listed withdrawal effects were anxiety/panic (66%) and irritability (62%). The most common spontaneously reported 'other' withdrawal effect was suicidality (2%). 40% reported that they felt addicted, with 39% of these describing their addiction as 'severe'. Over half (55%) reported some degree of difficulty coming off, with 27% ticking 'very difficult', and 11% 'very easy'. Duration of treatment was related to withdrawal, addiction and difficulty coming off. Younger people experienced more frequent withdrawal effects. Only six people (0.7%) recalled being told anything about withdrawal, dependence or addiction by the initial prescriber.

Conclusions

These findings confirm previous studies, using a range of methodologies, finding high incidences of withdrawal effects, frequently at severe levels. National guidelines, and those of professional organisations, urgently need to be updated to reflect this evidence.

Introduction

In the U.K. antidepressant [AD] prescribing has doubled over ten years. By 2016-17 more than seven million adults (16% of the adult population) were prescribed ADs in England (DHSC, 2018). Similar rates occur in Australia, Belgium, Canada, Denmark, Iceland, Portugal, and Sweden (OECD, 2017, OECD, 2018), with the highest being in the U.S. (Pratt, Brody, & Qu, 2017).

These high prescription rates do not seem to be explicable in terms of increases in depression or help-seeking (Munoz-Arroyo, Sutton, & Morrison, 2006). UK data on 189,851 GP patients showed that a doubling of prescribing over eight years was probably explained by a doubling of prescriptions per patient, rather than by increases in new prescriptions (Moore, Yuen, Dunn, Mullee, & Maskell, 2009). By 2011, half of AD users in England, about 3.5 million people, were taking ADs for longer than two years (Johnson et al., 2012). About half of AD users in the U.S. (about 18 million) take them for at least 5 years (Mojtabai & Olfson, 2014). Average duration has doubled since the mid-2000s in the U.K. (NHS Digital, 2017) and the U.S. (Mojtabai & Olfson, 2014). In the U.K., a third of people taking ADs for more than two years have no clinical need for them (Cruickshank, MacGillivray, & Bruce, 2008). Similar rates of apparently unnecessary long-term prescribing occur elsewhere, including in Australia (Ambresin et al., 2015) and the Netherlands (Eveleigh, 2015).

Difficulty stopping the drugs because of withdrawal effects might explain why long-term prescribing is increasing, including to people who are deemed not to have a clinical need for them. The notion of AD withdrawal effects was officially recognised by a 'consensus panel' funded by drug company Eli Lilly in 1996, and was immediately minimised by creating the term 'discontinuation syndrome' (Schatzberg et al., 1997), still sometimes unquestioningly deployed today. Since then withdrawal from ADs has been portrayed, by guidelines and professional bodies, as rare, minimal and brief.

The President of the UK's Royal College of Psychiatry (RCP) and the Chair of the RCP's Psychopharmacology Committee recently wrote 'We know that in the vast majority of patients, any unpleasant symptoms experienced on discontinuing antidepressants have resolved within two weeks of stopping treatment' (Burn & Baldwin, 2018). U.S.A guidelines similarly claim symptoms 'typically resolve without specific treatment over 1-2 weeks' (A.P.A., 2010, p. 39). U.K. guidelines state 'symptoms are usually mild and self-limiting over about 1 week, but can be severe, particularly if the drug is stopped abruptly' (NICE, 2009, 1.9.2.1 in CG90). Freedom of Information requests revealed that the current NICE guidelines on AD withdrawal are not based on any research studies (Davies & Read, 2019a, p. 119).

Three systematic reviews have now established that such statements and guidelines have been minimising the problem (Davies & Read, 2019a, Fava et al., 2018, Fava et al., 2015). The most recent systematic review (involving the current author) was undertaken at the request of the UK's All Party Parliamentary Group for Prescribed Drug Dependence, to inform an enquiry by Public Health England (an agency of the Department of Health and Social Care). Fourteen studies, including small RCTs and large scale surveys, found that withdrawal incidence rates ranged from 27% to 86% with a weighted average of 56%. Four studies produced a weighted average of 46% of those experiencing withdrawal effects endorsing the most extreme 'severity' rating. Seven of ten studies with data on duration contradict the U.K. and U.S.A. guidelines, by finding that a significant proportion of people who experience withdrawal do so for far more than two weeks, and that it is not uncommon for people to experience withdrawal for several months. The reviewers (Davies & Read, 2019a, p. 120) concluded:

"We recommend that U.K. and U.S.A. guidelines on antidepressant withdrawal be urgently updated as they are clearly at variance with the evidence on the incidence, severity and duration of antidepressant withdrawal, and are probably leading to the widespread misdiagnosing of withdrawal, the consequent lengthening of antidepressant use, much unnecessary antidepressant prescribing and higher rates of antidepressant prescriptions overall. We also recommend that prescribers fully inform patients about the possibility of withdrawal effects".

The Davies and Read review was sharply critiqued by two psychiatrists who characterised it as a 'War on antidepressants', claimed that the review had exaggerated the extent, severity and duration of withdrawal effects, and disagreed with our call for guidelines to be urgently reviewed (Jauhar & Hayes, 2019). Our response carefully documented their 'many serious mistakes and misrepresentations (and/or misunderstandings)' that led us to describe their critique as 'clearly imbalanced, imprudent and inaccurate' (Davies & Read, 2019b), an assessment shared by another commentator (Hengartner, 2019).

Jauhar and Hayes did, nevertheless, raise legitimate concerns about using online surveys (such as the one that generated the data for the current paper) to estimate incidences. Participants in such surveys are certainly not randomly selected or generalizable to all antidepressant users. It is possible, therefore, that they may over-represent dissatisfied or disgruntled patients. We were able to reassure them, however, (Davies & Read, 2019b) that in the largest survey 83% believed the antidepressants had reduced their depression (Read, Cartwright, & Gibson, 2014). In the current survey this was the case for 63% (Read & Williams, 2018).

Jauhar and Hayes (2019), having corrected what they believed (rightly or wrongly) to be the errors in the Davies and Read review, proposed that a better estimate of the incidence of withdrawal effects among people who try to come off is 44%. This would still represent 3.2 million people in England alone. So researchers on both sides of a rather charged debate agree that about half (somewhere between 44% or 56%) of people experience withdrawal effects when they try to come off ADs.

The current paper reports further findings from an international survey about positive and negative effects of ADs (Read & Williams, 2018). The survey had found that withdrawal effects were reported by 59%, and addiction by 40% of 1,431 CE users from 38 countries. The current paper, analysing only responses from participants who had tried to come off or reduce their ADs, reports on the frequency of six specific types of withdrawal effects, on self-reported ease/difficulty of coming off, and on whether patients were told about withdrawal; plus analyses by demographics, treatment duration and drug type.

Very few studies have reported on how often people are informed about withdrawal effects when being prescribed the drugs (Read et al., 2018, Read et al., 2018). This is only the second survey to report on ease/difficulty withdrawing (Read et al., 2018). It is the first large survey to report the incidence or severity of specific withdrawal effects. A recent analysis of 110 postings on a withdrawal website may be the next largest report on specific withdrawal effects (Stockman, Odegbaro, Timimi & Moncrieff, 2018). RCTs tend to have artificially short treatment durations, small sample sizes, rarely report on withdrawal at all, let alone on specific withdrawal symptoms, and also tend not to analyse by demographics Davies & Read, 2019a, Davies & Read, 2019b. It is hoped that mapping the most common withdrawal effects might assist in the identification of patients experiencing withdrawal, and that any links with demographic groupings might lead to extra caution in prescribing, and while withdrawing, with those groups.'

Section snippets

Instrument

The AD sections of 'The Experiences of Anti-depressant and Anti-psychotic Medication Survey' (see Read & Williams, 2018) were based on the New Zealand 'Views on Antidepressants' questionnaire (Gibson et al., 2016, Read et al., 2014, Read et al., 2018, Read et al., 2015). These sections generate quantitative data (yes/no and multiple-choice questions) and qualitative data (open-ended questions) about: the prescribing experience, positive and negative effects of ADs, beliefs about causes of

Sample characteristics

Respondents' were aged 18 to 77 years, with an average of 45.8 (sd = 13.6); and 70.8% were women. IP addresses showed that the respondents lived in 31 countries, most commonly Australia (408; 47.1%) (from where the survey was conducted), the UK (152; 17.5%), and the USA (115: 13.3%). Seven other countries had more than 10 respondents: New Zealand (29), Germany (36), Denmark (21), Canada (20), Ireland (18), the Netherlands (11), and Sweden (11). Twenty one contributed up to eight participants:

Treatment duration

The long treatment durations reflect the large increases in duration noted earlier. A recent UK online survey of 752 CE users found that 36% had been taking them for at least five years, and 26% expected to be on them forever (Read et al., 2018).

Withdrawal symptoms

The proportion of people experiencing some degree of withdrawal effects reported here (61.5%) is even higher than the 55% previously reported for this survey (Read & Williams, 2018), and the 55% found in a New Zealand survey with identical methods (Read

Limitations

Although this is the second largest sample (and largest international sample) directly surveyed, it is a self-selected, convenience sample. Almost the entire sample lived in Europe, North America or Australasia. The over representation of women (70.8%) is not, however, a limitation because women are prescribed ADs approximately twice as often as men.

The excluded subgroups might present specific characteristics lowering the representativeness of the final sample. Those leaving the questionnaire

Conclusions

The views of 'experts-by-experience' in general, and Patient-Reported Outcome Measures (PROMs) in particular, are now recognised as crucial to understanding whether mental health services are beneficial and safe (Gibson et al., 2014, Gibson et al., 2016, Krägeloh et al., 2015). This survey confirms other surveys (Read et al., 2014, Read et al., 2018, Royal College of Psychiatrists, 2012), and the recent systematic review (Davies & Read, 2019a), in finding that more than half of people

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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Davies, J., Pauli, G., & Montagu, L. (2018). A survey of Antidepressant Withdrawal Reactions and their Management in...

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How common and severe are six withdrawal effects from, and addiction to, antidepressants? The experiences of a large international sample of patients

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The incidence and severity of withdrawal effects when coming off antidepressants (ADs) have recently received considerable attention. National guideli...

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The belief that antidepressants/medications are/aren't affecting the patient when the drug isn't doing anything physically.

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Whether or not patients follow their prescribed amount of medication. It can lead to addiction and other symptoms.

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This article talks about how the data doesn't support the effectiveness of antidepressants. The study explores the idea of bias within patients who take surveys concerning antidepressants efficacy. It was dtetermined that the effect of antidepressants is insignificant and varies from patient to patient.

Another idea presented within the article is whether or not patients are getting too much or too little medication. This can lead to a multitude of different side effects and risks that are presented when taking antidepressants.

Source 1: https://psycnet.apa.org/record/2019-47717-001?doi=1

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This article finds that there is a 50% reduction in Hamilton depression score relative to placebo. The researchers delve deeper into how bias and placebo affect this score. It was found that a majority of people described their experience as either having a bias or a placebo for antidepressants

Soource: https://oce-ovid-com.proxy.libraries.rutgers.edu/article/00011905-202009000-00001/HTML

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How does the freedom to self-govern and being kind conflict with the ethical decision-making of prescribing antidepressants and how can this issue be avoided? 

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How does the freedom to self-govern and being kind conflict with the ethical decision-making of prescribing antidepressants and how can this issue be avoided? 

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What are the potential ethical challenges and consequences of overprescribing or prescribing an inappropriate amount of antidepressants and how can we find the correct balance of medications?

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What are the potential ethical challenges and consequences of overprescribing or prescribing an inappropriate amount of antidepressants and how can we find the correct balance of medications?

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To address ethical concerns, general practitioners must familiarize themselves with patients' medical behaviors. A solution explored in this study was for general practitioners to regularly review patients’ medication decisions which could enhance shared decision-making. Enhanced shared decision-making will help general practitioners to make more informed/accurate prescriptions. This ensures the correct dosage is prescribed for every patient and is a much more ethical practice. Source: https://www.sciencedirect.com/science/article/pii/S0277953608005133

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What are the potential risks and benefits of long-term antidepressant use?

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What are the potential risks and benefits of long-term antidepressant use?