Withdrawal of unnecessary antidepressant medication: a randomised controlled trial in primary care

It is extremely heartening to read the letters from Daniel Dunleavy and Peter Lucassen. Daniel Dunleavy clearly has a very good understanding of the issues involved here and the need for fractured relationships to be repaired between the prescribed dependent community and the medical profession. There is an overwhelming sense of anger and deep sense of betrayal felt by many of us which cannot be overstated and the need for acknowledgement of the harm done to us is overwhelming. It is therefore very welcome that Peter Lucassen is wiling to discuss openly the problems with their clinical trial and the need for a new clinical trial. It is just a pity that the research team had not considered involving the online patient community from the outset. We could have saved them time and money and helped them achieve a more positive outcome.

We would agree that patients need to be offered more access to talking therapies rather than simply being prescribed drugs. And the research into optimum tapering methods is of course very welcome. However, I am astonished that it has taken decades of antidepressant prescribing to reach this point. The situation is the same in the UK, existing tapering guidelines are not fit for purpose as they are based on studies of patients who have taken the drugs for relatively short periods.¹ Many patients find themselves seriously harmed either by consuming antidepressants and/or withdrawing from them and some seem to be irreversibly damaged to the extent they can no longer function normally. It seems there is little understanding of this type of damage in the medical community. Surely it is imperative that such extreme levels of harm are openly acknowledged for what they are and research needs to be conducted into the nature of this harm and the possibilities for reversing it.

References
1. National Institute for Health and Care Excellence. Depression in adults: recognition and management: 1.9 Continuation and relapse prevention. Clinical guideline [CG90] https://www.nice.org.uk/guidance/cg90/chapter/1-Guidance#continuation-and-relapse-prevention (accessed 19 Jan 2018)

The study by Eveleigh et al¹ provides an important contribution to the literature on psychiatric drug withdrawal and highlights the difficulties of coming off antidepressants. Psychiatric drugs of all classes (i.e. antidepressants, neuroleptics, benzodiazepines, etc.) can cause physical and psychological withdrawal effects.^2–5 Approaches for their discontinuation require further study.⁶

As noted in previous letters (and subsequent responses from the authors), the rate of withdrawal can impact patient outcomes. We know that rapid discontinuation can cause intense physical and emotional discomfort,⁷ which may explain the low success rate in the study’s intervention group.1 Unfortunately, despite the enormous financial investment in drug research, there is a dearth of empirical evidence, from both a short- and long-term standpoint, about how different withdrawal schedules and dose reductions compare.^1,5,8,9 Researchers, physicians, and patients will have to work together to disentangle the risks and benefits of various protocols and how they differ across condition (i.e. purely psychiatric conditions vs. purely medical conditions vs. mixed presentations), drug-class (i.e. SSRIs vs. TCAs vs. SGAs, etc.), and demographic groups (e.g. women vs. men; young vs. old), among other factors.

This collaboration will have to begin with professional acknowledgement of the iatrogenic harms caused by these substances, whether intentional or not. Overtreatment, coercive treatment, and lack of informed consent have left many patients feeling betrayed or alienated by the medical system; in part leading to the development of patient-driven support groups and withdrawal initiatives.^9–11 Professional trust must be repaired and strengthened, to increase the chances of withdrawal success. Likewise, patients and physicians will have to reconcile their beliefs about the nature and treatment of conditions like depression,¹² which can cause apprehension (in either party) at the notion of discontinuing treatment. Eveleigh et al¹ have provided one step toward achieving this goal. It is encouraging to read that their work on drug withdrawal will continue, with some of these considerations in mind.

References
1. Eveleigh R, Muskens E, Lucassen P et al. Withdrawal of unnecessary antidepressant medication: a randomized controlled trial in primary care. BJGP Open 2017. doi: https://doi.org/10.3399/bjgpopen17X101265
2. Nielsen M, Hansen EH, Gøtzsche PC. Dependence and withdrawal reaction to benzodiazepines and selective serotonin reuptake inhibitors. Int J Risk Saf Med  2013; 25(3):155-68. doi: https://doi.org/10.3233/JRS-130594
3. Fava GA, Gatti A, Belaise C, et al. Withdrawal symptoms after selective serotonin reuptake inhibitor discontinuation: a systematic review. Psychother Psychosom 2015; 84(2), 72-81.
4. Moncrieff J. Why is it so difficult to stop psychiatric drug treatment? It may be nothing to do with the original problem. Med Hypotheses, 2006; 67(3), 517-523. doi: https://doi.org/10.1016/j.mehy.2006.03.009
5. Breggin PR, Cohen D. Your drug may be your problem: How and why to stop taking psychiatric medications. Cambridge, MA: De Capo Press, 1999.
6. Ostrow L, Jessell L, Hurd M, et al. Discontinuing psychiatric medications: a survey of long-term users. Psychiatr Serv, 2017; 68(12), 1-7.
7. Baldessarini RJ, Tondo L, Ghiani C, et al. (2010). Illness risk following rapid versus gradual discontinuation of antidepressants. Am J Psychiatry, 167(8), 934-941. doi: https://doi.org/10.1176/appi.ajp.2010.09060880
8. Glenmullen J. The antidepressant solution: a step-by-step guide to safely overcoming antidepressant withdrawal, dependence, and “addiction”. New York, NY: Free Press, 2005.
9. AGIDD-SMQ. Taking back control: My self-management guide to psychiatric medication. Montreal, QC: Association des groupes d'intervention en défense des droits en santé mentale du Québec, 2003.
10. Hall W, The Icarus Project and Freedom Center. Harm reduction guide to coming off psychiatric drugs (2nd edition). http://www.willhall.net/files/ComingOffPsychDrugsHarmReductGuide2Edonline.pdf (accessed 15 Dec 2017).
11. Moore J. Letter to Secretary of State for Health, Jeremy Hunt. https://www.change.org/p/provide-tapering-strips-to-help-users-who-want-to-stop-taking-anxiety-depression-drugs (accessed 15 Dec 2017)
12. Cohen D, Hughes S. How do people taking psychiatric medications explain their “chemical imbalance”? Ethical Hum Psychol Psychiatry, 2011; 13(3), 176-189.