Antidepressant pill strife: ‘rethink rush to prescribe’

Doctors are calling for a national review into the overprescription of antidepressant drugs amid concerns that hundreds of thousands of people may be on the medications unnecessarily.

NHS clinical research fellow in psychiatry Mark Horowitz.

Doctors are calling for a national review into the overprescription of antidepressant drugs amid concerns that hundreds of ­thousands of Australians may be on the medications unnecessarily, with withdrawal symptoms sometimes so severe that people remain stuck on the pills for years.

There is growing concern that many people who are prescribed antidepressants remain on them for much longer than clinically recommended, with some of these patients having been inappropriately prescribed in the first place with mild ­depression and not recom­mended alternative therapies.

Evidence is growing in medical literature that side effects can intensify the longer patients are on the drugs, and can be long-lasting, while withdrawal symptoms upon coming off the drugs can be even more intense than their original anxiety or ­depression.

Such concerns – and an ­acknowledgment that the health system was not equipped to manage them – prompted a ­national review in the UK that has ushered in a system-wide focus on weaning patients off drugs, or deprescribing.

Australia’s first clinical trial into deprescribing has now launched in Queensland, while in Melbourne a pilot run by a major public hospital is also aiming to educate and support doctors and patients as to the withdrawal process from widely prescribed Selective Serotonin Reuptake Inhibitors.

Some psychiatrists are now calling for a national approach.

“Australia needs to take the same approach to prioritising patient safety as has been taken in the UK,” said Mark Horowitz, an NHS clinical research fellow in psychiatry who completed a PhD in the neurobiology of ­depression and the pharmacology of antidepressants at King’s College London.

Dr Horowitz’s writing on the extreme severity of his own withdrawal symptoms coming off long-term antidepressants brought the issue to public attention in the UK and helped prompt a national review into overprescribing.

Dr Horowitz, who is Australian, said Australia had been very slow in following the UK example, especially in light of this country’s high SSRI prescription rates. One in seven Australians was prescribed an SSRI in 2021, government figures show.

“It is clear now that these drugs are much harder to stop than previously realised and people need help to safely stop them that is not currently available in the health system,” Dr Horowitz said. “The public needs to be warned that withdrawal effects from antidepressants can be severe and last for months or years, and can be debilitating.”

Antidepressant prescription medicine Zoloft.

He added that antidepressants were less effective than they were touted to be and there were numerous treatments that were as effective and cost-­effective.

The UK overprescribing inquiry prompted changes to National Institute for Health and Care Excellence guidelines, which are also highly influential in Australia, to the effect that evidence indicated certain non-pharmaceutical methods could be as effective as antidepressants.

Sydney’s St Vincents Hospital consultant psychiatrist Michael Millard said it was encouraging to see pushback against a medication-first culture that had long been underpinned by the now-debunked theory that depression was caused by a chemical imbalance in the brain.

“It is great to see the NICE guidelines reiterating what Australian clinical practice guidelines have clearly stated – that antidepressants should only be used as part of a package of care that begins with addressing lifestyle modification and evidence-based psychological treatment such as cognitive behavioural therapy,” Dr Millard said “Additionally, the UK has led the world in highlighting the need for established and evidence-based approaches to reducing medication in those who would like to do so, or who may no longer require it.

“We know that if this is not managed well, the withdrawal ­effects of the medication can be intolerable and may be mistaken for a relapse of the original problem, resulting in long-term use of medications that may not otherwise have been required.”

More than 32 million scripts for SSRIs were issued in 2021, three-quarters of them by GPs. Zoloft and Lexapro are both among Australia’s top 10 most prescribed drugs. Australia has one of the highest rates of SSRI prescription in the world.

The rate of prescription of SSRIs has doubled in the past 10 years, and 5 million more scripts per year were issued in 2021 than two years before that. The average duration of treatment is four years, despite clinical guidelines typically recommending the drugs be taken for six to 12 months or up to two years for people at risk of relapse.

The Royal Australian and New Zealand College of Psychiatrists says it is working to emphasise to patients – particularly in light of the steep rise in prescriptions since the Covid pandemic – that antidepressants should not always be the first choice. “SSRIs are useful medications, they have a very good evidence base in terms of depression,” said RANZCP president Elizabeth Moore. “But it is really important that we do look and see what alternatives there are.”

According to a recent review, surveys of antidepressant users suggest that between 30 and 50 per cent of long-term prescriptions have no evidence-based or clear medical reason to keep taking them. It follows that taxpayers are subsidising potentially unnecessary antidepressant prescriptions to the tune of hundreds of millions of dollars each year.

Adverse effect risks rise the longer someone is on an SSRI and include sleep disturbance, weight gain, sexual dysfunction, and persistent feelings of emotional numbness.