Australian psychiatrist co-authors first antidepressant deprescribing guidelines

Doctors are being warned that the benefits of the drugs will be outweighed in some patients by adverse effects.

The guidelines state that many patients are on SSRIs – including the widely prescribed drugs Zoloft and Lexapro – unnecessarily or for too long, and struggle to get off them because of severe withdrawal symptoms.

Growing disquiet about the overprescription of antidepressants has been acknowledged in the first guidelines on deprescribing, with doctors being told the benefits of the drugs will be outweighed in some patients by adverse effects including physical dependence, impaired capacity for feeling, memory or concentration difficulties, and sexual side effects.

The new Maudsley Prescribing Guidelines – the world’s foremost manual for prescribing in psychiatry – has published the first-ever manual on the deprescribing of selective serotonin reuptake ­inhibitors – a textbook that also challenges the effectiveness of ­antidepressants and acknowledges that they likely do not work by increasing the levels of serotonin in the brain, as drug companies have long claimed.

The guidelines have been drafted by British psychiatrists amid concern that the numbers of ­patients being prescribed SSRIs is far too high – one in six people in many Western countries, including Australia. They will be used by psychiatrists across the world, including Australia.

“For a portion of patients, the benefits of medication will be outweighed by adverse effects and will provide limited benefits in some people,” the guidelines state.

“In some people, the medication may never have been particularly effective but has continued because of inertia, a lack of attention to deprescribing, or a desire not to ‘rock the boat’.”

The guidelines have been backed in Australia by a group of psychiatrists and scientists who have signed a letter of endorsement. “The guidelines align with the worldwide consensus that medication must be used in a high-quality manner including safely deprescribing medications when no longer needed,” the letter reads.

The guidelines state that many patients are on SSRIs – including the widely prescribed drugs Zoloft and Lexapro – unnecessarily or for much too long, and struggle to get off them because of severe withdrawal symptoms which are often mistaken by doctors for symptom relapse.

In their advice for deprescribing, the authors say doctors are tapering patients’ medication down too quickly, and very gradual withdrawal is required which will often require tiny liquid doses.

“I think this is a significant ­moment in psychiatry,” said guidelines co-author Mark Horowitz, an Australian doctor who is a training psychiatrist and clinical research fellow at the North London NHS Trust, where he runs a drug deprescribing clinic.

Guidelines co-author Mark Horowitz.

“It means that people are finally taking seriously how to stop these drugs as much as how to start them.”

Professor of Psychopharmacology at King’s College London David Taylor is the other author.

Regarded as “the bible of psychiatry”, it is the first time Maudsley has published any deprescribing guidelines, and it comes amid widespread patient experience of sometimes severe withdrawal effects when trying to stop antidepressants after many years of use, occasionally resulting in hospitalisation and suicidiality.

Many of these patients express “outrage”, says the deprescribing textbook, at the lack of medical assistance for stopping psychiatric medications. The deprescribing guidelines also cover benzodiazepines, gabapentinoids and z-drugs.

“Some doctors are apparently still suggesting antidepressants do not cause withdrawal symptoms,” the deprescribing guidelines say. But “physical dependence is a predictable physiological response to chronic use of psychotropic medication” which “inevitably and predictably leads to a withdrawal syndrome” which can be long-lasting. This is likely due to the effects of the drugs on the nervous system.

Psychological withdrawal symptoms can include low mood, anxiety, insomnia, panic attacks and obsessive thinking, which are sometimes worse than the original symptoms that prompted the prescription.

The guidelines estimate that 30 to 50 per cent of patients on SSRIs do not have evidence-based reasons for being on them, and that the drugs may work for as little as 15 per cent of patients.

Antidepressants are not recommended as a first-line treatment for mild to moderate depression and anxiety, yet many doctors prescribe them for such regardless.

“One central concern is that short-term symptom control might be prioritised over long-term functional outcomes, especially as most studies guiding treatment protocols measure symptomatic outcomes over short time periods rather than functional outcomes over longer periods.

“Alongside this disquiet regarding overprescription there has been renewed scrutiny of the effectiveness of some psychiatric medications.”

The guidelines say recent studies that have debunked the serotonin theory suggest a large proportion of patients will not derive significant benefit from acute use of antidepressants.

“Arguably, there has been widespread acceptance of the idea … that antidepressants are necessary to reverse a ‘chemical imbalance’. There is now general consensus that a simple relationship between low serotonin and depression is unsupported by evidence.

“Consequently, patients should not be told that antidepressants ‘correct a chemical imbalance’ especially as it is known that patients who believe this are reluctant to stop medication even when it is no longer indicated.”

Child and adolescent psychiatrist at the Alfred Hospital in Melbourne, Paul Denborough, said the guidelines were long overdue, with the overprescription of SSRIs a “massive problem” in Australia which has the second-highest rate of prescription in the world.

“I think the root cause of the issue is this belief in our culture that depression is a biochemical imbalance,” Professor Denborough said. “That is not the case but it’s very hard to change that cultural view. We are really just medicalising mental distress.

“These guidelines are fantastic. I really welcome them.”

Professor Katharine Wallis from the University of Queensland, who is conducting a randomised control trial in deprescribing, said the guidelines were “sorely needed”.

“While there are many guidelines for starting medication, there are few for stopping,” she said.