By Allen Frances
It's so easy to start antidepressants, but so hard to stop them. That's why they are prescribed for about 12% of the population in both the UK and the US. In England the number of antidepressant prescriptions doubled between 2008 and 2018,(1) despite the fact that the pills are now off patent, which means that pressure from manufacturers to prescribe can likely be ruled out as a factor. There is no reason to believe that the incidence of psychiatric disorder has increased over time - so why are these pills so popular with practitioners and their patients?
The most important thing to understand is that general practitioners write most of the prescriptions. Often they must do so after rushed visits with patients they don't know very well; who frequently present on one of the worst days of their lives; with nonspecific symptoms of stress, depression, or anxiety. The quickest way to get a worried patient out of the consulting room is to write a prescription.
Half the patients who start an antidepressant continue to take the pills for at least two years (2) – sometimes for decades, or even for life. This is often best practice for those with severe and recurring depressions. But it can be worst practice for the majority of patients who began with mild symptoms that likely would have disappeared on their own with time, stress reduction, placebo effect, and regression of symptoms to the mean. Previous research has shown that between one-third and half of patients taking antidepressants long-term have no evidence-based reason to be on them.(3)
Patients who don't really need antidepressants nonetheless often stay on them for two reasons: misattribution and withdrawal symptoms. A person who feels better after starting antidepressants understandably assumes it was the pills that caused improvement – not understanding that most mild symptoms are stress related, self-limited, and likely to go away on their own. Stopping pills that never were, or are no longer, necessary is hard to do once the person believes they have worked.
Half the patients who start an antidepressant continue to take the pills for at least two years (2) – sometimes for decades, or even for life.
Withdrawal symptoms are most likely to occur when medications are stopped abruptly, after prolonged use, and at higher doses. Withdrawal can be very unpleasant and scary, causing lethargy, sadness, anxiety, irritability, trouble concentrating, sleep problems, nightmares, ’flu symptoms, nausea, dizziness, and strange sensations. They can also go on for a long time. Twenty-five per cent of users are still experiencing some symptoms after 3 months, and for some withdrawal can last 6 months.(4) Withdrawal occurs when doctors fail to deprescribe slowly enough or patients stop on their own. Partly because of the widespread misconception that antidepressants don't cause withdrawal, patients and doctors routinely misinterpret the symptoms as relapse – triggering what is often unneeded long term treatment.
Antidepressants are also increasingly being used in children and teenagers, in the UK as well as in the US,(5) despite considerable evidence they don't work in young patients and may even increase risk of suicide.(6) I think antidepressants should be used very rarely in kids, and only for very clear indications and when prescribed by a child psychiatrist.
Some highly publicized reviews of the depression literature have concluded that antidepressants are no more effective than placebo.(7) I would argue that this is an artefact caused by the fact that so many of the subjects included in these studies had only milder symptoms that are very placebo responsive. Severe depressions do not respond to placebo or psychotherapy and do require medication or even electro-convulsive therapy (ECT).(8) The trick is targeting – reducing medication use in those who don't need it, while identifying and treating those who do.
Self-report depression screening scales have become popular, but result in the massive overdiagnosis of clinical depression in the worried well
So what are possible solutions to the rampant over-prescription of antidepressants? The single most powerful intervention is giving general practitioners more time to know their patients and to explain why jumping to a prescription is not a good idea. For mild depressions, the best first steps are watchful waiting, normalization, advice, stress reduction, and a repeat visit after several weeks. For moderate or more prolonged depressions, psychotherapy should be tried first. Medication should always be started immediately for severe depressions, but should be only a last resort in those milder ones that persist, are impairing, and haven't responded to time or talk therapy.
Self-report depression screening scales have become popular in the offices of general practitioners. Unfortunately, they result in the massive overdiagnosis of clinical depression in the worried well, with resulting overuse of medication. It is important that we train GPs on the difference between severe and milder depressions and give them time to evaluate their patients more thoroughly. Routine screening for depression is best reserved for high risk groups such as mothers in perinatal period, patients with chronic illness, and people with a history of mental illness or suicidal behaviour.
Better initial evaluation and more targeted treatment is certainly costly up front but should be weighed against the harms and costs of long term, unneeded medications and the consultations to prescribe them and deal with side effects.
Patients who don't need medication are much better off without them. They avoid the side effectsand inconvenience of long term treatment and also gain the sense of mastery and resilience that comes from enduring and prevailing in the face of life's inevitable stresses.
Professor and Chair Emeritus, Department of Psychiatry, Duke University, North Carolina, US
Chair, DSM-IV Task Force
Dr Frances is author of 'Essentials of Psychiatric Diagnosis' (pub. Guilford Press, 2013) and 'Saving Normal: An Insider's Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life' (pub. William Morrow, 2013)
- BBC News. Jump in antidepressant prescriptions in England. 28 Mar 2018. https://www.bbc.co.uk/news/health-47740396
- Kendrick A. Long-term antidepressant treatment: time for a review? Prescriber, 5 Oct 2015: https://wchh.onlinelibrary.wiley.com/doi/epdf/10.1002/psb.1389
- Cruickshank G et al. Cross-sectional survey of patients in receipt of long-term repeat prescriptions for antidepressant drugs in primary care. Ment Health Fam Med 2008;5:105–9.
- All-Party Parliamentary Group for Prescribed Drug Dependence. Antidepressant Dependency and Withdrawal. May 2018. http://prescribeddrug.org/wp-content/uploads/2018/06/APPG-PDD-report-on-antidepressant-dependence-and-withdrawal.pdf
- BBC News. Antidepressant prescriptions for children on the rise. 24 Jul 2018. https://www.bbc.co.uk/news/health-44821886
- Suicidality in Children and Adolescents Being Treated With Antidepressant Medications. 5 Feb 2018. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/suicidality-children-and-adolescents-being-treated-antidepressant-medications#:~:text=Antidepressants%20increase%20the%20risk%20of,suicidality%20with%20the%20clinical%20need.
- Munkholm K et al. Considering the methodological limitations in the evidence base of antidepressants for depression: a reanalysis of a network meta-analysis. BMJ Open 2019;9:e024886. doi: 10.1136/bmjopen-2018-024886
- National Institute for Health and Care Excellence (NICE). Step 4: Complex and severe depression in adults. https://pathways.nice.org.uk/pathways/depression#path=view%3A/pathways/depression/step-4-complex-and-severe-depression-in-adults.xml&content=view-node%3Anodes-inpatient-care
22 April 2021