Approximately one in six individuals in Western countries use antidepressants. The increasing prevalence of antidepressant use does not align with the incidence rates of mood and anxiety disorders. This rise is primarily attributed to prolonged usage durations.
In the United States, the average duration of antidepressant use exceeds five years. Surveys conducted among long-term antidepressant users in the United Kingdom, the Netherlands and Australia reveal that 30-50% of these individuals may lack a clear evidence-based indication for continued use and might consider discontinuing treatment.
There is concern that one reason for the continued use of antidepressants is the difficulty individuals experience when attempting to discontinue them. These challenges, potentially linked to withdrawal symptoms, are often misdiagnosed as a relapse of the underlying condition.
Several reasons to consider deprescribing antidepressants include the lack of ongoing benefit from the medication, completion of the treatment course, uncertainty regarding the relapse prevention properties of antidepressants, patient preference, preference for alternative treatments and the impact of adverse effects, tolerability and quality of life.
After completing a treatment course and achieving symptom remission, patients with major depressive disorder typically continue antidepressants for an additional 4-9 months, as recommended by the APA and NICE. This duration varies with different illnesses. For instance, patients with PTSD or OCD require longer-term antidepressant therapy. Surveys indicate that approximately 50% of patients exceed the recommended duration of treatment.
There is uncertainty about the relapse prevention properties of antidepressants. Discontinuation studies, such as the ANTLER study (2021), struggle to differentiate between withdrawal symptoms and illness relapse. Gradual tapering of antidepressants over six months, instead of the conventional two months, has shown benefits, suggesting minimal to no excess relapse compared to continued use.
The notion that depression is directly linked to low serotonin levels, previously known as the monoamine hypothesis, lacks robust evidence. This outdated belief might cause patients to be reluctant to discontinue antidepressants even when they are no longer needed, despite increasing adverse effects.
Antidepressants can cause side effects such as drowsiness, restlessness, excessive sweating, dry mouth, gastrointestinal issues, weight gain, and emotional blunting. Emotional blunting is acknowledged as a dose-dependent side effect but can also result from the underlying condition. Long-term use of antidepressants is increasingly associated with more significant weight gain than short-term clinical trials suggest.
Sexual side effects, including reduced desire, diminished sexual sensation, and difficulty achieving orgasm, affect 25% to 80% of patients. Post-SSRI sexual dysfunction (PSSD), recognised by the European Medicines Agency, indicates that these side effects can persist after discontinuing the medication in some patients.
The 2022 NICE guidelines on deprescribing recommend regular reviews for individuals taking antidepressants, focusing on the ongoing need for the medication, adverse effects, benefits and patient preferences. Addressing potentially erroneous beliefs about antidepressants, such as the misconception of a chemical imbalance or serotonin deficiency, is also crucial.
Patients often report that withdrawal symptoms from antidepressants are under-recognised or minimised by clinicians, likely due to official guidelines downplaying the frequency and severity of these symptoms. As a result, many patients seek help outside the medical system, including private online groups.
Clinicians should carefully consider withdrawal as an important differential diagnosis when antidepressant doses are reduced or missed, as withdrawal symptoms are frequently misdiagnosed as a relapse.
In summary, considerations for antidepressant deprescribing should begin with regular reviews of ongoing prescriptions at least every six months, particularly if adverse effects are present or the patient is pregnant or planning pregnancy. These reviews should include mood monitoring, side-effect assessment, addressing perpetuating factors, and exploring patient preferences.
In the next part of this series, I will discuss specific clinical aspects of antidepressant withdrawal, including duration, severity, influencing factors, and management strategies.
Key messages
- Withdrawal symptoms often misdiagnosed as relapse hinder discontinuation
- Many patients exceed recommended antidepressant treatment duration
- Gradual tapering may reduce relapse and withdrawal symptoms.
Author competing interests – nil