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Antidepressants are some of the most commonly prescribed medications globally and in Australia, but knowledge of how they work and how hard it is to come off them remains highly contested.
Data from the Australian Institute of Health and Welfare shows nearly four million Australians — roughly one in seven — take antidepressants.
A large systematic review of research into the process of withdrawing from the drugs was published this week, but it quickly faced backlash from some psychiatrists and experts.
The authors found coming off antidepressants after short-term use was not associated with a “clinically significant” risk of withdrawal symptoms. However, long-term antidepressant use — that is longer than 12 months — is increasingly common and comes with a greater risk of harm.
The review found withdrawal symptoms — such as dizziness, nausea, vertigo — occur in a minority of cases, but they are on average manageable and not severe, especially with proper clinical support.
The authors suggest that depression after stopping antidepressants is probably a relapse of the original mental health condition, as the results were similar among placebo groups.
The meta-analysis examined the findings of 50 randomised controlled trials, involving 17,828 participants.
The review published in JAMA Psychiatry included 38 studies with an observation period longer than two weeks, the critical time frame during which withdrawal symptoms are expected to occur.
The average age of the participants was 44, and 70 per cent were female. In Australia, women are prescribed antidepressants at 1.5 times the rate of men — a trend that’s seen in other parts of the world.
Some health professionals say the review provides useful insights, despite its limitations, while others have been highly critical.
UK antidepressant researchers Mark Horowitz and Julie Moncrieff said the review “risks underestimating the potential harms to long-term antidepressant users by focusing on short-term, industry-funded studies.”
Several of the JAMA Psychiatry article’s senior authors declared receiving payments from drug companies.
Horowitz and Moncrieff argue that the article’s “main analysis” is based on eleven trials, six of which looked at people who had taken antidepressants for eight weeks and four for 12 weeks.
“There is growing recognition that stopping antidepressants — especially after long-term use — can cause severe and sometimes debilitating withdrawal symptoms, and it is now acknowledged by the UK government as a public health issue,” they wrote in The Conversation.
New resources have been developed to support people safely stopping the use of antidepressants over time usually months, through what’s called a tapering plan.
The Maudsley Deprescribing Guidelines, published last year and co-authored by Horowitz, has been accepted by the Royal Australian College of General Practitioners as an Accepted Clinical Resource.
On again, off again antidepressant prescriptions
Allied health professional Kizzy said she never wanted to be reliant on anti-depressants and has stopped taking them twice in the past.
“I was initially quite resistant to any kind of medication, but I got to a point a couple of years ago … where I was really struggling with suicidal thoughts and just being able to function and do things because of my mood, and all of these horrible feelings and thoughts I was having, and finally got convinced to try sertraline”.
She said she noticed the drug — a commonly prescribed antidepressant sometimes sold under the name Zoloft — was making her feel “numb”.
“My hope is that I can one day be not require antidepressants and still maintain this level of functioning and mental health,” she said adding that her current medication “potentially affects” her liver.
The United States National Library of Medicine says liver abnormalities reportedly occur in around 1 per cent of people who take sertraline, “but elevations are usually modest and infrequently require dose modification or discontinuation”.
Professor Paul Fitzgerald is the director of the School of Medicine and Psychology at Australian National University and a member of the Royal Australian and New Zealand College of Psychiatrists.
He was not involved in the review.
He said it’s important to be aware of the more severe cases of side effects.
“There are some unusual symptoms that patients experience. The most dramatic one the patients find quite disturbing is the phenomena that patients often talk about as brain zaps.”
“They get this very strange sensation of electrical zaps in their head or down their spinal cord, and if they haven’t been warned about it, it can be quite distressing. It just seems strange.”
He said it’s unclear from this latest review whether the symptoms recorded by researchers are a relapse of a previous mental health condition or withdrawal effects from discontinuing antidepressants.
“What happens when somebody’s stopping a medication and their underlying symptoms of their condition get worse?
“In other words, start to experience more depression or more anxiety, and it can be really difficult to know under those circumstances.
“Are those symptoms that they’re experiencing some sort of discontinuation or is it really just the symptoms of the illness coming back because the treatment’s been withdrawn?”
Sonya Morrissey is the national GP adviser at Headspace, a platform supporting the mental health and wellbeing of younger people.
She said that, in the past, patients weren’t sufficiently warned about discontinuation symptoms of antidepressants.
“It is something that we are, I think, recognising more and there’s lots more research being done now, which is great, although there’s not a significant amount of research yet in the cohort that we see, which is the 12 to 25 year olds,” she said.
She said antidepressants are not their first line of treatment at Headspace, but will be used occasionally if needed.
The Royal Australian College of General Practitioners’ Western Australia vice-president, Dr Ramya Raman, said the recently published meta-analysis still provides useful insight for GPs but said more research on withdrawing from long-term anti-depressant use was needed.
She also highlighted the importance of a good doctor-patient relationship when withdrawing from psychiatric medication.
“When weaning off of the medication and there is a trusted relationship with the GP, and a regular follow-up with that doctor, the risk of having the discontinuation symptoms are less of a concern compared to when patients actually abruptly stop it.
Kizzy also said finding a GP with an interest in mental health can make a big difference when navigating the use of antidepressants and the withdrawal process.
“I think it’s important to find a GP who has a genuine interest in that area rather than just going to your generic GP, finding a regular one who you know can rely on, who can really support you and speak to you in a way that you’re going to feel respected and really understood.
“And I think that’s a really important kind of foundation support to have because once you have that, then you will feel safe enough to be checking in with them, sharing all your concerns, talking about coming off or going on or switching medications and still be okay through all of that.”
Readers seeking crisis support can ring Lifeline on 13 11 14 or text 0477 13 11 14, the Suicide Call Back Service on 1300 659 467 and Kids Helpline on 1800 55 1800 (for young people aged up to 25). More information and support with mental health is available at beyondblue.org.au and on 1300 22 4636.
