Too many patients are taking the drugs long-term, and often without first meeting guideline criteria – particularly women and older people.
Antidepressant use is booming in Australia, and patients and clinicians desperately need better information on withdrawal symptoms and management, according to GP mental health experts.
Hundreds of doctors and patients have called for more practical resources, such as step-by-step tapering plans and guidance on how to access mini doses for withdrawal, Professor Katharine Wallis, head of the general practice clinical unit at the University of Queensland, and colleagues wrote in the MJA.
“Around one in seven Australians is now taking antidepressants (3.9 million people, 14%), and the prevalence of use is rising. Two antidepressants, sertraline and escitalopram, are now in the top ten drugs by defined daily dose per 1000 population per day,” Professor Wallis wrote in her perspective article.
Evidence suggested antidepressants were overprescribed, she said.
“Patients, more commonly women and older people, are both started on antidepressants when clinical guideline criteria are not met, and continued on antidepressants for longer than clinical guidelines recommend for most people, where the potential harms likely outweigh the potential benefits, and where better alternatives are available,” Professor Wallis wrote.
Women were prescribed the drugs at rates 50% higher than men, and older Australians were twice as likely to be taking the drugs compared to their peers under the age of 65 years. One in four people over the age of 75 years are on antidepressants, they wrote.
While it was possible that there was simply more depression in the community, it was “unlikely” that 14% of the population fit the clinical guideline criteria for antidepressant use, they said.
Non-drug interventions were the first-line therapy for anxiety and mild to moderate depression, and medication was recommended for only six-to-12 months in those with severe depression before deprescribing should be considered, they added.
But evidence suggested that patients were not stopping their medication, and this long-term behaviour was driving the uptick in antidepressant use, Professor Wallis and colleagues wrote.
“Around half of people taking antidepressants take them for longer than two years,” they said.
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Dr Cathy Andronis, psychotherapist and chair of the RACGP specific interest group in psychological medicine, agreed that long-term use was a major driver, and supported the call to reexamine and review antidepressant use more often.
One common misconception Dr Andronis saw was when patients missed tablets for whatever reason, they got immediate and unpleasant withdrawal effects – and attributed this to a relapse in their depression or anxiety.
“Some people get quite severe side effects when they try to go off them, and it’s most commonly because they’ve gone off them too quickly,” Dr Andronis said.
Dr Andronis supported the authors’ calls for more widespread use of the Maudsley deprescribing guidelines, which are an Accepted Clinical Resource by the RACGP, and recommend hyperbolic tapering.
But other Australian guidance for how to stop the medication “remains unchanged and unhelpful”, Professor Wallis wrote.
“Further, some psychiatrists continue to argue against antidepressant deprescribing, citing as evidence the Royal Australian and New Zealand College of Psychiatrists’ (RANZCP) guidelines, which claim that hyperbolic tapering is impractical and not feasible, without suggesting any viable alternative,” she wrote.
More research was needed to understand the optimal tapering regimen, and if it even works for all patients, she said.
“It is possible that some people will not be able to stop their antidepressant due to the severity of withdrawal symptoms,” Professor Wallis wrote.
“If so, then informed consent discussions about starting antidepressants need to include information that, once started, it may not be possible to stop antidepressants, and patients may have to take them for the rest of their life with associated risks. For most people there are better alternatives available.”
Professor Wallis and colleagues pointed out that if only 2% of antidepressant users had severe withdrawal symptoms, “the scale of the problem is alarming given that nearly 2 million Australians are long term antidepressant users”.
Dr Andronis said that, in some respects, SSRIs were “the new Valium”.
“[People] are using them to get some chemical emotional regulation where they are not designed for that specifically,” she said.
Australians were more stressed, overworked, not getting enough sleep, not eating healthy and balanced diets and not exercising enough – “things that are protective against depression and anxiety”, she said.
If these, and other, social determinants were not addressed before or while patients were on antidepressants, then patients may not have the tools or changes needed to function without the medication, Dr Andronis said.
“There is a small proportion of people who do get repeat long-term depression symptoms or generalised anxiety who find that that [treatment] is not an easy, short-term proposition. It’s something that’s lifelong,” she said.
“But that is a smaller group. What is happening is that we’re starting people on the medication for the short term, but they are finding it’s making them feel calmer – and they prefer that feeling.
“They find that when they do go off medication, even if they don’t have many withdrawal effects, that their natural capacity to be resistant to that stress isn’t as good as it should be.”
This often led to patients restarting medication again.
“What I’d like to see is more people having regular reviews to discuss why they’re feeling the way they’re feeling, and what their options are,” Dr Andronis said.
