Withdrawal support - what works?

Katie Haylor spoke to primary care professor Tony Kendrick from the University of Southampton about trial currently underway to better understand how to help those trying to step down from their antidepressant medications. First up Katie asked Tony, how much do we actually understand the science of withdrawing from antidepressants?

Tony - We have quite a lot of evidence, but it's certainly not perfect. We could get more evidence in terms of both the proportion and numbers of people who get problems when they stop antidepressants. And also what's actually going on inside their head when they stop antidepressants. So most of the evidence on the numbers and proportion of people who get problems is from surveys, usually asking people after the event whether they had problems, rather than real time measurement of a whole representative sample of people taking antidepressants, as they come off them. And we really don't understand what's going on inside the brain when somebody comes off antidepressants, having been on them for some months and certainly years. There are probably changes in the brain which takes some time to return to normal. And some people even fear that they might not return to normal at all, in a few cases where people have been taking antidepressants for many years.

Katie - So I think about one in 10 UK adults are currently being prescribed these drugs, is that about right?

Tony - Yes. In fact, the Public Health England survey suggested that, at any one time, more than 7 million people were taking antidepressants. Over a three year period from 2015 to 2018 it was getting on for a million who were taking it for longterm use.

Katie - Okay, so do we know how many of those people might struggle with coming off them?

Tony - The best evidence we have is that as many as one in two people, 50% of people will get some withdrawal symptoms. And of those around a half might find them quite troubling. That may be an overestimate because it's based partly on internet surveys and we know that the people who reply to internet surveys tend to be those who've had more of a problem. But it's certainly a good proportion of people and therefore it needs to be taken seriously. Antidepressants should not be stopped suddenly because the likelihood of withdrawal symptoms is much greater. They should be tapered off. And if people get problems, they should be able to discuss that with the prescriber, ask whether they need to go more slowly, or even go back up to the previous dose. And in some cases, probably a small minority, people find it quite hard to come off at all.

Katie - So do we know anything about the factors that might make that withdrawal more difficult? That half of the half of people you were talking about?

Tony - Some of the drugs have a what's called a shorter half life. They don't stay in the body for so long. So when you stop them, the level of drug in your bloodstream and in your brain drops quite quickly and that gives more withdrawal symptoms. So drugs like paroxetine and venlafaxine are well known to be more likely to cause withdrawal. So certainly by drug type. Probably by length of taking the antidepressant, the longer you've been on them, probably the more likely it is that you will get withdrawal. But as, we haven't done systematic studies of taking people off antidepressants at different intervals of time, we can't be sure about that. But certainly it does seem, and we advise caution when someone's been on antidepressants for certainly more than a few months,  that the tapering should be carefully monitored in case they get withdrawal symptoms.

Katie - What is the motivation to come off? If you're feeling better, you may want to stay on them.

Tony - Yes. That's why we're getting so many people now who are taking antidepressants long term because they feel a certain fear that if they stop them, they might get depressed again. And they feel "well, if I'm okay on taking these, then I'll continue them". And their doctor may well go along with that as well. Neither the patient nor the doctor wants to risk having a relapse of depression, which can be catastrophic in somebody's life. And so the, kind of default position has been to continue them. But the problem with that is that we don't really know how long they're beneficial for. And we also are starting to recognise more and more side effects, some of which can be quite serious.

Katie - So how easy is it to tell if someone's ready to come off them or not?

Tony - Well, the current guidance is rather grey. The current recommendation from NICE (the National Institute for Care and Health Excellence) is for the first episode ever of depression that's treated with antidepressants, you'd probably come off after feeling well for about six months. So if it takes a few months to get better and then you continue them for six months, you probably should come off after about nine months, or certainly within the first year, and try doing without them. With recurrent depression, the recommendations are that antidepressant should be continued for two years in the first instance, before then reviewing them and possibly trying to come off them. But the evidence behind that two years is not very strong. More research is needed. But what we do know is that more than half the people on antidepressants have been on them for more than two years, and some of them have been on them for decades, and we really don't know that that's doing them any good. The reason for continuing them for two years is that we want to try and prevent them getting depressed again and studies up to two years have shown that if you stop them, you are more likely to get more depression. But many people can stop them without getting more depression. The worry is, that with longer and longer use you'll get more side effects and the type of antidepressant that's mostly in use these days - the Prozac type antidepressants - we've had them since the late eighties early nineties and it's only in recent years that we've started to see more and more side effects emerge. And some of those side effects can be relatively serious in a small minority of people.

Katie - From my conversation with Tony, there seemed to be two problems coming to the fore. One, a significant number of people experience difficulties coming off these drugs, and two, perhaps some people are on them without getting benefit because they're worried about coming off. Tony is part of a study trying to better this situation. The "reviewing longterm antidepressant use by careful monitoring and everyday practice study", luckily termed REDUCE for short, is based at the University of Southampton, and it's asking whether internet and telephone based psychological support for patients stepping down from antidepressants, as well as internet guidance for the GPs supporting them, could be of benefit.

Tony -So the support for patients is 2 fold, it's internet support - we have a new programme we've developed with patients, called Adviser, which is advice about antidepressants. And we have put cognitive therapy, mindfulness based therapy, and commitment and acceptance based therapy-type interventions into that online support. Psychological interventions can help people come off antidepressants and reduce the risk of relapse.

The second type of support for patients is phone calls from a psychologist to ask them how they're doing while they come off antidepressants. And to check if they're having symptoms of withdrawal or depression coming back. And encouragement to continue with the withdrawal as long as all is well. And then also support for the doctors - there's a separate programme called Adviser for Health Professionals. That's internet guidance on different schedules for tapering off the drugs, advice on timing the start of reduction. And information about the advice and telephone support for patients so that the GPs can direct patients to the support.

Katie - It sounds like quite a lot of this includes education for healthcare professionals on this topic. Is it fair to say that's been a bit lacking, so far?

Tony -To be fair to the health professionals, the guidelines have been inadequate. We are currently updating NICE guidance. There's been more guidance coming out of other countries like Holland, the Netherlands and Australia. Different countries are developing more guidance, so there's been a lack of clear guidance on how best to take people off long term antidepressants. Also, these days, general practices are so busy, as you will know if you've tried to make an appointment recently, the extra work involved in taking someone off antidepressants. Unfortunately the easiest thing to do is to continue to prescribe the antidepressant. And if the patient feels that they don't want to try coming off and the doctor doesn't want to rock the boat, that tends to be the default position in many cases.

Katie - Do you have any promising results? How confident are you that these strategies will work?

Tony - We don't have any results in terms of how effective this strategy is. We have done a feasibility trial. We engaged 50 patients and their GPs in that, and we showed that it was acceptable to patients. They liked getting involved, they liked having the internet support and the telephone support. Therefore,  the method is acceptable and feasible. We have to continue the trial for the next three years and involve all together about 400 people before we'll know whether it's really more effective than simply prompting the GP to review the patient.

Katie - Understandably, we've got a UK focus in this conversation, but the podcast is a global one and the problem is a global one as well, isn't it? So do you think your study might have applications beyond the UK?

Tony -It is a global issue. Certainly in all the developed countries where people have looked at this, the number of people on antidepressants is increasing. There's an even greater proportion in America taking antidepressants, but it's also an issue in Holland, Australia, all the Western countries where it's been studied. There's a team that we're working with in Melbourne who are doing something similar to us with nurse led intervention in general practice to help people come off. There's a Dutch group that's doing a lot of work on it as well. Anywhere where people speak English could potentially benefit from our internet support. Telephone support would obviously have to be developed in each country.

Katie - Antidepressant drugs are just one way of treating depression. There's talking therapies, lifestyle medicine might be another. Do you think generally we've got the balance right, in terms of drugs compared to other strategies?

Tony - No, and I don't think many people would think we've got it right. 80% of people who are diagnosed with depression of significant severity get antidepressants in general practice. Really it's not the recommended first treatment by any means. NICE recommends guided self help and psychological treatments before drug treatment. Unfortunately it's often a long wait to get this sort of help. What we'd urge our students and trainees and GPs generally to do is to try and hold off from prescribing antidepressants, give people a chance to recover, through talking it over, getting some support from their family, from the community and from their doctor, maybe from the pharmacist, and hold off for some weeks if possible. It's more difficult if people have had depression before, they've had antidepressants before when they come asking for them again. But even then it's worth checking back and thinking "did they really need to have the antidepressants in the first place?" If we can put fewer people on antidepressants, that would be a good thing generally, because many of those people will benefit from other types of support and can improve without drug treatment. If we are starting drug treatment, we should warn them about the possibility of problems when they try to stop them.