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Antidepressant discontinuation reactions - dependence on antidepressants is significant
- D B Double (1 May 1998)
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Authors have updated their views
- D B Double (2 April 2000)
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Re: Antidepressant discontinuation reactions - dependence on antidepressants is significant
- Sharon (4 February 2001)
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re: anti-depressant withdrawal symptoms-professionally and personally
- Audrey A. Mahoney (2 May 2006)
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Physical and Psychological aspects interact
- Sharif El-Leithy (5 May 2006)
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D B Double, Consultant Psychiatrist, Norfolk Mental Health Care NHS Trust Hellesdon Hospital, Norwich NR6 5BE
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(Copy of letter sent a few weeks ago to 100730.1250@compuserve.com - before online letters feature available - to which I have not yet had reply, nor am I sure whether is being considered for publication) Haddad et al minimise the problems caused by discontinuing antidepressant treatment, claiming without evidence that antidepressants are not drugs of dependence.1 The dependence potential of drugs has regularly been denied in history, until eventually accepted for drugs such as opiates, barbiturates and most recently benzodiazepines.2 Discontinuation symptoms were regarded as evidence of benzodiazepine dependence, but this clinical condition would now hardly meet the modern DSM-IV criteria for substance dependence.3 Recognition of the withdrawal effects of benzodiazepines caused a collapse in their market. It may be suspicious that Haddad et al prefer the term discontinuation reaction rather than withdrawal reaction, but it is difficult to assess their bias as they do not declare a conflict of interest. Semantic confusion about discontinuation, withdrawal and relapse can be traced to dissatisfaction with the definitions of addiction and habituation, leading to the introduction of the single term drug dependence by a WHO Expert Committee in 1964. Since then there have been varying shades of meaning of dependence. The Diagnostic and Statistical Manual of the American Psychiatric Association made tolerance or withdrawal a required criterion in DSM-III, but in DSM-IIIR dependence was redefined as the antisocial syndrome of clinically significant behaviours and symptoms indicating loss of control of substance use and continued use despite adverse consequences. The former distinction between physical and psychological dependence may still have some relevance in clinical practice. Haddad et al leave open the question of the nature of antidepressant discontinuation reactions. They may be nonspecific effects. More worryingly though are the few reports of suspected neonatal withdrawal reactions resulting from maternal SSRI use in pregnancy.4 Nonetheless it is disingenuous to criticise the public for their commonsense belief that people can become dependent on medication which is regarded as improving mood.5 High placebo response rate of antidepressants is recognised and suggestion can play an important part in initial response to treatment, so expectations are as likely to play a role in withdrawal. Although discontinuation reactions may be minimal, placebo effects can be powerful. Evidence for the value of continuation treatment means patients are likely to remain on antidepressants for some time, increasing the risk of discontinuation reactions. This reliance on medication is significant and is present with other psychotropic medication such as neuroleptics and lithium. Simplistic, dismissive views such as Haddad et al will not help the recognition of these difficulties. Yours faithfully D B Double, Consultant Psychiatrist, Norfolk Mental Health Care, Hellesdon Hospital, Drayton High Road, Norwich NR2 2AE. (Duncan_Double@bigfoot.com) 1. Haddad P, Lejoyeux M, Young A. Antidepressant discontinuation reactions. Are preventable and simple to treat. BMJ 1998;316:1105-6 (11 April). 2. Medawar C. Power and dependence. Social audit on the safety of medicines. London: Social Audit, 1992 3. Medawar C. The antidepressant web. International Journal of Risk and Safety in Medicine 1997;10:75-126 and http://www.socialaudit.org.uk 4. Kent LSW and Laidlaw JDD. Suspected congenital sertraline dependence. British Journal of Psychiatry 1995;167:412-3 5. Double DB. Prescribing antidepressants in general practice. People may become psychologically dependent on antidepressants. [letter] BMJ 1997;314:829 |
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D B Double, Consultant Psychiatrist 80 St Stephen's Rd, Norwich NR1 3RE
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Haddad et al appear to have now altered their conclusion about the significance of antidepressant discontinuation reactions. In a letter to the Lancet they admit that such reactions are common.1 They propose routine evaluation of discontinuation reactions in all new psychotropic medications. Such research is important for evaluation of the issue of reliance on psychotropic medication. 1. Young A, Haddad P. Discontinuation symptoms and psychotropic drugs. Lancet 2000; 355:1184 [Full text] |
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Sharon home looking after children
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I am a sufferer of depression,i have taken various drugs to help control it<anti-depressants, sleeping tablets and anti anxiety drugs.My point i am making simply is this i strongly beleive there are withdrawel symptoms when comming of certain tablets.For me i have suffered some extreamly distressing symptoms when discontinuing anti depressants such as instantanious lower mood,chronic anxiety.imsomnia.I would like to warn of in particular discontinuation of imipramine my doctor would have liked for me to reduce the dosage slowly,on the other hand my phyctrist wanted me to stop them suddenly.I am suffering very bad withdrawel effects ie,feelings of unreality,chronic anxiety irritability and a deffinate mood decrease.I beleive some medication can increase symptoms and therefore make the problem worse.Most antidepressants i have tried and stopped have caused deffinate withdrawel symptoms.They are not the only answer to ridicate depression although i do acknowledge they can be helpful to treat it, my depression differs in severity at its worst most tablets help but bye no means are the cure.I would advise anyone to voice there concers to the doctor when stopping any mood altering drugs. Sincely yours miss s whitty. |
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Audrey A. Mahoney, RN IPU- Hospice Facility
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As an RN, responsible for medicating my patients properly, particularly during the active dying process, I find it essential to be familiar with the medications, uses, and side effects; particularly any withdrawal symptoms that may occur with abrupt discontinuation of long- term meds. If I am remiss in how a patient could be effected, not only would I be using poor nursing judgement, I may be defeating the long-held Hospice belief of improving the quality of life remaining, by symptom management, mostly focused on the control of pain and anxiety. Withdrawal from "major players", such as ativan, and benzodiazapines, are easily remembered. Where the concern lies is in educating our work force on lesser recognized medications that can cause withdrawal syptoms, such as the SSRI's and SNRI's, and what those symptoms include. From personal experience,I have found the pharmacists unwilling to assist with preventing these painful symptoms, which could be circumvented with a simple phone call to the physician. These symptoms are REAL, and they HURT. happyiswe2@aol.com Competing interests: None declared |
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Sharif El-Leithy, Clinical Psychologist Traumatic Stress Service, London SW17
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In my clinical work I have often noticed how anti-depressants' physical effects can interact with the psychological aspects of taking medication. In this respect it is worth reiterating that recent research would suggest that a large proportion of the efficacy of anti-depressants is psychological (placebo) in origin. This is evident when people first visit a clincian to seek help for a condition such as depression. Whilst they get tablets, they also get a listening ear, an explanation for their problems (e.g. "your problem is depression") and a sense of hope that things can improve ("take this, it will help change the way you feel"). When the physical effects of the anti-depressants kick in, this in turn serves to support both the explanation ("I feel the anti-depressant working so it must be depression") and the sense of hope. The resulting positive expectancy is, in my opinion, a significant factor in the resulting improvement in symptoms. One also sees this when people come to withdraw from medication. Even though they may have completed therapy (pharmacological and perhaps psychological), and appear to have improved through that process, clients often find coming off medication a worrying time. Understandably people greatly fear a relapse, more so where they have not had any form of psychological therapy and so have nothing but medication to attribute their improvement to. As such it is common for clients to get very anxious about cutting down or stopping their medication even though they feel better and have done for some time. What makes this worse is that in some cases the discontinuation effects are very similar to the problem they were taking the medication for, e.g. feeling tense and anxious. In the absence of other explanations, clients can easily take these physical symptoms as further evidence that the medication is primarily what has got them, or is keeping them, better. The resulting anxiety about the possibility of an imminent relapse, heightened by the physical sensations from withdrawal, can in themselves lead to a deterioration in mental state, a sort of self-fulfilling prophesy. This has the potential to create a classic vicious circle, where the physical and psychological discontinuation effects act as evidence for the need to continue the medication. The potential is that, without an understanding of this dynamic, the client stays on medication beyond the point at which they actually require it. Competing interests: None declared |
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