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Antidepressant withdrawal guidance must be updated to reflect evidence

BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2283 (Published 21 May 2019) Cite this as: BMJ 2019;365:l2283

Linked Letter

Clinical guidelines on antidepressant withdrawal urgently need updating

  1. Elisabeth Mahase
  1. The BMJ

Recommendations on antidepressant withdrawal need to be updated urgently to reflect the scientific evidence, said a group of experts writing in The BMJ.1

It was a concern that the evidence base contradicted the official position of the UK National Institute on Health and Clinical Excellence on antidepressant withdrawal, they said, and they warned that if doctors were following these recommendations many people may have had their withdrawal symptoms misdiagnosed as a relapse or a failure to respond to treatment.

As a result, patients who were trying to come off antidepressants may have had them reinstated or switched, or had the dosage increased.

The current NICE depression guidelines say that doctors should tell patients who are stopping or reducing the dose of their antidepressants that they may have discontinuation symptoms, which are “usually mild and self-limiting over about 1 week.”2 Clinicians are then advised to “consider reintroducing the original antidepressant at the dose that was effective (or another antidepressant with a longer half-life from the same class) if symptoms are severe.”

However, this guidance has been challenged by two researchers who obtained the evidence used to support the advice through a freedom of information request. They found that it was based on only two short review articles that did not support the one week claim and that cite sources that actually contradict it.3

In the letter to The BMJ the expert group also highlighted the pooled results of two recent surveys showing that fewer than 2% of around 3000 patients could recall being told about withdrawal symptoms, dependence, or potential difficulties in discontinuing treatment.

The group wrote, “These practices, if routinely enacted, would help partly explain why the average time a person spends taking antidepressants has doubled in the UK since the guidelines were introduced in 2004, why antidepressant prescriptions are rising overall, and why patients regularly report that their withdrawal is not properly acknowledged, understood, and managed by doctors.”

They added, “It is worrying that antidepressants are causing withdrawal effects that can be long lasting and severe and that this is not being sufficiently recognised by current clinical guidelines—and, by extension, many prescribers.

“NICE is now in the process of updating its depression guidelines, and we call on it and the royal colleges to revise their practice guidelines and recommendations to bring them in line with the scientific evidence base.”

NICE’s update of its depression guidelines has already faced controversy.

The guidance was due to be released in January 2018, but NICE agreed to undertake a second consultation after a group of mental health specialists warned in November 2017 that they were “extremely concerned about significant flaws in methodology, lack of transparency and inconsistencies in the document.”4

After the second consultation, NICE was then forced to redraft the guidance and take the recommendations to a third consultation, after admitting that the evidence base needed updating.5

The guidelines are now set to be published in February 2020, over two years after they were originally due.

References

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