Tapering off antidepressants no easy matter

Vrouw met pil
Ellen Van Leeuwen
Ellen Van Leeuwen
Ellen Van Leeuwen is a general practitioner in the Community Health Centre Nieuw Gent, clinical pharmacologist and is associated with the Department of Fundamental and Applied Medical Sciences and the Department of Public Health and Primary Care at the Faculty of Medicine and Health Sciences. She is involved in the education on the prescription (and discontinuation) of medications. Recently, she obtained her Ph.D. with a thesis on the discontinuation of psychopharmaceuticals in primary care, under the guidance of Prof. Thierry Christiaens (Department of Fundamental and Applied Medical Sciences).

OPINION/ 1.22 million Belgians take antidepressants daily. That’s more than 1 out of every 10 people in the entire population. What’s remarkable is that many continue to take the pills for years. Tapering off is recommended, but hardly any research has been done into how one best goes about it. General practitioner and clinical pharmacologist Ellen Van Leeuwen thinks there is an urgent need to invest in helping people discontinue the use of antidepressants.

Use over many years on the rise

Those suffering from serious depression are often prescribed antidepressants in combination with psychotherapy by their doctor. Generally, the rule is that these pills are prescribed over a period of six months, or two years for those who have suffered multiple depressions. But many continue to use the pills for much longer. Over forty percent of antidepressant-users in Belgium report using them longer than three years. Research has shown that the fact that use has grown over the last decades is not due to more people suffering from depression, but rather that they are taking the pills for longer periods of time. Other Western countries are dealing with the same problem. Is it really so hard to stop taking this one pill?

“Never change a winning a team”

In practice, there’s a lot of reticence regarding discontinuation. A survey taken of general practitioners and patients alike shows as much. The answers my team and me were given, reveal a painful truth.

Patients prefer not to taper down when things are going well. They fear the onset of a new depression. “Were I to stop, I fear it would mean the end of my relationship,” says Hilde, 59 years old, who has been taking antidepressants for 26 years.

In addition, patients doubt whether they’d be able to cope with every-day problems without the help of their medication. Marleen, 61 years old and a 35-year-long-user of antidepressants: “I often have crises. I can’t cope with them on my own, so I need my medication.”

It turns out it’s difficult for general practitioners, as well, to instruct a patient to start tapering off when they are doing well. “Never change a winning team,” many doctors tell us. They, too, fear relapses. Hans, a 48-year-old general practitioner, says: “I don’t even discuss it anymore. Because, when a patient relapses, you are accountable as well.” This means that nobody is particularly enthusiastic about tapering off the pills. It’s clear that, without additional support for both parties, people won’t start tapering off and discontinuing use by themselves. But, currently, it’s still anyone’s guess what this kind of support would look like, specifically.

“It turns out it’s difficult for general practitioners, as well, to instruct a patient to start tapering off when they are doing well. “Never change a winning team,” many doctors tell us. They, too, fear relapses.”

Research still in its infancy

We know precious little of how you end the use of antidepressants. The rare studies dedicated to researching the topic, are not really up to good scientific standards. On the other hand, research into initialising the use of pills is abundantly available. This comes as no surprise. Nearly all of these studies were sponsored by pharmaceutical companies. For them, discontinuation really isn’t a priority.

What we do know, is that around half of all people that taper off experience withdrawal symptoms such as fly-like symptoms, unease and dizziness. Having sombre thoughts and experiencing fear are also possible. These are exactly the kind of symptoms associated with depression itself. This is why patients often think they are relapsing into depression and consequently restart their medication. It would help us to know who, exactly, develops these side-effects and what the risk factors are. In doing so, we would create the possibility for them to taper off under medical supervision.

Is stopping really necessary?

“If we don’t know how to stop, and patients seem to fair well regardless, why would people have to stop?” is a remark we often got.

Even though there is hardly any research into the negative effects of long-term use of antidepressants, taking these pills continuously is always associated with risks and costs. Many users report difficulty sleeping, weight gain, sexual problems, haemorrhaging and stomach- and bowel complaints. Emotional blunting also frequently occurs: “I felt like my creative urge had been suppressed and I wasn’t myself,” Flemish singer Selah Sue said during the release of her single “Pills”, in which she described the negative effect the pills had on her.

Also important: one year of antidepressant-use costs thirty euros to the patient and eighty euros to health insurance. And this doesn’t include medical follow-up. This is money that could be spent on other forms of healthcare.

“In the end, a solution also demands a shift in the approach we have towards to psychological problems. Besides the administration of medication, talking remains essential.”

What now?

Whether you should live with or without antidepressants is obviously still a hot topic in the media. The current moment, therefore, is ideal for policymakers to seriously start investing in solutions for the problem. The first step is to focus the public’s attention on the risks associated with long-term use. To make this possible, better studies are absolutely vital as a basis on which both patients and doctors could base their judgements on regarding the pros and cons of discontinuation.

But, most likely, this probably won’t suffice to solve the problem. In the end, a solution also demands a shift in the approach we have towards psychological problems. Besides the administration of medication, talking remains essential. “When, like last month, I go through a tough period mentally, I try to avoid going under by talking to the people who are close to me,” 48-year-old Els, who stopped her use of antidepressants after eight years, told us. What we learn from this testimony comes back again and again in our research: a strong network of good people who surround the patient improves the chances of recovery.

(Quotes have been anonymised and are based on the results of the qualitative research.)

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