According to a recent study, few antidepressants should be prescribed by doctors and for a shorter period of time.
The use of antidepressants is also associated with a range of side effects, while the clinical trial data mostly doesn’t assess the outcomes that matter most to patients, said the authors. And there is no clinically relevant difference between these drugs and placebo on depression.
While there might be a role for antidepressants among patients with severe depression, the cons may outweigh the pros in those with mild to moderate depression or in those whose symptoms don’t yet qualify as depression, they added.
The prescribing of antidepressants, primarily the newer generation classes–selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs)–has risen steadily in England, with an estimated 7.8 million people issued at least one prescription in 2019-20.
This is equivalent to an antidepressant prescribed to one in every six adults, with prescription rates 50 per cent higher among women.
Much of the evidence for the effectiveness of antidepressants in adults came from placebo-controlled trials lasting just 6-12 weeks. And the results didn’t meet the threshold for a clinically important difference, said the authors.
The findings in teenagers and children were even less convincing. Yet the number of 12 to 17 year-olds prescribed antidepressants more than doubled between 2005 and 2017, they added.
What’s more, most of the studies didn’t include outcomes that matter most to patients, such as social functioning or quality of life, focusing instead only on symptom measures.
Side effects are also common. Around 1 in 5 patients on SSRIs reported daytime sleepiness, dry mouth, profuse sweating, or weight gain; at least 1 in 4 reported sexual difficulties; and about 1 in 10 reported restlessness, muscle spasms or twitching, nausea, constipation, diarrhoea or dizziness. The prevalence of side effects may be even higher among those taking antidepressants for more than 3 years and included emotional numbness and mental ‘fogginess’.
Patients trying to come off their treatment often experienced withdrawal symptoms: these can include anxiety, insomnia, depression, agitation and appetite changes, and can interfere with social functioning and professional life, particularly if treatment is stopped abruptly. “The recognition that withdrawal effects from antidepressants are more common, more long-lasting and more severe than previously recognized prompted the Royal College of Psychiatrists to issue a position paper, alerting prescribers to this issue, including the recommendation that patients be informed of this risk,” noted the authors. Gradual dose tapering may best help patients to stop, said the authors, although “there is no guarantee that patients will avoid consequences such as long-lasting sexual side effects or persistent withdrawal symptoms even with a cautious taper,” they wrote.
But they pointed out, “The gradual reductions in the dose and the very small final doses required for pharmacologically informed tapering will necessitate the use of formulations of medication other than the commonly available tablet forms.”
Patients attempting to stop antidepressant use, particularly long term users, may very well need additional help, said the authors. But “there are currently no dedicated NHS services to support antidepressant de-prescribing,” they added.
They concluded, “There continues to be considerable uncertainty about the benefits of antidepressant use in the short- and long-term, particularly in regard to the lack of a clinically significant difference between antidepressant and placebo treatment. “In light of this uncertain balance of benefits and harms, we should re-visit the widespread–and growing–prescription of antidepressants,” they added. They went on to say, “Increasing knowledge about the difficulty that some patients have in stopping antidepressants should lead to more cautious prescribing practice–with antidepressants given to fewer patients, for shorter periods of time.
