Antidepressant use has risen steadily for 30 years. Over 10% of adults in England now take them long-term, but evidence suggests up to half lack clear medical justification to continue.
Patients and doctors are reluctant to stop treatment due to fears of relapse and withdrawal effects.
Research indicates more proactive treatment review, slower drug tapering regimes, and extra patient support could enable many to successfully withdraw.
Key Facts:
- Antidepressant prescribing has doubled every 10 years since the 1980s, mostly due to longer treatment durations rather than more people starting medication.
- Over 10% of adults now take antidepressants long-term; surveys suggest 30-50% lack evidence-based reasons to continue.
- Withdrawal symptoms affect over half of patients stopping antidepressants, fueling fears of relapse that perpetuate unnecessary long-term use.
- Research shows structured support encouraging patients to withdraw, alongside slower drug tapering by doctors, can significantly increase successful antidepressant cessation.
Source: Br J Clin Pharmacol. (2021)
Antidepressant Use Keeps Increasing in Western Countries
Antidepressant use has risen exponentially in Western countries for over 30 years.
In England, the number of antidepressant items dispensed has doubled every decade since the selective serotonin reuptake inhibitors (SSRIs) became widely used in the late 1980s.
Over 70 million antidepressant prescriptions were issued in 2017-18, making these medications among the most commonly prescribed drugs in the National Health Service (NHS).
Several studies analyzing NHS prescribing data over time have revealed this growth is not primarily due to more people starting antidepressant treatment for mental health issues like depression and anxiety.
While improved recognition of these problems has caused some increase in patients beginning medication, research consistently finds the main driver of rising antidepressant use is that patients are staying on the drugs for longer.
Whereas antidepressants used to be taken for months, it is now common for patients to remain on them for years or even decades.
The median duration is over 2 years, and almost a quarter of the 4.8 million antidepressant users in England as of 2018 had been on them continuously for 3 years or more.
Consequently, over 10% of adults now take antidepressants long-term.
Risks of Long-Term Antidepressant Use
There are good reasons to avoid unnecessarily prolonged antidepressant treatment.
Taking any medication for years often causes side effects, some potentially severe with antidepressants like weight gain, sleep problems, and sexual dysfunction.
Elderly patients are particularly susceptible to adverse effects like falls, stroke, and gastrointestinal bleeding.
And animal research indicates long-term antidepressant use can make it harder to feel emotions and diminish self-reliance.
Crucially, over 50% of people stopping antidepressants suffer withdrawal symptoms including depression, anxiety, and disturbed sleep. These fuel fears the original illness is returning, driving long-term use.
Surveys suggest that while guidelines often recommend continuing antidepressants for 2 years after recovering from recurrent depression, 30-50% of long-term users lack clear medical justification and could try safely withdrawing.
Selective Serotonin Reuptake Inhibitors (SSRIs)
Examples: Fluoxetine (Prozac), Sertraline (Zoloft), Citalopram (Celexa)
Common Long-Term Effects:
- Sexual Dysfunction: Reduced libido, difficulty achieving orgasm, and erectile dysfunction are common and can persist even after stopping the medication.
- Weight Gain: Some individuals may experience significant weight gain over long-term use.
- Emotional Blunting: A reduced ability to feel emotions, both positive and negative, which some patients describe as feeling ‘numb’.
- Withdrawal Symptoms: Stopping SSRIs abruptly can lead to withdrawal symptoms, including flu-like symptoms, insomnia, nausea, imbalance, and sensory disturbances.
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
Examples: Venlafaxine (Effexor), Duloxetine (Cymbalta)
Common Long-Term Effects:
- Blood Pressure: Some SNRIs, particularly at higher doses, can lead to sustained increases in blood pressure.
- Withdrawal Symptoms: SNRIs can cause significant withdrawal symptoms that can be more pronounced than SSRIs, including severe mood swings and irritability.
- Fatigue and Insomnia: These can persist as long-term effects, impacting overall quality of life.
Tricyclic Antidepressants (TCAs)
Examples: Amitriptyline (Elavil), Nortriptyline (Pamelor)
Common Long-Term Effects:
- Cardiac Issues: Long-term use can affect heart rhythms and function, particularly in those with pre-existing heart conditions.
- Anticholinergic Effects: Dry mouth, constipation, urinary retention, blurred vision, and confusion, especially in the elderly.
- Weight Gain: Like SSRIs, long-term use of TCAs is often associated with weight gain.
Monoamine Oxidase Inhibitors (MAOIs)
Examples: Tranylcypromine (Parnate), Phenelzine (Nardil)
Common Long-Term Effects:
- Dietary Restrictions: Long-term use requires maintaining a strict diet to avoid hypertensive crisis caused by foods high in tyramine.
- Sleep Disturbances: Insomnia and sleep disturbances are common.
- Weight Gain: This is a potential long-term effect, along with edema.
Doctors & Patients Reluctant to Initiate Antidepressant Withdrawal
Yet very few patients seem to come off antidepressants in practice.
Qualitative research finds doctors rarely initiate discussion about stopping medication, while patients assume their doctor will advise them if appropriate.
Without prompting, the default is simply continuing prescriptions.
Doctors moreover lack consistent advice on tapering medication once withdrawal is attempted.
Mainstream guidance has often suggested relatively rapid dose reductions over weeks, but this frequently causes symptoms forcing patients to resume treatment.
Consequently, while most long-term users are open to withdrawing in principle, fears of relapse and withdrawal mean attempts are seldom made.
Structured Support May Help Antidepressant Withdrawal
But emerging research indicates more patients may successfully stop medication with the right support.
Several randomized controlled trials using psychological therapies to bolster coping self-efficacy, alongside very gradual drug tapering over months, have enabled 40-95% of patients to quit antidepressants with no greater depression relapse than continuers.
Internet interventions are now being developed to provide similar therapy support to the many patients who lack access to face-to-face psychotherapy.
Researchers argue actively prompting doctors to review long-term antidepressant use, combined with them having clear advice on tapering regimes minimizing withdrawal effects, could likewise increase appropriate cessation.
New evidence suggests withdrawal symptoms can be mitigated by ‘hyperbolic’ dose tapering, an initially fast reduction slowing progressively towards the end.
Tailored drug tapering programs utilizing special medication strips to facilitate very gradual dose lowering also show promise.
Ongoing research, like the REDUCE trial, will provide clearer guidance on enabling withdrawal.
But it is already apparent a combination of structured psychosocial support, proactive treatment review, and optimized drug discontinuation schedules could reduce over-reliance on unnecessary long-term antidepressant prescribing.
The Origins of Increasing Long-Term Antidepressant Prescribing
It is first essential to analyze what drove the exponential rise in antidepressant prescribing over the past three decades, to understand why long-term use is so entrenched.
Specifically, did more people start taking antidepressants because mental health issues became more recognized and destigmatized? Or are patients simply staying on these medications much longer than before?
Several major studies examined NHS prescribing databases tracking hundreds of thousands of patients over years to illuminate trends underlying increased antidepressant use:
- Analysis of Dutch medical records found both more initial antidepressant prescribing and longer treatment courses over time, with almost 30% of users becoming long-term patients over a decade.
- An English study likewise found more first-time antidepressant prescribing explaining part of the growth, but longer durations of use driving a near doubling of total prescriptions.
- Another English analysis revealed prescription numbers doubled from 1995 to 2001, primarily thanks to a 50% increase in duration of prescribing.
- From 2003 to 2013, incidence of new diagnosed cases of depression remained steady, but prescription length doubled.
The conclusion across multiple studies is that improved recognition and diagnosis of depression has caused some growth in antidepressant use.
Much more significant, however, is that courses of treatment have lengthened dramatically – typically from months to years.
Consequently, over 10% of English adults now use antidepressants long-term.
Navigating Long-Term Antidepressant Use: Considerations & Strategies
As the journey with antidepressants is highly personal and varies significantly among individuals, it’s crucial to approach long-term use with careful consideration.
Understanding the potential long-term effects, recognizing the importance of regular medical reviews, and considering alternative therapies are essential steps.
Here are some key considerations and strategies for individuals and healthcare providers navigating the complexities of long-term antidepressant use:
1. Informed Decision-Making
- Collaborative Approach: Decisions about starting, continuing, or stopping antidepressants should be made collaboratively between the patient and healthcare provider. Patients should be fully informed about the potential benefits and risks.
- Personalized Plan: Treatment plans should be tailored to the individual, considering their specific symptoms, response to treatment, personal preferences, and overall health.
2. Regular Monitoring and Review
- Scheduled Assessments: Regular appointments to review the effectiveness of the medication, discuss any side effects, and evaluate the ongoing need for treatment are vital.
- Adjustments as Needed: Be prepared to adjust the treatment plan based on changes in symptoms, side effects, and individual circumstances.
3. Managing Side Effects and Withdrawal
- Awareness of Side Effects: Stay informed about potential long-term side effects and discuss any changes in health or well-being with a healthcare provider.
- Gradual Changes: If the decision is made to stop or change medications, it should be done gradually and under the guidance of a healthcare professional to minimize withdrawal symptoms.
4. Exploring Alternatives & Complementary Therapies
- Holistic Approach: Consider incorporating psychotherapy, stress-reduction techniques, exercise, and other non-pharmacological treatments into the overall treatment plan.
- Ongoing Research: Stay informed about new research and emerging treatments that might offer alternative options or enhance current therapy.
5. Advocating for Personalized Care
- Self-Advocacy: Patients should feel empowered to ask questions, express concerns, and advocate for their needs and preferences in treatment.
- Support Networks: Leverage support from family, friends, support groups, or mental health organizations to navigate the challenges of long-term treatment.
6. Societal & Healthcare System Considerations
- Reducing Stigma: Continued efforts to reduce the stigma associated with mental health treatment can encourage more open and honest discussions about the benefits and challenges of long-term antidepressant use.
- Policy and Access: Advocating for policies that ensure access to regular medical reviews, mental health services, and a range of treatment options is crucial for supporting individuals on long-term antidepressants.
Takeaway: Long-Term Antidepressants
Long-term antidepressant use is a complex issue that requires a nuanced approach.
While these medications can be life-changing for some, it’s essential to regularly evaluate their need, manage side effects, and consider the whole person in treatment decisions.
By staying informed, advocating for personalized care, and exploring a comprehensive treatment approach, individuals and healthcare providers can work together to ensure that long-term antidepressant use is as effective and safe as possible.
Remember, the journey with antidepressants is unique to each individual, and ongoing dialogue and support are key to navigating this path.
References
- Study: Strategies to reduce use of antidepressants
- Author: Kendrick (2021)
