Antidepressant Withdrawal and Scientific Consensus

Why did academic psychiatry take two decades to recognize the condition?

Posted Aug 26, 2019

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A shift in scientific consensus can be difficult to pinpoint, much less measure accurately, but its causes and effects are still important to assess.

That is especially true of Antidepressant Withdrawal (AW), a medical syndrome academic psychiatry took more than two decades to recognize that is now starting to receive the research and media coverage it deserves, given the millions of patients affected worldwide.

Last week, the Cambridge journal Epidemiology and Psychiatric Sciences published “Antidepressant Withdrawal—The Tide Is Turning,” a paper by leading European researchers Michael P. Hengartner, James Davies, and John Read documenting psychiatry’s protracted delay in recognizing AW as a full-blown medical disorder. “The preferred narrative,” they write, was that the condition amounted to symptoms that “affect only a small minority, are mostly mild, and resolve spontaneously within 1-2 weeks.”

SSRI antidepressants instead demonstrate “remarkably high rates of withdrawal reactions … shortly after discontinuation,” they write, with medical indicators even after slow and careful tapering including “anxiety, irritability, agitation, dysphoria, insomnia, fatigue, tremor, sweating, shock-like sensations (‘brain zaps’), paresthesia (‘pins and needles’), vertigo, dizziness, nausea, vomiting, confusion and decreased concentration.”

Until recently, the “mild, minority, and self-resolving” narrative was the official position of the American Psychiatric Association (APA) and the UK’s National Institute for Health and Care Excellence (NICE). That, in turn, determined guidelines adopted in both countries since the first SSRI antidepressants (Prozac, Zoloft, and Paxil) were approved in the late 1980s and early 1990s.

The preferred narrative may have been built on sand. The evidence base for AW was painfully thin because withdrawal and discontinuation issues tied to such blockbuster medication had for years gone almost completely unstudied.

“It took almost two decades after the [SSRIs] entered the market for the first systematic review to be published,” the researchers note. “More reviews have followed,” and those, in turn, have come to reinforce “that the dominant and long-held view … was at odds with the sparse but growing evidence base.”

Contrast the near-total silence about AW with the startling reminder that, while prescribing rates rose sharply across OECD countries for those two decades, “almost 200 meta-analyses on the efficacy of new generation antidepressants [were] published between 2007 and 2014 alone, many with industry involvement.”

To call that “disproportionate” would be putting it mildly. There has, they write, “been a dearth of empirical research on this important issue [AW] over the years.” Those publishing ratios tell us plainly that efficacy is a topic that industry will sponsor and promote ad infinitum, while equivocal or negative results will be left unstudied and unpublished, revised by a switched outcome, or simply overwhelmed by the firehose capacity of “the preferred narrative” to drown out all else.

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Academic psychiatry, write Hengartner, Davies, and Read, has “long clung to the illusion that withdrawal reactions or discontinuation symptoms are minor problems that affect only a small minority and which resolve spontaneously.”

That has meant turning a deaf ear to the hundreds of thousands of online posts from patients, caregivers, and relatives, for two decades the clearest indication of adverse medical effects, themselves a direct consequence of psychiatry’s own prescribing patterns.

One especially well-documented meta-study—“A systematic review into the incidence, severity, and duration of antidepressant withdrawal effects”—drew world press last October. Even as it corroborated earlier investigations, it became the target of “some astonishingly fierce attacks on both the review and on the authors personally by prominent UK psychiatrists.”

Incredibly, despite years of silence and neglect of the issue, the same psychiatrists who decided to go on the attack, all the while downplaying their own financial ties to industry, insisted that there was now actually a “War on Antidepressants.

The language was telling—a sign of how fiercely academic psychiatry had fought to maintain silence on this, as it took to labeling as “anti-psychiatry” those intent on documenting the drugs’ empirical effects. Even to report on AW for the benefit of its many sufferers was seen as an attack on SSRIs’ most ardent and well-paid defenders.

Meanwhile, to audiences too large to be ignored, psychiatrists themselves wrote of their own persistent adverse effects, which they documented as “strange and frightening and torturous” experiences lasting weeks, underscoring to those still prone to mishear that there was indeed a problem—one of enormous scope, given the scale of prescribing.

It seemed to take psychiatrists themselves suffering from AW before enough people would listen. One such psychiatrist in Scotland was then subject to the same kind of “gaslighting” (his word) by colleagues at the Royal College of Psychiatry, London. Apparently, they were so enamored by the preferred narrative that even for their colleague to dispute it gave rise to charges that he was struggling with mental illness.

This is what happens when a preferred narrative collapses under the weight of long-suppressed counter-evidence. Those who have invested decades and careers in its assumptions are likely to try to cling to its illusions, seemingly unaware that in doing so they’re misinforming their patients on the high probability of AW and other adverse effects.

NICE, we learn, has “committed to reviewing its position, held for over 14 years, that antidepressant withdrawal is usually mild, resolving over about a week”—a commitment that has yet to result in meaningful policy changes, but hopefully will. The APA has yet to give any such sign, seeming to prefer silence and inertia to reform, because it puts off a serious reckoning with its own two-decade narrative about antidepressants as correctives to a “chemical imbalance.”

The new paper “Antidepressant Withdrawal—The Tide Is Turning,” writes Joanna Moncrieff, Professor of Psychiatry at University College London, “is part of a series of pieces on the persistent adverse effects of antidepressants, with another on post SSRI sexual dysfunction [forthcoming]. These emphasize how antidepressants disrupt normal biological processes, and the disruption can be long-lasting.”

If the tide is at last turning, then Hengartner, Davies, Read, and Moncrieff are among those deserving credit for its world-changing implications for medicine and the treatment of depression and anxiety. One such effect is that we can’t any longer pretend not to know that AW is widespread, often “severe,” and can last for months, even years. The question is: How long must we all wait before the official bodies catch up?

Note: Given the scale and gravity of Antidepressant Withdrawal, patients concerned about the drugs’ adverse effects are strongly advised not to terminate treatment abruptly, but instead to taper carefully and gradually by microdoses over a course of several months, always in consultation with their doctor, to ensure their own safety.

Peer-reviewed, specialist information on discontinuation issues is available on the website Surviving Antidepressants, with a forum specifically on “Tapering.” Much of the early bibliography on withdrawal is also detailed in this 2011 post on “Side Effects.”

References

Hengartner MP, Davies J, Read J. (2019). Antidepressant withdrawal—The tide is finally turning. Epidemiology and Psychiatric Sciences 1-3. https://doi.org/10.1017/S2045796019000465 (August 22). [Link]