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Eveleigh, 2017, Too Much or Too Little Antidepressant Medication: Difficult to change. Two rcts

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Mental Health in Family Medicine (2017) 13: 1-9


Too Much or Too Little Antidepressant Medication: Difficult to Change. Two Rcts


Rhona Eveleigh, Esther Muskens, Peter Lucassen, Peter Verhaak, Jan Spijker, Chris van Weel, Richard Oude Voshaar, Anne Speckens.


Full text link - http://www.mhfmjournal.com/open-access/too-much-or-too-little-antidepressant-medication-difficult-to-change-two-rcts.pdf 




Background: Antidepressant use has increased exponentially in the last decades, mostly due to long continuation.


Objective: To assess the effectiveness of a tailored recommendation to cease or adjust antidepressant treatment.


Methods: Two cluster-randomized controlled trials (PANDAstudy) in primary care. Long-term antidepressant users (> 9 months) were selected from GPs prescription databases. Patients were diagnosed with the Composite International Diagnostic Interview. Long-term users were split up in patients without indication for maintenance treatment (over-treatment trial) and patients undertreated despite maintenance treatment. The intervention consisted of disclosure of the current psychiatric diagnosis combined with a tailored treatment recommendation. We followed patients 12 months. Results: We included 146 participants from 45 family practices in the over-treatment trial. Of the 70 patients in the intervention group, 34 (48%) did not comply with the advice to stop their antidepressant medication. Of the 36 (52%) patients who agreed to try, only 4 (6%) succeeded. These figures were consistent with the control group, where 6 (8%) of the 76 patients discontinued antidepressant use successfully. In terms of relapse rate, patients who were recommended to discontinue their antidepressant medication reported a higher relapse rate than the control group (36% versus 14%, p = 0.015). We included 58 patients in the undertreatment trial, with 29 patients in both the intervention and control group. The proportion of remission was equal in both groups (n = 13, 45%).


Conclusion: Changing inappropriate long-term antidepressant use is difficult.

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Thanks for posting Dalsaan.

Gee this is one scary study.


They talk about discontinuing patients so i kept wondering how?

The answer was found in 'reference 21' which i searched for and to my surprise found here.


Muskens E, Eveleigh R, Lucassen P, van Weel C, Spijker J,
et al. Prescribing ANtiDepressants Appropriately (PANDA):
a cluster randomized controlled trial in primary care. BMC
Fam Pract. 2013; 14: 6.


Go down the page to Table1 in this study and we find some very disturbing stuff. So much so that i was horrified and felt sick when i saw it.


Table 1

Applied schemes for tapering long-term antidepressant usage in primary care

I dont know how to get the table copied into here but take paroxetine long term user on 40mg appears to be tapered in 4, 2 week steps

being 40, 30, 20, 10.


Basically this is a 6 week taper for someone on 40mg of paroxetine.

(BM just took 6 years!! to do this taper)


Interesting they define long term user as  equal to or greater than 9 months use.


In this group i have no doubt that there are people here with many years exposure. And now they are subjected to the above tapering. Thats criminal! I feel outraged.

No wonder "(48%) did not comply with the advice to stop their antidepressant medication"


Yet look at this sentence under the tapering table...the word 'proposals ' i would think are the tapering proposals.

To check the reliability of the proposals by the GP and psychiatrist, we provided another GP (CvW) and psychiatrist (AS) with 10 randomly selected case vignettes from included patients. Comparing these judgments, there was a 100% agreement.


At the end of the study they say:

We found a noncompliance with the given recommendation in almost half of the cases.

Does this surprise anyone here. What about the other half what on earth became of them?


Due to the pragmatic nature of this study, we did not impose our intervention on the patients and their GPs.

Thank goodness for that. Perhaps better to say due to the dangerous nature of this study...


This is also considered conservative, as in contrast to benzodiazepines, psychological dependency does not play a major role in long-term use of antidepressants.



The full conclusion from the study 'too much [ado about the obvious] is':


This study demonstrates the difficulty of correcting inappropriate long-term antidepressant use (according to the guidelines), fuelled by an apprehension from both patient and GP to change. A recommendation to discontinue in case of over-treatment is not effective, and maybe even counterproductive. It might be useful to forewarn patients about the difficulty to discontinue and to encourage using antidepressants for a limited period. Regular review could possibly prevent both over and under-treatment.


Its all about 'the guidelines', cant someone in 2017 with half a brain question the guidelines for goodness sake!!



"5 of every 6 antidepressant users do not benefit "

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From the first paragraph:


During the 1990’s, antidepressants were promoted widely and general practitioners (GPs) were criticized for under-diagnosing and under-treating depressive and anxiety disorders.

Efforts were made to increase quality of care and prescription rates for antidepressants increased.

Now, contrary concerns are raised concerning overtreatment with antidepressants . Long-term continuation contributes to the large amount of antidepressant use.


Isnt it just so sad the way the medical profession equate 'increased quality of care' to 'increased prescribing of antidepressants.'

Efforts were made by who? who was doing the criticizing?  ...probably pharma.

I wonder if they actually realise the reason for  long term continuation being the difficulty in getting off the drug their taper procedure doesnt reflect this.

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it's kind of scary how stupid these investigators are, eh?


they seem to have no critical thinking skills at all.


and the pts who supposedly "relapsed"?? what do you want to bet that was WD mis diagnosed as symptoms of disease


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