Dr. Duncan Double: Antidepressant discontinuation reactions

[Altostrata]

Highly informative page by a UK psychiatrist and principal in the Critical Psychiatry Network. This is undated but appears to be from 2006(?). (Emphases below are mine.)

 

Since 1990 a warning has been printed in the British National Formulary about withdrawal from antidepressants - "Gastro-intestinal symptoms of nausea, vomiting, and anorexia, accompanied by headache, giddiness, 'chills', and insomnia, and sometimes by hypomania, panic-anxiety and extreme motor restlessness may occur if an antidepressant (particularly an MAOI) is stopped suddenly after regular administration for 8 weeks or more. Reduction in dosage should preferably be carried out over a period of about 4 weeks."1 Case reports of discontinuation reactions have appeared since antidepressants were introduced.2 However, the problems of withdrawal have been underestimated and even denied. More recently the importance of discontinuation reactions has generally been conceded,3,4 although there is still controversy.5,6,7,22

 

NICE guidelines23 have recently stated that:-

 

All patients prescribed antidepressants should be informed that, although the drugs are not associated with tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping, missing doses or, occasionally, on reducing the dose of the drug. These symptoms are usually mild and self-limiting but can occasionally be severe, particularly if the drug is stopped abruptly.

 

There has been a reluctance to concede that people can become dependent on antidepressants.24 ....

 

The definition of dependence changed in the International Classification of Diseases between ICD-9 and ICD-10.11,12 (See ICD-9 and ICD-10 definitions.) In ICD-9, dependence was not necessarily associated with the development of tolerance and physical dependence. Consistent with this view, Russell, in attempting to define dependence, suggested that the "notion of dependence ... requires the crucial feature of a negative affect experienced in its absence. The degree of dependence can be equated with the amount of this negative affect, which may range from mild discomfort to extreme distress, or it may be equated with the amount of difficulty or effort required to do without the drug".13 This commonsense definition was amended following the syndromal approach of Edwards et al,14 and the operationalisation of diagnostic criteria. The presence of a withdrawal state is neither sufficient nor necessary for a diagnosis of dependence in ICD-10.

 

....Antidepressants do not have primary reinforcing effects like psychostimulants, such as amphetamines and cocaine. Tolerance and physical dependence are said to develop not only with opioids, ethanol and hypnotics, but also after long-term administration of a wide variety of drugs which are not self-administered by animals or used compulsively by man eg. anticholinergics, dopaminergic antagonists and imipramine.10

 

The crucial issue is whether discontinuation reactions are characteristic for particular antidepressants, which implies physical dependence due to neuroadaptation. This has been particularly suggested with paroxetine and is now incorporated in the BNF warning. There are a few reports of suspected neonatal withdrawal reactions resulting from maternal SSRI use in pregnancy.16 Reported cases of SSRI-induced neonatal withdrawal syndrome, including convulsions, to the WHO database of adverse drug reactions are more frequent than expected,25 although inconsistent spontaneous reporting makes this data difficult to interpret.26 Among the SSRIs fluoxetine is reported to be less likely to cause discontinuation reactions, maybe because of its longer half-life,17, 18 although there is conflict of interest in this work.19

 

Suspicion has been raised that the reluctance by authorities to acknowledge the dependence potential of antidepressants is affected by commercial interests.20 The dependence potential of benzadiazepines was eventually officially accepted, leading to restrictive guidelines about their use. Nonetheless, there are those who advocate the use of the SSRI antidepressants as "lifestyle" drugs.21 If SSRIs continue to be "abused" in this way, perhaps they will even meet ICD-10 criteria for drug dependence

 

References

 

1. British Medical Association and Royal Pharmaceutical Society of Great Britain. British National Formulary. London: BMA and Pharmaceutical Press, 1990.

 

2. Mann AM, MacPherson AS. Clinical experience with imipramine (G22355) in the treatment of depression. Can Psychiatr Assoc J 1959;4:38-47.

 

3. Haddad P, Lejoyeux M &Young A. Antidepressant discontinuation reactions. Are preventable and simple to treat. BMJ 1998;316:1105-1106 Full text]

 

4. Anon. Withdrawing patients from antidepressants. Drugs and Therapeutics Bulletin 1999;37:49-52

 

5. Double DB. Antidepressant discontinuation reactions - dependence on antidepressants is significant. http://www.bmj.com/cgi/eletters/316/7138/1105#EL2 (1 May 1998)

 

6. Medawar C. Industry sponsored consensus statements? Reflections on a BMJ editorial. http://www.socialaudit.org.uk/4200peha.htm

 

7. Medawar C. A suitable case for re-evaluation? http://www.socialaudit.org.uk/4200dtb.htm

 

8. Priest RG, Vize C, Roberts A, Robert A, Tylee A. Lay people's attitudes to treatment of depression: result of opinion poll for Defeat Depression Campaign just before its launch. BMJ 1996; 313: 858-859 [Medline].

 

9. Double DB. Prescribing antidepressants in general practice. People may become psychologically dependent on antidepressants. [letter] [Full text] BMJ 1997;314:829

 

10. Jaffe JH. Drug addiction and drug abuse. In Goodman and Gilman's The pharmacological basis of therapeutics. eds. Gilman et al. Eighth edition. McGraw-Hill: New York, 1990.

 

11. World Health Organisation. International Classification of Diseases, ninth revision (ICD-9). WHO: Geneva, 1977.

 

12. World Health Organisation. The ICD-10 classification of mental and behavioural disorders. WHO: Geneva, 1992

 

13. Russell MAH. What is dependence? In Drugs and drug dependence. Eds. G Edwards et al. Saxon House: Westmead, 1976

 

14. Edwards G. Nomenclature and classification of drug- and alcohol-related problems: a WHO memorandum. Bull WHO 1981; 59:225-42

 

15. Raftery EB. Cardiovascular drug withdrawal syndromes. A potential problem with calcium antagonists? Drugs 1984;28:371-4

 

16. Kent LSW and Laidlaw JDD. Suspected congenital sertraline dependence. Br J Psychiatry 1995;167:412-3

 

17. Zajecka J, Fawcett J, Amsterdam J, Quitkin F, Reimherr F, Rosenbaum J et al. Safety of abrupt discontinuation of fluoxetine: A randomised, placebo-controlled study. J Clin Psychiatry 1998;18:193-7

 

18. Rosenbaum JF, Fava M, Hoog SL, Ascroft RC, Krebs WB. Selective reuptake inhibitor discontinuation syndrome: A randomised clinical trial. Biol Psychiatry 1998;44:77-87

 

19. Medawar C. http://www.socialaudit.org.uk/5001-1.htm

 

20. Medawar C. The antidepressant web. International Journal of Risk and Safety in Medicine 1997;10:75-126 and http://www.socialaudit.org.uk

 

21. Charlton BG. Psychopharmacology and the human condition. J Roy Soc Med 1998;91:699-601

 

22. Young A, Haddad P. Discontinuation symptoms and psychotropic drugs. Lancet 2000; 355:1184 [Full text]

 

23. National Institute for Clinical Excellence Management of depression in primary and secondary care. NICE: London, 2004

 

24. DB Double. The recognition of antidepressant discontinuation reactions.

 

25. Sanz EJ, De-las-Cuevas C, Kiuru A, Bate A, Edwards R. Selective serotonin reuptake inhibiotrs in pregant women and neonatal withdrawal syndrome: a database analysis. Lancet 2005;365:482-487

 

26. Ruchkin V, Martin A. SSRIs and the developing brain. Lancet 2005;365:451-453

 

http://www.uea.ac.uk/~wp276/antidepressant.htm

 

About Duncan Double http://www.mentalhealth.freeuk.com/homepage.htm

 

His blog http://dbdouble.blogspot.com/

[Barbarannamated]

'...physical dependence due to neuroadaptation.' It's validating to see that in print although my mental editor wants to add 'mal' in front of 'adaptation'.

 

Has any study, anecdotal or other, tracked the number of 'mild and self-limiting' reactions to determine that they constitute 'most'. What percentage is 'most'?

 

Good find. Where has this doc been hiding?

 

I need SARCASM emoticon.

[Altostrata]

....

Has any study, anecdotal or other, tracked the number of 'mild and self-limiting' reactions to determine that they constitute 'most'. What percentage is 'most'?

 

Good find. Where has this doc been hiding?

....

 

Barb, the $1M question is what constitutes "most" and what "minority" means when it comes to antidepressant withdrawal.

 

Dr. Double is the moving force behind the Critical Psychiatry Network, based in the UK.

[strawberry17]

Thanks Barbaranimated for linking this for me, yes I have come across Dr Double on the internet, I had no idea he was local to me though.

[Altostrata]

Please note that Dr. Double has modified his views and wrote to me asking he be added to our doctors list.

 

If you talk to him, strawb, I'd be very interested to hear what he says.

[strawberry17]

I'm going to put a comment on his Critical Psychiatry blog linking to my blog and let him know I'm in his area, I'll be surprised if I hear anything back and I don't have a lot of faith but you never know do you?

[Altostrata]

I thinks he's pretty accessible. He might talk to you if you rang him up.

[strawberry17]

Really? I wonder what his number is, I think knowing how things operate here I'd have to get a referral through my doctor.

[Barbarannamated]

Excellent suggestions, Marmite!

 

Perhaps contact him in a journalistic way..?

[strawberry17]

Hi you two

I couldn't find a phone number, but I did find an e mail address, so I have e mailed him and told him about my role here and about my blog and that I'm in his neck of the woods, I also posted something on his web site. I'll let you know if I hear anything back.

strawberry

[strawberry17]

Not a dicky bird.

[Barbarannamated]

Not a dicky bird.

 

Translation?

 

Found it!

 

"So, 'not a dicky-bird' means 'not a word', i.e. silence, especially in the context where a spoken or written word might have been expected - for example, 'Jack said he would write, but I haven't heard a dicky-bird from him for weeks'".

[Sparrow]

Cockney rhyming slang, maybe?

[strawberry17]

Sorry, and Bananaanimated your guess was spot on, nothing, complete radio silence