UK's NICE health guidelines now caution about severe and prolonged antidepressant withdrawal symptoms

[Altostrata]

The United Kingdom's medical treatment arbiter National Institute for Health and Care Excellence (NICE) just revised its guidelines for the use of antidepressants to treat depression.

 

You might print out this article from the UK's Royal Pharmaceutical Society journal for your doctors and pharmacists.

 

https://www.pharmaceutical-journal.com/news-and-analysis/news/nice-amends-depression-guideline-highlighting-severe-and-long-lasting-withdrawal-symptoms/20207226.article

 

Quote

 

NICE amends depression guideline highlighting 'severe' and long-lasting withdrawal symptoms

 

The Pharmaceutical Journal 22 OCT 2019 By Julia Robinson

 

The National Institute for Health and Care Excellence (NICE) has amended its guidelines on depression in adults to highlight that antidepressant withdrawal symptoms may be severe in some patients.

 

The guidance, which was published in 2009 originally said that antidepressant withdrawal symptoms were usually “mild” and “self-limiting” over the course of a week.

 

The amendment, dated September 2019, clarifies that there can be “substantial variation in people’s experience” and that symptoms can persist for months or more and be “more severe for some patients”.

 

It also advises that before stopping antidepressant medication, patients should discuss the decision with their practitioner.

 

The amendments are in line with a position statement released by the Royal College of Psychiatrists (RCPsych) in May 2019.

....

NICE delayed the release of a planned full guideline update due in 2018 after a coalition of 14 organisations, including the Royal College of Psychiatrists, British Psychological Society and the charity Mind, said the draft of the updated guideline was underpinned by a flawed methodology, a lack of transparency and several inconsistencies.

 

They added that, if the guideline was published as it was, it could “seriously impede the care of millions of people in the UK suffering from depression, potentially even causing clinical harm” and demanded a full revision.

....

 

 

[bubbles]

I believe this is the NICE document https://www.nice.org.uk/guidance/cg90/chapter/1-Guidance#care-of-all-people-with-depression

 

The tapering section 1.9.2 does talk about problems stopping but the recommended taper period is very short.

[VincentV]

This is a good beginning.

On 10/28/2019 at 10:22 PM, bubbles said:

The tapering section 1.9.2 does talk about problems stopping but the recommended taper period is very short.

 

Yes it does. I believe they have put out a call for more research on tapering. I'm sure that they will eventually revise these but not until "harder" evidence for longer tapering becomes available. We need to agitate for more research. Hopefully acknowledging the problem will lead to wider acknowledgement and more official data collection which will then lead on to more research. Its an extremely long battle. For some its already lasted 30 years already. I have hope though that within the next ten years we'll at least see more sensible tapering advice and more useful help depensed from Drs. I believe some kind of new helpline for those who are dependent on prescribed medication is due to be set up shortly, though I'm a little sketchy on the details. 

 

 

[bubbles]

8 hours ago, VincentV said:

have hope though that within the next ten years we'll at least see more sensible tapering advice and more useful help depensed from Drs. I believe some kind of new helpline for those who are dependent on prescribed medication is due to be set up shortly, though I'm a little sketchy on the details. 

 

I think research is needed and I'm surprised that they're sticking to such a rapid taper when they're acknowledging that people suffer, presumably when following those guidelines. 

 

[Superwoman]

Below are the past guidelines from April 2018.  I copied this from a topic in the tapering section.  This way people can compare the new guidelines with the old guidelines side by side w/o having to back and forth between two different posts.  I hope no one minds that I copied it here. 

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  •  

Posted May 28, 2019

These guidelines were updated April 2018.

 

https://www.nice.org.uk/guidance/CG90

 

Here is the updated ONLINE section on withdrawal:

1.9.2 Stopping or reducing antidepressants

1.9.2.1 Advise people with depression who are taking antidepressants that discontinuation symptoms^[16] may occur on stopping, missing doses or, occasionally, on reducing the dose of the drug. Explain that symptoms are usually mild and self-limiting over about 1 week, but can be severe, particularly if the drug is stopped abruptly.

1.9.2.2 When stopping an antidepressant, gradually reduce the dose, normally over a 4-week period,although some people may require longer periods, particularly with drugs with a shorter half-life (such as paroxetine and venlafaxine). This is not required with fluoxetine because of its long half-life.

1.9.2.3 Inform the person that they should seek advice from their practitioner if they experience significant discontinuation symptoms. If discontinuation symptoms occur:

• monitor symptoms and reassure the person if symptoms are mild

• consider reintroducing the original antidepressant at the dose that was effective (or another antidepressant with a longer half-life from the same class) if symptoms are severe, and reduce the dose gradually while monitoring symptoms.

 

From the full National Clinical Practice Guideline 90 for CG90 (707-page pdf file available at the bottom of this page https://www.nice.org.uk/guidance/cg90/evidence  )

 

11.8 ANTIDEPRESSANT DISCONTINUATION SYMPTOMS

The following sections on antidepressant discontinuation symptoms marked by asterisks (**_**) are from the previous guideline and have not been updated except for style and minor clarification.

 

11.8.1 Introduction

There can be confusion over the use of the terms‘addiction’, ‘psychological depend- ence’ and ‘physical dependence’ when referring to drugs. This has been associated with concern in the mind of the public about whether antidepressants (and indeed other psychotropic drugs) may be addictive. The DSM–IV (APA, 1994) definition of ‘substance dependence’ consists of a combination of psychological, physiological and behavioural effects that together comprise what is commonly called addiction. The diagnosis of substance dependence/addiction requires at least three of the following:

 

(1)  tolerance (marked increase in amount; marked decrease in effect)

(2)  characteristic ‘withdrawal’ symptoms or substance taken to relieve withdrawal

(3)  substance taken in larger amount and for longer period than intended

(4)  persistent desire or repeated unsuccessful attempt to quit

(5)  much time/activity taken to obtain, use and recover from the substance

(6)  important social, occupational, or recreational activities given up or reduced

(7)  use continues despite knowledge of adverseconsequences (for example, failure to fulfill role obligation, using when physically hazardous).

Physical dependence refers to the first two features (tolerance to the effect and ‘withdrawal’ symptoms) and substance dependence/addiction can be with or with- out physical dependence. There is no evidence that antidepressants cause psycho- logical dependence or adverse behavioural and functional effects in the sense defined by criteria 3 to 7 above, and therefore antidepressants are not ‘addictive’ in the accepted sense of the word used to describe dependence on drugs like alco- hol or opioids. There is also no good evidence to support tolerance to the therapeu- tic effect of antidepressants (Zimmerman & Thongy, 2007) and therefore the debate about whether or not antidepressants cause physical dependence centres on the symptoms some people experience when stopping antidepressants. It is impor- tant to understand the nature of the phenomenon and its implications for people with depression who have antidepressant treatment. In this guideline these are described as ‘discontinuation symptoms’, which is a term that makes no assumption about their status.

Discontinuation symptoms can be broadly divided into six groups; affective (for example, irritability), gastrointestinal (for example, nausea), neuromotor (for exam- ple, ataxia), vasomotor (for example, sweating), neurosensory (for example, paraes- thesia), and other neurological (for example, dreaming; Delgrado, 2006). They may be new or hard to distinguish from some of the original symptoms of the underlying illness. By definition they must not be attributable to other causes. They are experi- enced by at least a third of patients (Lejoyeux et al., 1996; MHRA, 2004) and are seen to some extent with all antidepressants (Taylor et al., 2006). Of the commonly used antidepressants, the risk of discontinuation symptoms seems to be greatest with paroxetine, venlafaxine and amitriptyline (Taylor et al., 2006). There have been prospective studies, including some RCTs and quasi-randomised trials, which have examined the effect of discontinuation in people taking paroxetine and other anti- depressants. These studies suggest an increase in discontinuation symptoms in those taking paroxetine compared with escitalopram (Baldwin et al., 2006), fluoxetine (Rosenbaum et al., 1998; Bogetto et al., 2002; Hindmarch et al., 2000; Judge et al., 2002; Michelson et al., 2000), sertraline (Hindmarch et al., 2000; Michelson et al., 2000), and citalopram (Hindmarch et al., 2000). In addition two RCTs measuring discontinuation symptoms when stopping antidepressants after 8 weeks of treatment found that these were more common with venlafaxine than escitalopram (Montgomery et al., 2004) and moderate and severe symptoms were more common with venlafaxine compared with sertraline (Sir et al., 2005).

 

The onset is usually within 5 days of stopping treatment, or occasionally during taper or after missed doses(Rosenbaum et al., 1998; Michelson et al., 2000). This is influenced by a number of factors, which may include a drug’s half-life. Symptoms can vary in form and intensity and occur in any combination. They are usually mild and self-limiting, but can be severe and prolonged, particularly if withdrawal is abrupt. Some symptoms are more likely with individual drugs, for example dizziness and electric shock-like sensations with SSRIs, and sweating and headache with TCAs (Lejoyeux et al., 1996; Haddad, 2001).

 

11.8.2 Factors affecting the development of discontinuation symptoms

**Although anyone can experience discontinuation symptoms, the risk is increased in those prescribed short half-life drugs (Rosenbaum et al., 1998), such as paroxetine and venlafaxine (Fava et al., 1997; Hindmarch et al., 2000; MHRA, 2004). They can also occur in patients who do not take their medication regularly. Two-thirds of patients prescribed antidepressants skip a few doses from time to time (Meijer et al., 2001). The risk is also increased in those who have been taking antidepressants for 8 weeks or longer (Haddad, 2001); those who developed anxi- ety symptoms at the start of antidepressant treatment (particularly with SSRIs); those receiving other centrally acting medications (for example, antihypertensives, antihistamines, antipsychotics); children and adolescents; and those who have experienced discontinuation symptoms before (Lejoyeux & Ades, 1997; Haddad, 2001).

Discontinuation symptoms may also be more common in those who relapse on stopping antidepressants (Zajecka et al., 1998; Markowitz et al., 2000).

 

11.8.3 Clinical relevance

The symptoms of a discontinuation reaction may be mistaken for a relapse of illness or the emergence of a new physical illness (Haddad, 2001) leading to unnecessary investigations or reintroduction of the antidepressant. Symptoms may be severe enough to interfere with daily functioning. Another point of clinical relevance is that patients who experience discontinuation symptoms may assume that this means that antidepressants are addictive and not wish to accept further treatment. It is very

important to counsel patients before, during and after antidepressant treatment about the nature of this syndrome.**

 

11.8.4 How to avoid discontinuation symptoms

Although it is generally advised that antidepressants (except fluoxetine) should be discontinued over a period of at least 4 weeks, preliminary data suggest that it may be the half-life of the antidepressant rather than the rate of taper that ultimately influences the risk of discontinuation symptoms (Tint et al., 2008).

 

When switching from one antidepressant to another with a similar pharmacolog- ical profile, the risk of discontinuation symptoms may be reduced by completing the switch as quickly as possible (a few days at most). A different approach may be required at the end of treatment where a slower taper is likely to bebeneficial.

 

**The half-life of the drug should be taken into account. The end of the taper may need to be slower as symptoms may not appear until the reduction in the total dailydosage of the antidepressant is substantial. Patients receiving MAOIs may need dosage to be tapered over a longer period. Tranylcypromine may be particularly diffi- cult to stop. It is not clear if the need for slow discontinuation of MAOIs, and partic- ularly tranylcypromine, is due to the discontinuation syndrome or the loss of other neurochemical effects of these drugs. Since it is not possible to disentangle these phenomena, the clinical advice is that patients on MAOIs and those at-risk patients need a slower taper (Haddad, 2001).**

 

Many patients experience discontinuation symptoms despite a slow taper. For these patients, the option of abrupt withdrawal should be discussed. Some may prefer a short period of intense symptoms over a prolonged period of milder symptoms. [NO CITATION]

 

11.8.5 How to treat

**There are no systematic randomised studies in this area. Treatment is pragmatic. If symptoms are mild, reassure the patient that these symptoms are not uncommon after discontinuing an antidepressant and that they will pass in a few days. If symptoms are severe, reintroduce the original antidepressant (or another with a longer half-life from the same class) and taper gradually while monitoring for symptoms (Haddad, 2001; Lejoyeux & Ades, 1997).**

 

11.8.6 From evidence to recommendations

Since the previous guideline, the evidence base for discontinuation symptoms with antidepressants is largely unchanged. Practitioners should ensure that they discuss the issue fully with all patients, and consider prescribing antidepressants that are associ- ated with fewer discontinuation symptoms (for example, fluoxetine), particularly for patients who have had previous experience of these. The previous recommendations are therefore retained, but rewritten to fit the updated NICE style.

 

11.8.7 Clinical practice recommendations

 

11.8.7.1 When prescribing antidepressants, explore any concerns the person with depression has about taking medication, explain fully the reasons for prescrib- ing, and provide information about taking antidepressants, including:

●  the gradual development of the full antidepressant effect

●  the importance of taking medication as prescribed and the need to

continue treatment after remission

●  potential side effects

●  the potential for interactions with other medications

●  the risk and nature of discontinuation symptoms with all antidepres-sants, particularly with drugs with a shorter half-life (such as paroxe-tine and venlafaxine), and how these symptoms can be minimised

●  the fact that addiction does not occur with antidepressants. Offer written information appropriate to the person’s needs.

Advise people with depression who are taking antidepressants that discon- tinuation symptoms179 may occur on stopping, missing doses or, occasion- ally, on reducing the dose of the drug. Explain that symptoms are usually mild and self-limiting over about 1 week, but can be severe, particularly if the drug is stopped abruptly.

 

When stopping an antidepressant, gradually reduce the dose, normally over a 4-week period, although some people may require longer periods, partic- ularly with drugs with a shorter half-life (such as paroxetine and venlafax- ine). This is not required with fluoxetine because of its long half-life: Inform the person that they should seek advice from their practitioner if they experience significant discontinuation symptoms. If discontinuation symptoms occur:

●  monitor symptoms and reassure the person if symptoms are mild

●  consider reintroducing the original antidepressant at the dose that was effective (or another antidepressant with a longer half-life from the same class) if symptoms are severe, and reduce the dose gradually while monitoring symptoms.

[bubbles]

This always makes me wonder:

 

"1)  tolerance (marked increase in amount; marked decrease in effect)

(2)  characteristic ‘withdrawal’ symptoms or substance taken to relieve withdrawal

(3)  substance taken in larger amount and for longer period than intended

(4)  persistent desire or repeated unsuccessful attempt to quit

(5)  much time/activity taken to obtain, use and recover from the substance

(6)  important social, occupational, or recreational activities given up or reduced

(7)  use continues despite knowledge of adverseconsequences (for example, failure to fulfill role obligation, using when physically hazardous)."

 

I have 2, 3, 4 and 7. Withdrawal symptoms, substance taken for years longer than intended, persistent desire to quit, continued use despite knowledge of adverse effects - bruxing, knowledge that it's damaging my bones. But they state that 3-7 are not valid for this class of drugs.

[Hms123]

Feels strange reading this as every GP in the UK i've spoken to about withdrawal says that it doesn't exist/it's impossible.

[Kiasofia]

Came across this: Campaigner who helped draw up official draft guidelines on battling drug dependency reveals why he took a stand.

 

"On its website NICE claims it takes ‘a comprehensive approach to assessing the best evidence that is available’. Yet for the draft of these guidelines it has not done so. It failed to review the many articles on hyperbolic tapering. It has not invited withdrawal experts to give testimony, nor reviewed submissions from patient groups and withdrawal charities."