Karter, 2020 Conversations with clients about antidepressant withdrawal and discontinuation.

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Karter, J. M. (2020). Conversations with clients about antidepressant withdrawal and discontinuation. Therapeutic Advances in Psychopharmacology. https://doi.org/10.1177/2045125320922738

 

Free full text https://journals.sagepub.com/doi/full/10.1177/2045125320922738

 

The issue of antidepressant withdrawal has received increased scientific and public interest over the last several years.¹ Clinical practice guidelines suggesting that withdrawal symptoms tend to be mild and likely to resolve without treatment in a few short weeks are no longer consistent with the evidence,^2–5 and ignore the experiences of some service users.⁶ Indeed, the latest changes to the National Institute for Care and Health Excellence (NICE) depression guidelines recommend that mental health providers inform clients about the potential for severe and long-lasting withdrawal symptoms.⁷ Facing rising rates of long-term antidepressant use across the US and UK,³ the lack of evidence of a favorable risk–benefit ratio for long-term use,⁸ and increased public awareness of these issues,⁹ mental health providers may benefit from guidance concerning how to initiate discussions about the risks of antidepressant withdrawal.

 

By initiating these conversations, mental health providers, including psychiatrists, psychologists, counselors, family physicians, and social workers, can be honest about the limitations of the current science, and play an important role in limiting overuse and mitigating harm to clients. Qualitative research with those taking antidepressants for longer than 9 months who were given medical advice to discontinue antidepressants suggests that fear of recurrence and belief in an underlying serotonin deficiency or chemical imbalance,¹⁰ create barriers to discontinuation and prevent clients from following medical advice.¹¹ Mental health workers can speak directly to these concerns and misunderstandings by providing robust informed consent and accessibly presenting the state of the research on this issue and discontinuation strategies.

The following example of such a conversation is intended to provoke a much-needed discussion among providers about how best to present this information to clients.....

 

Following this discussion, providers should inquire about what may have been unclear and what questions this conversation brought up for them. It is important that providers be open to hearing clients’ frustration with the lack of information about these issues that they may have been provided at the outset, and be honest about the limitations of the current science. Research suggests that the quality of the relationship between the provider and service-user impacts expectations about taking or coming off a medication.¹⁴ As a result, the professional can significantly affect the experience of discontinuation and contribute to the effectiveness of the intervention. Therefore, it is recommended that providers utilize motivational interviewing skills throughout these conversations by expressing empathy, normalizing the ambivalence about discontinuing, and supporting self-efficacy and optimism. For additional information, providers may want to reference the new “Guidance for Psychological Therapists: Enabling conversations with clients taking or withdrawing from prescribed psychiatric drugs,” developed by the Council for Evidence-based Psychiatry (available at: https://prescribeddrug.info/guidance-for-psychological-therapists).¹⁵ Service users may also benefit from peer support and information provided by networks for those discontinuing antidepressants including Surviving Antidepressants, the Withdrawal Project, Inner Compass, and Mad in America.