Today I am learning about antidepressants. I recently had an experience with a client who was hesitant to take antidepressants and had questions for me. Basic ones that, as a therapist, I should be able to answer, I think. I found myself feeling at a loss and uninformed. I know antidepressants help some of my clients. In this case, I felt like it was time to encourage it. But I didn’t feel like I knew enough.
So I decided to do a deep dive and try to inform myself. I opened up a can of worms, for sure. First, I went looking for a simple answer, do antidepressants help? This may seem like a strange thing for a mental health professional to do. But a few years ago, I saw a famous CBT therapist, David Burns, at a workshop claiming they don’t help at all. I was floored and flat-out rejected this. I had seen many of my clients improve. But many of them had been on them for a long time. And some of them were afraid to get off, and some never got off.
Do Antidepressants Work?
I know it’s not a scientific journal, but I checked the New York Times. Sure enough, up came an article from 2018, “Do Antidepressants Work?”
This article summarized how our field was rocked in 2008 by a paper that argued that antidepressants were just a myth. You can check out the paper here.
The gist of this article is that in the past, the results of antidepressants have been overblown. Positive studies are released while it seems someone or something has a hand in burying the less positive ones.
But ten years later, an extensive review was done that redeemed antidepressants somewhat. Small benefits with antidepressants applied to people with major depression only and in the short term. This was found in the most comprehensive review to date.
My takeaways from these two articles:
- Remember, what is published may be biased. We aren’t seeing the less favorable studies it seems.
- We also have to have a better understanding of what we are reading and interpreting. News headlines are not reliable. We should be reading research critically. I plan to try and remember what I learned in my research and statistics classes.
- Research on antidepressants for every kind of depression isn’t solid. It’s most compelling for major depressive disorder. They likely won’t help with mild depression.
- Antidepressants won’t and don’t help everyone.
Are some antidepressants worse than others?
Paroxetine ( Paxil) has the worst withdrawal rate of the SSRIs, and fluoxetine ( Prozac) has the lowest rate. The SNRI venlafaxine ( Effexor) has also been shown to cause withdrawal effects( Osser and Pies 2019).
Are antidepressants addictive?
Next question. Are antidepressants addictive? I get this question often. I assumed the answer was a definitive no. But is it?
I found a SELF article in the archives of my Evernote files that seemed very well written. Not a journal article, but apparently, I can’t trust those anyway. Also, I am not a psychiatrist; I want a way to inform my clients generally. They trust me to have good information. This article, “What I Tell My Patients About Antidepressant Withdrawal,” by Dr. Jessica Gold, seemed pretty straightforward.
Dr. Gold says in this article:
- Some people need to stay on their antidepressants forever, and some don’t.
- The amount of time you need to stay on your antidepressant depends on your number of episodes and the severity.
- The more episodes you have had and the more severe the episode, she says, the longer you need to stay on the antidepressant.
- If you decide to get off your antidepressant, you need to do so with doctor supervision because of antidepressant discontinuation syndrome ( ADS) .
- According to Dr. Gold, 20 percent of patients who stop abruptly will experience ADS.
About ADS
Learning about ADS seemed crucial to the question of addiction, so I read more articles.
Here is what I learned.
ADS can happen a few days after stopping meds and, for some, can occur if you miss just one pill. You may be able to predict whether you will have this syndrome. For example, certain kinds of antidepressants make it more likely. The longer you are on your antidepressant, the more likely you are to have ADS, and if you had ADS before, you are more likely to have it again. Also, if you missed a pill and had symptoms in the past, you are likely to have ADS. Osser and Pies, in The Psychiatric Times article “Sorting out the Antidepressant “Withdrawal” Controversy,” describe ADS as lasting 1 to 10 days and typically resolving spontaneously within 2 to 3 weeks. However, some people report that it lasts up to a year. Dr. Gold indicates doctors fully understand ADS but suspect it has to do with reducing serotonin on the central nervous system.
So what is ADS?
There is an acronym Dr Gold uses -“FINISH” to help you know what it is :
- F: Flu-like symptoms (fatigue, headache, joint aches, sweating)
- I: Insomnia (often with nightmares or vivid dreams)
- N: Nausea (potentially accompanied by vomiting)
- I: Imbalance (dizziness, lightheadedness)
- S: Sensory disturbances (feelings of burning, tingling, and shock-like sensations that are often called “brain zaps”)
- H: Hyperarousal (anxiety, irritability, aggression, mania, physical jerkiness)
So with all of these issues with withdrawal, does that mean antidepressants are addictive?
Dr. Gold says no unequivocally antidepressants are not addictive. You do not develop cravings or a tolerance.
On I go to check and make sure it’s good advice. I find “Are antidepressants addictive in google scholar. Most professionals agree it is not, but some argue you can develop a tolerance and discuss other exciting things.
Here’s what I find:
An article which is a commentary entitled “The Case for Discontinuing Discontinuation Syndrome”.
This article essentially argues that there has been a serious effort to use a misleading term when 40 percent of people have withdrawal symptoms when stopping antidepressants. But I wonder if these are people that suddenly stop or do it gradually? I don’t know. Anyway, the article goes on to argue that it should be called antidepressant withdrawal.
Conspiracy theory? Failure to use the term withdrawal was a deliberate attempt to deceive because of pressure from pharmaceutical companies. :
- Lack of informed choice by patients
- Lack of appropriate taper strategies
- According to the Psychiatric Times article, most prescribers ( 80 percent are not psychiatrists but General Practitioners) of antidepressants indeed discontinue antidepressants TOO rapidly. and
- It’s challenging to find professional guidelines for how to taper antidepressants. However, it looks like this might be changing as of this year.
I have heard and witnessed this in my practice, have you?
Due to a lack of support guidelines and education, patients experiencing withdrawal have created support groups to help them with it. One study studied 13 Facebook support groups filling the void left by professionals not adequately helping with this issue.
Take Away
- Antidepressants do help, but maybe less than we think
- Most professionals agree that antidepressants are not addictive like street drugs or others like some anti-anxiety drugs. It’s argued that you may build a tolerance, but danger during withdrawal and craving for the drug does not happen.
- Getting off antidepressants can be challenging for a good percentage of people because they also have serious withdrawal side effects. Many people don’t get off their antidepressants because of this.
- Due to fear of being honest about the withdrawal from antidepressants, it seems that people have suffered unnecessarily, perhaps because of big pharma. This may have translated into getting on drugs they may not have needed.
- A doctor has to be skilled in knowing how to manage ADS, and it looks like primary care doctors don’t know how to do that for the most part.
How will I use all of this knowledge?
- I will caution my clients about getting off their medications on their own
- I will suggest if they are going off their antidepressants, they do so under a skilled psychiatrist and not their GP
- I will tell my clients that antidepressants are not known to be addictive
- I will tell my clients that people don’t have to be on their medication forever but that some are
- I may give them that SELF article
I will caution them when reading news studies. Headlines are not always accurately interpreting research.
Would you like to learn more about antidepressants?
Here are some more pages on this site about depression. These are just a few of them.
References
Carroll, A. (2018, March 12). Do antidepressants work? Retrieved November 27, 2021, from https://www.nytimes.com/2018/03/12/upshot/do-antidepressants-work.html
Cipriani, A. et all (n.d.). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. Retrieved November 27, 2021, from https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32802-7/fulltext
Gold, J. (2019, November 18). Here’s what I tell my patients who are worried about ‘antidepressant withdrawal’. Retrieved November 27, 2021, from https://www.self.com/story/avoiding-antidepressant-withdrawal
Lugg, William. (2021). The case for discontinuation of the ‘discontinuation syndrome’. Australian & New Zealand Journal of Psychiatry. 000486742110434. 10.1177/00048674211043443.
White E, Read J, Julo S. The role of Facebook groups in the management and raising of awareness of antidepressant withdrawal: is social media filling the void left by health services? Therapeutic Advances in Psychopharmacology. January 2021. doi:10.1177/2045125320981174
Davies J, Read J. A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based? Addict Behav. 2019 Oct;97:111-121. doi: 10.1016/j.addbeh.2018.08.027. Epub 2018 Sep 4. PMID: 30292574.
Osser, D. M., MD, & Pies, R. W., MD. (2019, March 11). Sorting out the antidepressant “withdrawal” controversy. Retrieved November 28, 2021, from https://www.psychiatrictimes.com/view/sorting-out-antidepressant-withdrawal-controversy
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