Fresh concerns have been raised over long-term use of antidepressants, with a new summary of evidence revealing limited benefits and higher health risks, prompting calls for treatment reviews every six months.
Researchers from Adelaide University and The University of Queensland were involved in the clinical overview, which has been published in the Australian Journal of General Practice.
They found there was little robust evidence to suggest that antidepressants prevent relapse beyond 12 months and believe the widely cited benefits supporting long-term use may be overstated due to a fundamental flaw in research design.
“Much of the evidence supporting long-term antidepressant treatment comes from so-called relapse prevention trials,” said Associate Professor of Psychiatry Mark Horowitz, at Adelaide University’s School of Medicine.
“These studies typically compare patients who continue medication with those who stop abruptly or rapidly. Because they don’t distinguish between withdrawal symptoms and the return of depression, we believe many apparent relapses may actually be withdrawal effects from the medication.”
Short-term trials of antidepressants reveal only small differences in improvements when compared to a placebo. There was also some research indicating that the apparent benefit of long-term treatment may be due to the suppression of withdrawal symptoms rather than the true prevention of depression or anxiety.
The research also highlights growing evidence of risks associated with long-term use, including sexual dysfunction, emotional numbing, cognitive impairment, weight gain and increased risk of physical health problems in older adults.
Withdrawal symptoms can be severe and long-lasting, sometimes persisting for months or even years.
“Symptoms such as anxiety, low mood and insomnia occur in both withdrawal from antidepressants and a return of depression. As these studies do not distinguish between them, they will mis-categorise withdrawal as a return of depression as this is the focus of such studies,” said Associate Professor Horowitz.
“If the same approach was taken with cigarettes and feeling worse on stopping them was interpreted as evidence that people should continue smoking them, we know that would be absurd. But the same sort of evidence is used to recommend long-term antidepressants.
“Guidelines need to be updated to reflect that there are no good studies which show that antidepressants are effective in the long term.”
Nearly one in seven Australians are taking antidepressants, with a third of people staying on them for more than a year. Most of this medication is being prescribed by general practitioners, often in situations where guideline criteria may not be fully met.
“Concerningly, the risk of withdrawal effects appears to increase with the duration of use – one reason for stopping antidepressants sooner rather than later,” said Associate Professor Horowitz.
Researchers say many patients recover from depression without long-term medication and are calling for a re-think of how depression is treated long-term, noting that non-drug approaches such as psychological therapies may offer more durable benefits.
“As GPs, we are becoming more aware of the limited benefits and possible harms associated with long-term antidepressant use and the need to reconsider the ‘set and forget’ approach to prescribing these medicines,” said Professor Katharine Wallis, Head of General Practice at The University of Queensland Medical School.
“There is increasing emphasis on supporting patients to make informed choices about antidepressant use and to stop antidepressants by slowly decreasing the dose.”
Other recommendations include addressing misconceptions about depression being caused by a ‘chemical imbalance’, recognition that worsening symptoms on stopping antidepressants may be linked to withdrawal rather than relapse and wider adoption of gradual weaning strategies when discontinuing medication for long-term users.
Australian Journal of General Practice
Systematic review
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