A few years ago, new drugs for depression were hailed as superior and less toxic than the older generation of pills that they replaced. Selective Serotonin Reuptake Inhibitors (SSRIs) like prozac and venlafaxine were thought to produce fewer side effects than older medications like amitriptyline.
This sounds good, but history should have warned us to be wary of such claims. Ask the thousands of patients still being weaned off diazepam prescriptions started years ago without being told they would become dependent.
The scale of antidepressant prescription is staggering. Seventy million prescriptions were issued last year for the 7 million adults using them. The rapid rise in prescribing is viewed by some as treatment catching up with need, for others this is medicalising problems which have their roots in social problems responsible for the misery and lack of hope that people present to their GP.
However another issue with these medications has emerged; could they be addictive?
The most comprehensive review of the potential for antidepressants to create dependence was unable to identify any research that specifically investigated this. A lack of evidence does not mean dependence isn’t possible, it just means it hasn’t been researched.
The same review did find evidence supporting the potential these medications have to induce withdrawal symptoms such as low mood and insomnia. This demonstrates how difficult and messy it is to discern whether symptoms like low mood should be attributed to withdrawal from an antidepressant or an indication that the person’s low mood has persisted.
So while there is evidence of withdrawal symptoms from these drugs, there is not evidence of dependency. That seems like an academic difference and is of little comfort to those who experience these symptoms.
Researchers and clinicians distinguish dependence from withdrawal, although they are connected. For example, dependence is marked by a need for more of a drug, not something people on antidepressants routinely report. But understandably people experiencing withdrawal symptoms following a reduction in antidepressants might want more of the drug to avoid negative symptoms like insomnia or anxiety.
Beyond withdrawal, some patients believe they have developed dependence on antidepressants. Science and medicine doesn’t have a monopoly on knowledge so it is important we take these testimonies seriously. Professional snobbery is inclined to dismiss these accounts merely as anecdotal, as the lowest form of evidence in our modern hierarchy of evidence which elevates randomised control trials to the top.
Even if we acknowledge that some people will develop dependency on antidepressants, we are unable to predict who is specifically at risk.
The only way we can determine this is when the drug is reduced or stopped, which seems like a blunt and brutal way of finding out. Guidance suggests professionals should advise potential patients about these risks, something that does not happen routinely.
The dilemma for doctors and patients is the lack of alternatives; talking treatment is effective but waiting times are very often too long. So the reality is even if you are informed of the risks, your choice is take or leave it. I can’t think of a comparable example in physical care where this would be acceptable or tolerated, but it seems we lack ambition for our mental health system.
I prescribe a large dose of humility in recognising how little we really know about the potential for these medications to induce dependence. While we wait for the science to catch up with personal testimony of those taking these drugs, we shouldn’t compound their suffering by demoting the status of their evidence.
Ian Hamilton is a senior lecturer in addiction and mental health at the University of York
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