A recent review published in JAMA Psychiatry has sparked concern among mental health professionals and advocates. This review, authored by several academics with known financial ties to drug manufacturers, risks underestimating the potential harms associated with long-term antidepressant use by primarily focusing on short-term studies funded by the pharmaceutical industry.
There is a mounting acknowledgment that discontinuing antidepressants, particularly after prolonged use, can lead to severe and often debilitating withdrawal symptoms. The UK government has recognized this issue as a significant public health concern. For years, medical guidelines, including those from Nice (England's National Institute for Health and Care Excellence), have inaccurately characterized withdrawal effects as brief and mild. This misrepresentation was largely based on studies conducted by drug companies, which typically involved participants taking the medication for only eight to twelve weeks.
As a result of these misleading guidelines, many healthcare professionals did not take seriously the severe, long-lasting withdrawal symptoms reported by patients. Our recent research sheds light on this discrepancy, revealing a direct correlation between the duration of antidepressant use and the severity of withdrawal symptoms experienced. In a survey of NHS patients, we discovered that individuals who had been on antidepressants for over two years were:
Ten times more likely to experience withdrawal effects. Five times more likely to report severe withdrawal symptoms. Eighteen times more likely to have long-lasting symptoms compared to those who had taken the medication for six months or less.For patients who had used antidepressants for less than six months, withdrawal symptoms were generally mild and brief. Approximately three-quarters reported either no symptoms or mild ones lasting less than four weeks. In contrast, among long-term users (more than two years), two-thirds reported experiencing moderate to severe withdrawal effects, with one-quarter indicating severe symptoms. Alarmingly, nearly one-third of long-term users reported symptoms persisting for more than three months.
According to a BBC investigation, approximately two million people in England have been on antidepressants for over five years. In the United States, at least 25 million individuals have taken antidepressants for more than five years. The findings of short-term studies—often based on eight to twelve weeks of use—do not accurately reflect the experiences of millions of long-term users who face significant challenges when stopping their medication.
In light of this ongoing issue, the recent review published in JAMA Psychiatry draws on short-term trials, many of which are funded by pharmaceutical companies. The authors concluded that antidepressants do not cause significant withdrawal effects. Their analysis included eleven trials that primarily focused on participants who had taken antidepressants for only eight to twelve weeks. They reported a marginal increase in withdrawal symptoms among those who stopped taking antidepressants, claiming this did not indicate a clinically significant withdrawal syndrome.
Furthermore, the authors suggested that withdrawal symptoms might be attributed to the nocebo effect, where negative expectations lead to worse experiences. However, we believe that this perspective significantly underrepresents the actual risks of withdrawal for the millions of people on these medications for extended periods.
The review failed to establish a clear relationship between the duration of antidepressant use and withdrawal symptoms due to an insufficient number of long-term studies. Additionally, it likely underestimated short-term withdrawal effects by incorrectly assuming that withdrawal-like symptoms experienced when stopping a placebo or continuing an antidepressant negate the withdrawal effects from actual antidepressants.
While it is true that antidepressant withdrawal symptoms can overlap with other side effects, this overlap does not imply they are equivalent. Symptoms reported after discontinuing a placebo tend to be milder compared to those experienced when stopping antidepressants, which can be severe enough to necessitate emergency care.
The review omitted several well-conducted studies that documented high rates of withdrawal symptoms. For instance, a study conducted in the United States found that over 60% of individuals who stopped taking antidepressants after eleven months experienced withdrawal symptoms. The authors of the review suggest that any depression observed after stopping antidepressants is merely a return of the original condition, not withdrawal symptoms. This conclusion is based on limited data from only five studies.
We hope that the uncritical dissemination of this review, which relies on the same short-term studies that previously led to under-recognition of withdrawal effects, does not hinder the growing acknowledgment of this problem. It is crucial for the health system to address the needs of potentially millions of individuals who may be severely impacted by antidepressant withdrawal.
Mark Horowitz, Visiting Clinical Research Fellow in Psychiatry, UCL, and Joanna Moncrieff, Professor of Critical and Social Psychiatry, UCL, have contributed significantly to this discourse and advocate for a more nuanced understanding of the withdrawal effects associated with antidepressants.
