Reprinted from BMJ 1997;314:829 [Full text]
People may become psychologically dependent on antidepressants
Editor–Robert G Priest and colleagues advocate educating patients that discontinuing antidepressant treatment will not be a problem but remarkably do not cite any evidence to support their recommendation.1 They also complain that many lay people regard antidepressants as addictive. They suggest that people may be extrapolating from what they have heard about benzodiazopines. This may be, but it is also common sense to believe that discontinuing taking a drug that is thought to improve mood may be difficult. I think that the general public understands this issue better than the Royal Colleges of Psychiatrists and General Practitioners, which are responsible for the Defeat Depression Campaign.
Of course what Priest and colleagues mean is that there is little evidence of physical dependence caused by antidepressants, but this is not what they say. There are, however, case reports of a withdrawal syndrome.2 Clinical experience is that it can be difficult to withdraw treatment with antidepressants for various reasons. The general public might reasonably expect psychiatrists specialising in disorders of the mind to recognise psychological dependence, base their advice on clinical experience, and use their common sense.
Randomised controlled trials of discontinuation of antidepressant treatment have a relapse rate varying from 92%3 to 36%4 in the placebo group. Relapse rate is significantly reduced by continuing antidepressant treatment. Some patients therefore do maintain their therapeutic gains when antidepressants are withdrawn, but the relapse rate is not insubstantial and seems to support the general public's commonsense view rather than the Defeat Depression Campaign's purist scientific statement. Perhaps the public needs to be suspicious of the motives of a campaign that encourages them to seek medical treatment and also tries to help doctors recognise depression. Patronising misinformation is not constructive.
D B Double, Consultant psychiatrist
West Norwich City Community Team, Norfolk Mental Health Care NHS Trust, Norwich NR6 5BE