The Maudsley Deprescribing Guidelines provide a one-stop shop for direction on taking patients off antidepressants, benzodiazepines, gabapentinoids and z-drugs.
The RACGP’s endorsement of the Maudsley Deprescribing Guidelines as an “accepted clinical resource” marks shifting tides for antidepressant use in Australia.
“Nearly four million people are taking antidepressants across the country but as many are finding out, getting on them is considerably easier than coming off them,” said Australian lecturer at King’s College in London Dr Mark Horowitz.
The Maudsley Deprescribing Guidelines, authored by Dr Horowitz – who himself struggled while coming off antidepressants – and his colleague Professor David Taylor, provide a summary of evidence-based guidance on how to safely stop antidepressants, benzodiazepines, gabapentinoids and z-drugs.
The guidelines offer Australia-specific advice on how to taper off various classes and brands of antidepressant and will be made freely available by the RACGP to up to 500 members with an interest in psychology or addiction medicine. For other practitioners, they are available for purchase online.
They are intended for GPs, pharmacists, nurses, psychiatrists, psychologists and other clinicians to minimise patient distress during the withdrawal process.
According to the authors, a dearth of clinical guidelines – most of which contain “scarce and inadequate information” – has left doctors in the dark, struggling to differentiate between withdrawal effects and resurgence of pathology.
“Without the correct guidance, doctors advise stopping drugs too quickly, are poor at recognising withdrawal effects and often perceive problems coming off as due to an underlying disorder re-surfacing rather than withdrawal effects,” said Dr Horowitz.
“And so, in some cases, their advice is to recommend that their patients go back on the antidepressant and stay on it, sometimes life-long.
“It’s a bit similar to telling someone who becomes anxious when they stop smoking that they need to continue smoking to prevent their anxiety returning. When really what they need to do is to stop the drug more carefully.
“Antidepressants and cigarettes are not the same sort of drug of course, but the point is that withdrawal effects need to be taken into account.”
The evidence vacuum is the result of drug sponsors funding most antidepressant research, resulting in a wealth of evidence on starting the drugs, without any consideration of how to stop them.
Speaking to The Medical Republic, chair of the RACGP’s psychological medicine special interest group Dr Cathy Andronis said it was part of a GP’s role to regularly consider deprescribing, and work with patients who may wish to stop mediation explore other options.
“We should be reviewing regularly and adjusting our management in collaboration with the patient,” she told TMR.
“Patients are the experts on themselves and intuitively know what is or isn’t working.
“The job of the GP is to understand why they want to cease their medication and what other options are available to improve their wellbeing.”
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Dr Andronis said tailoring and monitoring the deprescribing process was important to reduce withdrawal symptoms, which often present early, and prevent relapse, which generally presents after many weeks or months.
“Patients often come to rely on the emotional numbing effect of antidepressants as a chemical emotional regulation,” she said.
“We know that emotional regulation can be best managed in the longer term by relaxation, mindfulness and grounding exercises that are life changing and under the control of individuals, so valuable to learn, practice and consolidate.
“This leads to better resilience and life satisfaction, so should not be overlooked.”
Dr Andronis added that medication was only one component of holistic care and that psychological therapies should be first line treatment.
RACGP president Dr Nicole Higgins said that while antidepressants were often helpful, they were not generally advised for use longer then 6-12 months.
“I urge anyone who wants to stop using antidepressants to see their GP for evidence-based support,” she said.
Dr Horowitz said he hoped the advice endorsed in the guidelines would catch on.
“We hope this support by the college is the first step towards safer practices for stopping these medications and that future clinical education will incorporate the principles and practices outlined in the book,” he said.
“We also hope that national, state and local hospital guidance for safely stopping these medications is influenced by the gradual, hyperbolic approach promoted in the guidelines.”
