Drug addiction is a massive societal problem. And one that’s not going away anytime soon.
The impact of risky substances, as they are quaintly referred as, is devastating to mental and physical health, with ramifications that extend far beyond the individuals affected.
But beyond the public persona of this being about alcohol, smoking, methamphetamine, opioids or cocaine, there’s another risky behaviour not being spoken about enough.
It’s about when people stay on prescribed drugs for longer than necessary.
What I’m focusing on here, is the long-term use of anti-depressants.
Did you know?
Australia has one of the highest anti-depressant prescribing rates in the world?
One in seven Australians (around 3.8 million) is taking an anti-depressant, and the numbers are continuing to rise.
Two, sertraline (Zoloft) and escitalopram (Lexapro), are in the top ten drugs prescribed in Australia.
More women than men and those aged 65 years or older (though there are a growing number of younger people) are prescribed anti-depressants and 92% of prescriptions are managed in primary care by GPs.
This is not disputing the fact that anti-depressants are often needed for treating moderate to severe depression and are very effective (in those who respond to the medication).
The recommended length of treatment is 6-12 months. This is long enough to enable the illness to resolve without the risk of relapse.
The issue is less about whether there is any benefit in extending the length of treatment, but whether this could induce potential harm.
It’s estimated that around half of those prescribed anti-depressants remain on them for 2 years or more.
This is because of the number of people who experience unpleasant side effects when they attempt to stop the medication, even after tapering the dose.
How long is too long to be taking an anti-depressant?
I wish I had a simple answer to that question. There isn’t one.
There are some people who experience multiple severe episodes of depression. In this instance, they may be advised to stay on them for the long term.
But not everyone falls into that group.
There are a couple of instances where the depression has successfully resolved, but the medication is continued.
The ‘I feel better on them’ group.
Here, a person was prescribed an anti-depressant for an episode of depression that they have long recovered from, but continues with the medication long after 12 months, because they believe they’re ‘better’ on them. Better in that they feel very well and happier overall.
In some instances, this group are able to continue with their medication because their GP continues to provide the repeat scripts without reviewing the need or having a conversation about deprescribing. The set and forget scenario.
The ‘I’ve tried to stop and felt terrible’ group.
When you want to stop anti-depressant medication it’s important to taper off the dose to avoid the risk of discontinuation effects which can be very unpleasant. These can make the person fearful that their depression has relapsed, so they jump back into taking their meds.
So, how long is too long, what do the discontinuation effects look like, and how should a protracted withdrawal be best managed.
We need a better way to safely deprescribe.
We’re told anti-depressants are not addictive. Which they are not, but the effects of withdrawal can be so unpleasant it can impact your quality of life, and in some instances last long after the drug is long gone from their system.
Anti-depressant discontinuation syndrome.
Yes, this is a recognised syndrome.
It’s a mixed bag of symptoms that vary from person to person in intensity and duration but typically start within 2-4 days of stopping the drug. Typically, they ease over the next couple of weeks but can persist up to a year of longer.
It’s never a good idea to try and go ‘cold turkey’.
Part of the issue is that doctors differ in their belief as to whether this is a real phenomenon or not, and there is still no single recommendation for how it should best be managed.
The symptoms of the discontinuation syndrome are found in the mnemonic FINISH.
Flu-like symptoms (fatigue, headache, muscle aches, sweating)
Insomnia, vivid dreams, or nightmares
Nausea or vomiting
Imbalance (dizziness, vertigo, light-headedness)
Sensory disturbances (burning, tingling, or electric shock–like “brain zaps”)
Hyperarousal (anxiety, agitation, irritability)
What needs to be stated very clearly is that these symptoms DO NOT indicate a relapse of the depressive illness.
In relapse, the symptoms take more than a few days to reappear and are quickly resolved by going back onto the medication.
When I first read about patients experiencing ‘brain-zaps’, I wondered what on earth these could be.
Until I experienced them myself.
We were on holidays overseas and I’d realised shortly after our arrival that I had inadvertently left my anti-depressants behind.
Despite knowing that we would be away for several weeks, I wasn’t too worried, thinking, well, maybe it’s time to come off them anyway.
Everything was fine for the first couple of days.
It was a fabulous trip, and we were enjoying ourselves immensely.
But I started to realise things weren’t quite right, when the brain-zaps started, weird, momentary zappy sensations in my head that were quite disconcerting.
If it had been just those, I might have persisted and waited for them to dissipate, but by the time we got home, I was becoming increasingly irritable, snappy, having difficulty sleeping and dizzy.
My poor husband was wondering what he had done wrong.
But these symptoms were totally unlike what I had experienced during my depressive illness.
The Maudsley Deprescribing Guidelines
I first heard Dr Mark Horowitz speak about how to safely deprescribe from anti-depressants a couple of years ago.
He had been on long-term anti-depressants himself – for fifteen years.
It was his own experience of terrible withdrawal symptoms that led him to conduct research into the problem at King’s College London. This resulted in the Maudsley Deprescribing Guidelines, which have since been endorsed by the RACGP.
At least now, there is a far better understanding of how to safely manage a patient coming off these drugs.
When used appropriately, anti-depressants can be a lifesaver.
I was very grateful to have been prescribed them to treat my own severe depression.
But it worries me that we have such a high prescribing rate here in Australia, and makes me wonder if we are sometimes using anti-depressants inappropriately for other societal challenges?
Not everything needs a pill.
But the traditional Western Medicine approach that I was taught and used was and remains very pharmacologically based.
This has also led to patients expecting a prescription at the end of a consultation.
I’ve heard too many stories of patients complaining they were put on an anti-depressant unnecessarily.
One example I hear many times is when a woman transitions through menopause.
Women can experience a variety of symptoms during this time including brain fog and anxiety and/or depression, but rather than being automatically being prescribed an anti-depressant it would be more helpful to have a conversation about whether or not they would benefit more from MHT.
Dr Matt Fisher is a senior research fellow with the University of Adelaide’s Stretton Institute. He believes that anti-depressants are being prescribed inappropriately for social and psychological distress.
What he’s talking about is modern life, which appears to be getting increasingly stressful, challenging and difficult.
Economic hardship, relationship issues, racism, trauma and domestic violence can cause significant distress and pain.
But medicating a problem doesn’t necessarily fix what is wrong.
In Lifestyle Medicine, we focus on six pillars of health, asking,
“What would keep this person well?”
The six pillars include:
Healthy Nutrition
Physical Activity
Restorative Sleep
Social Connection
Effective Stress Management
And avoiding risky behaviours such as smoking, excess alcohol and taking medication that is no longer warranted.
Managing mental health challenges require far more than just talking a pill.
For example, in a lifestyle medicine consultation you would be asked about:
1. Your eating habits.
It’s well described that consuming a diet that is high in sugar contributes to a risk of symptoms of depression.
The opposite was found by eating a diet low in fresh vegetables and fruit. The SMILES trial conducted by Professor Felice Jacka and team from Deakin University’s Mood and Food Institute was the first random controlled trial (in the world) that demonstrated how changing to a modified Mediterranean style diet improved mental mood and alleviated symptoms of depression over 12 weeks and led to multiple large other studies that confirmed the same thing.
A new study out of UCL and the Barcelona Institute for Global Health and published in the BMJ has also found that following a mediterranean pattern of eating is linked to higher levels of psychological well-being in those aged 50+
I loved this Q and A from the paper.
Q: How can eating fish and olive oil make a 60-year-old feel a greater sense of purpose and independence?
A: It sounds surprising, but your brain and your gut are connected by a non-stop biological communication superhighway. A Mediterranean diet is packed with specific nutrients, like omega-3 fatty acids from fish and polyphenols from extra virgin olive oil, that act as a biological shield. These components physically reduce inflammation in the brain and support a healthy gut microbiome, which is responsible for producing the vast majority of your body’s mood-regulating chemicals. When your brain is structurally protected from chemical stress and inflammation, you naturally experience higher energy levels, a more optimistic future outlook, and a greater sense of personal control.
OK don’t panic.
This doesn’t mean you have to radically overhaul your diet, just adding in more of the good stuff like extra virgin oil or a portion of fish or an extra serve of vegetables, piece of fruit or swapping a can of soda for water can start to make all the difference.
2. Physical activity and stress management.
The one thing I encourage anyone with anxiety, depression or chronic stress to do, is to add in a 20-30 minutes walk outside several times a week. An exercise prescription to spend time outside even for a few minutes has been shown to improve mood, lower blood pressure and stress levels.
Start with what feels manageable, i.e., start low and go slow and build gradually.
3. Restorative sleep.
Disturbed or fragmented sleep disrupts emotional control, coping skills and mood. Your sleep prescription here will also recommend time outside during the day to reset your circadian rhythm and help to restore a better sleep pattern.
4. Social connection.
Having someone to talk to, whether a friend, a colleague or a family member can assist in reducing the sense of social isolation or loss of purpose. A lifestyle medicine practitioner might suggest a social prescription to connect you to other people.
5. Risky behaviours.
When it’s time to safely reduce medication, a lifestyle medicine practitioner will provide you with the emotional support needed to keep you safe as you taper off slowly. It’s a journey taken together, not alone.
Lifestyle medicine is patient-centred, with all strategies employed being evidence-based.
Modern medicine provides us with so many opportunities to be restored to health.
But sometimes prescribed medication is taken for too long.
If you’ve been on anti-depressants for more than a year and want to come off them, it’s time to have that conversation with your GP (hopefully a lifestyle-medicine-trained practitioner) who can advise you how to successfully be deprescribed.
