Coming off Antidepressants
This month - with about 1 in 10 people in the UK on antidepressant drugs, we're asking what's it like to come off of these medications? How well is this change managed? And how can this be improved?
In this episode
02:51 - Generation "snowflake" - fact or fiction?
Generation "snowflake" - fact or fiction?
Helen Keyes, ARU; Duncan Astle, Cambridge University
Are youngsters really getting more hypersensitive? And what's going on in the brain when you chat with your baby? We're teasing apart some of the latest neuroscience news with our local experts. First up, Helen Keyes from Anglia Ruskin University spoke to Katie Haylor about a paper that wanted to find out if adult's and baby's brains sync up when they're directly communicating with each other...
Helen - Functional near infrared spectroscopy, which records levels of oxygenation in the brain, so we're able to get a good proxy for areas of the brain that are activated in kind of real time. What was interesting for this study is that the authors were looking at infants, 9 to 15 months old, and they recruited 42 infants initially. Half of those straight away were too wriggly and had to be excluded. And another 3 of those just refused flat out to wear the caps, so the authors ended up with 18 infants in this study.
And they had the same adult, the one researcher, interacted with these infants individually for five minutes. So they were reading with them, singing songs, directly interacting, and then in the control condition with the same infant, the adult would be turned away, engaging in stories with another adult. So the infant was still hearing the adult's voice, but wasn't directly interacting with them. They found that in the face to face sessions, the babies and adults brains synchronised in several areas, but most interestingly, they synchronised in the prefrontal cortex in areas involved in language processing, perspective taking, and even in prediction of what their behaviour is. So this area involved in a mutual understanding, it was highly synchronised. And when the adult was turned away, this synchronisation disappeared almost entirely.
Another interesting finding was that the infant brain often led here. So it wasn't just that the infant was passively following what the adult was doing. Often the infant's brain activity would predict by a few seconds what the adult's brain was going to do. So there is this really active feedback loop, anticipation and predicting, of the other person's behaviour.
Katie - It sounds very sensible and it's what I would expect to happen when you're directly communicating with a kid. But is this particularly surprising?
Helen - It's not surprising in that it's what we would often observe in natural interaction between parents and children. We get in sync with each other. But this may well turn out to be a nice prediction of things, like language development. Hopefully, as an extension of this study, the authors might be able to show that this early interactive, social communication may well be predictive of language ability in the ways that other observable things are. So a child following pointing behaviour for example, following where it is you're pointing to, does predict later language development. So it is likely that something like this can be used, hopefully, to stimulate that type of development in the brain.
Katie - Duncan?
Duncan - If we took two people and put them in totally separate rooms, and made them watch the same video of a facial expression reacting, and we looked at what happened in their brains, they would start to do similar things and we might conclude from that, that their brains are in sync, but it's because they're really watching the same sort of visual input. So in this case, you could imagine that if there's general mirroring of behaviour, then you could start to get what looks like syncing of the brain. That's one way of characterising it. But really it's about the kind of mimicking and the mirroring of physical behaviour.
Katie - So the kids might just be copying, is that what you're saying?
Duncan - Yeah, and vice versa, that the parents then copying the kid and vice versa, and that then gives the appearance in the brain activity of a syncing. But it's really just each person's brain responding says something quite similar that they're seeing.
Katie - Do you think, Helen, that could be the case in this study?
Helen - So firstly, the idea that two people watching something in two different rooms and their brains having similar response, they're not really in sync are they? They're just both responding to the same thing. So there's a huge literature around this showing that those kind of shared responses are really special. They're not shared with each other, but the similar response you and I might have when we understand a situation in a similar way is different from if you and I just heard some random noises playing. So it's not just that your brain is being stimulated, it's that the understanding part of your brain is being stimulated in a similar way to mine. So what this study is getting at is how that develops. So we're not saying that there's something about you and I being in the same room as each other that is necessarily syncing up our brains together. It's how do we develop that shared understanding so that when we do grow up, we might respond in a similar way to each other. Kind of across the spectrum, where we have a similar understanding to each other.
According to the Collins English dictionary, “snowflake generation” is termed as “the generation of people who became adults in the 2010s, viewed as being less resilient and more prone to taking offence than previous generations”. But is it really true? That’s the question that the paper cognitive neuroscientist Duncan Astle's been looking into for us this month has set out to answer.
Duncan - Hypersensitivity is part of a particular personality trait called narcissism. And so using some large cohort studies, we can start to ask the question whether indeed is the case that our level of hypersensitivity changes as we age, and whether there have been intergenerational changes in the level of hypersensitivity.
Katie - I'm conscious that narcissism and hypersensitivity can be quite loaded terms. Can you give us the scientific definition of what they mean?
Duncan - So in this case, the measure was taken from an in-depth interview, after which the interviewer completed something called the California Adult Q-sort, which is a personality questionnaire. And in it there were items like "is thin-skinned, sensitive to anything that can be constrained as criticism or a personal slight". And so they have individuals who are aged between 13 and 77 years old and these are the same individuals that are tracked over time. So it's not massive numbers of people. It's just over 700 in total. But the exciting thing is that they've tracked them over the life span. And because these are taken from different cohorts at different points in time, they can then start to ask their intergenerational question.
Katie - Oh, I see. So would a 21 year old in one decade show similar results to a 21 year old in another decade?
Duncan - Yeah, two separate questions. What is the impact of getting older on your narcissism and, have there been intergenerational changes in the level of narcissism? So the results are in. Firstly, men are more hypersensitive than women. You may or may not find that surprising. And people generally get less hypersensitive as they get older, especially when they get past 40. So you, as an individual, can expect to get less hypersensitive the older you get. But crucially, hypersensitivity is decreasing across successive generations.
Katie - That's so interesting. That's not what I thought you were going to say.
Duncan - No, exactly. So counter to the prevailing view of our young people today, they're so sensitive and blah, blah, blah and snowflake generation. Actually the data show that the opposite trend is happening.
Katie - And it's also interesting that you said 40 was the cutoff. Because anecdotally I've heard people say, as I get older, I care less if people think I'm such and such, or the opinions of others about me matters less.
Duncan - That's true. But if you look at the data, there's a particular inflection point at 40. And what happens at 40? I don't know why you suddenly stopped caring. I don't know. But that seems to be the critical age in the data. But it's also really interesting to think why is that? Maybe it's that we gradually have more control over our own lives as time goes on. You know, we adjust our own social circles, who we follow on social media, the bubbles that we enter ourselves into, so gradually over time maybe we are less exposed to views that we find irritating and personally offensive or maybe it's that we generally care less, the older we get. We have more perspective. We have a bit of a broader view on things and we're less bothered about individual comments.
Katie - Do we know anything about whether it correlates with life stressors, those like really big events, having children or the death of a parent or you know, something really monumental?
Duncan - No, we don't. So these data was so hard to come by that it means that there's not a lot else in there that we know about these individuals. The other interesting finding, I guess, is that the fact that across generations people are getting less hypersensitive and the authors actually don't really provide much of an account for why that could be. But we can all imagine, maybe it's for instance the advent of the internet, being exposed much more regularly to people who might say something to you that's slightly offensive, and gradually over time you become sort of slightly desensitized to all of that.
Katie - What do you make of these overall?
Duncan - A really interesting thing is why it contrasts so much with the story that's present in the popular media, and that's present in Collins English dictionary, which is that young adults are gradually becoming more and more sensitive and people weren't like that in the olden days because the data actually say the opposite. And I just wonder whether that's because it's easy to dismiss arguments if you can easily dismiss the individual as being too hypersensitive. So we're living through a period of immense change in terms of things like climate change, all sorts of social and demographic changes, and I wonder whether it's easier to dismiss some of the controversies and arguments surrounding that if you can just characterize the people who are espousing those views as being snowflakes.
Katie - Helen?
Helen - I think in the context of what you're saying about the popular media and its portrayal of young people as a snowflake generation and why this might be almost a useful way of dismissing people, I think that's really also interesting in terms of the gender findings. That certainly the popular media would portray at women as being more hypersensitive or thin skinned when indeed this study shows quite the opposite. And it may link in well there as an easy way to dismiss legitimate points that people are raising.
Duncan - I think one encouraging thing is that the data suggests that people are gradually becoming more accommodating of each other's perspectives, and ironically, probably the people who are most likely to use the term snowflake, according to the data, are the people who are probably the least accommodating or the most hypersensitive.
14:12 - Being prescribed antidepressants
Being prescribed antidepressants
Dr Sarah Smith, Cambridgeshire GP
Adam Murphy chats to GP Sarah Smith about her experiences prescribing antidepressants. First up, Adam asked, how might someone actually be feeling when they come to see a GP?
Sarah - So an average patient would perhaps come in saying that they're feeling lower in mood, sometimes they're sad and emotional and might be crying more. They can often feel tired and some people don't sleep very well. They can have increased or decreased appetite. And then with that, either some weight gain or some weight loss. And often just feel that they're not enjoying things as much, less motivated to get things done, sometimes feeling more hopeless with reduced self esteem.
Adam - How would you decide whether or not that person would need, say medication for the problem?
Sarah - Guidelines suggest that in most cases of mild to moderate depression, we can manage that with some sort of counselling or talking therapy. One problem is that we often don't have enough counsellors or psychologists at our fingertips to for someone to be seen within the next two or three weeks. And sometimes you can be on waiting lists for some therapies for several months. So for some people, they might need a depression medicine to just help prop them up while we're waiting for those other therapies to happen. And then we see some of the more severe depressions where it's appropriate to prescribe an antidepressant straight away.
Adam - And then what kind of antidepressants are there that you could prescribe?
Sarah - Nowadays we tend to use selective serotonin reuptake inhibitors, SSRI antidepressants, and they're quite nice because they have less side effects than the older-fashioned tricyclic antidepressants that we use historically. We pick and choose SSRI antidepressants depending on what the person's coming to see us with. So we might pick a certain one if they're more depressed and anxious or if they've got depression alone, obsessive compulsive disorder, or post traumatic stress disorder, we might pick a different one. And then we have others that we might use in cases of anorexia with depression, or in people that are depressed and can't sleep. So we've got several that we can choose from.
Adam - Do we know much about how these different antidepressants work?
Sarah - Yeah, so the more modern SSRI antidepressants help to lift our serotonin levels in our brains up. It's a neurotransmitter chemical in the brain, which sends messages from one nerve to another nerve. Because what happens normally is the serotonin is absorbed back into the cells. And what it does is it stops that process from happening. So there's more serotonin washing around and sending messages to the right nerve cells in our brain. If we have more serotonin washing around, we tend to feel more cheerful and upbeat, helps our mood, helps our emotions and helps our sleep.
Adam - And what kind of side effects do people have? And can you like make a path through antidepressants if one isn't working?
Sarah - Yes. So we warn people at the very beginning of taking them that they might feel a bit of nausea for the first week or 10 days. They might feel a little bit spaced out and not to worry if those simple things happen because it will pass. We always warn people to come and tell us if they're getting any major side effect problems or if they get an increase or sudden onset of any suicidal thoughts. And then we talk those through and then decide whether we need to change their antidepressant. If we've perhaps tried two or three different things and we're still not winning, we might ask the psychiatrist for their opinion, and then we can move forward that way.
Adam - How long would a course tend to be?
Sarah -If we go onto an antidepressant, it's sensible to keep taking it for six months. Studies have shown that if you stop it sooner than six months, you're more likely to have a relapse of your depressed mood. So we tend to advise people that when we're starting them on them as well. And ask people to come back to talk to us if they want to stop them or come off them so that we can plan it carefully.
Adam - Speaking of that, what is the procedure then when someone wants to, or is ready to come off an antidepressant?
Sarah -People come and have a chat with us and we tend to try and plan a phased reduction of their medication. So if they were taking, for instance, two tablets of a certain antidepressant, we might then suggest they take one for three or four weeks and then perhaps one every other day for a couple more weeks. Gradually wean them off because that's much better to do it that way with less withdrawal symptoms if they do it sensibly.
Adam - When we're talking about withdrawal, what kind of symptoms could people be looking at if they went into withdrawal like that? From an antidepressant?
Sarah -People get a variety of symptoms. They can feel dizzy, tired, they can get blurred vision, sometimes feeling more irritable or anxious. Some people struggle with their sleep and get insomnia, vivid dreams, um, nausea and sometimes tummy symptoms with diarrhoea or tummy aches. So it's sensible to come and have a chat with your GP or your psychiatrist and just plan to come off them very carefully over a four to six week period. And then you shouldn't have any problems, because the risk if you do stop them suddenly, you do generally get some withdrawal symptoms within the first five days. And if you've been on higher doses of antidepressant medicine that can go on for six weeks, so much better to come off them gently and gradually.
20:42 - Difficulty stepping down
Difficulty stepping down
Roma Riaz-Ul-Haq, CPFT Psychiatrist
Psychiatrist Roma Riaz-Ul-Haq is concerned that not enough is understood about coming off these drugs. She spoke with Katie Haylor...
Roma - Unfortunately the evidence is only limited, and most of the evidence that we are relying on is anecdotal, coming from influential professionals who have lately come up and shared their own personal experience, how difficult it was for them to come off the antidepressants. Also, some of the surveys that have been done lately to know people's experiences. Yes, there is a difficulty when people stop antidepressants suddenly. However, this is something that can be dealt with, and people have come off medication successfully and are living normal day to day life.
Katie - So what rough proportion of the people that you see who are on antidepressants, might struggle to come off them?
Roma - It's hard to put that in numbers, but there are certain factors that influenced that. First of all, it varies from person to person. Secondly, a lot of it is to do with how the antidepressants act. Some of the antidepressants take a longer time to be released in the blood and are steady for a longer time, which causes less of a problem with withdrawal. Whereas other antidepressants which break down quickly and are quick to release in the blood, do not last longer in the blood and are more likely to cause withdrawal symptoms.
Katie - Do you know who's most likely to struggle? Does it break down by age or gender or anything like that?
Roma - One of the things that people have experienced is that some of the personal characteristics such as apprehension around stopping medication can affect some symptoms of withdrawal. And the little evidence that we have do not support that age is a factor that contributes to it. So generally speaking, if someone has been taking the antidepressant medication for a longer time, the body gets adjusted to that, which would mean coming off as slow as we possibly can, to give the body enough time to adapt to the new changes.
Katie - Do we know anything about whether withdrawal is related to the severity of the depression? Are we just talking really extreme severe cases of depression where withdrawal's a problem, or is it a problem also in milder cases of depression?
Roma - So far the limited evidence that we have do not support this. There's no link that has proved to be between the severity of depression to severity of withdrawal symptoms.
Katie - Can people get hooked on antidepressants? Does dependence or addiction factor in this conversation?
Roma - To answer that, we need to be very clear about the characteristics of something we can say can cause dependence. First of all, the drugs which cause dependence do cause cravings if they're not taken. Secondly, there's a need to take more in order to get the same effect. Fortunately, with antidepressants it does not come with those properties so they do not cause dependence.
Katie - But I guess that doesn't necessarily mean there isn't a fear around the subject.
Roma - I think a lot of fear generally patients do express about stopping medication is that, firstly, they think the depression would come back. Secondly, a lot of it is to do with the apprehension around withdrawal symptoms, what they might start feeling or experiencing once the medication is stopped. But we as clinicians do empower the patients, try and educate them, try and monitor them to make the right choices.
Katie - But are those symptoms pretty obviously different from relapse into depression? Because I guess that's another thing you absolutely want to avoid if you can.
Roma - So that's one of the challenges clinically to differentiate relapse from withdrawal. Now we know some of the symptoms do overlap, like some of the mood symptoms, some of the cognitive symptoms, some of the physical symptoms. However, what's crucial is that with withdrawal, the onset of symptoms is usually within hours rather than days or weeks. And also the physical symptoms are more pronounced, more distinguished, as compared to the relapse. But yeah, this is one area which needs careful monitoring, it needs to be explored more, patients need to feel confident, the experiences that they're going through what it actually is.
Katie - Could you summarise the areas in which you think we really do need to learn more?
Roma - It's from the very basics, really. We need to learn more about what are the mechanisms of action in terms of withdrawing from antidepressants. And I think from a realistic and a practical perspective, as a clinician, I would really like to have more answers to the questions that I get asked about why it's happening, how long it would take, what are they exact guidelines to reduce medication. There's a lot that needs to be explored.
27:27 - Withdrawal support - what works?
Withdrawal support - what works?
Professor Tony Kendrick, Southampton University
Katie Haylor spoke to primary care professor Tony Kendrick from the University of Southampton about trial currently underway to better understand how to help those trying to step down from their antidepressant medications. First up Katie asked Tony, how much do we actually understand the science of withdrawing from antidepressants?
Tony - We have quite a lot of evidence, but it's certainly not perfect. We could get more evidence in terms of both the proportion and numbers of people who get problems when they stop antidepressants. And also what's actually going on inside their head when they stop antidepressants. So most of the evidence on the numbers and proportion of people who get problems is from surveys, usually asking people after the event whether they had problems, rather than real time measurement of a whole representative sample of people taking antidepressants, as they come off them. And we really don't understand what's going on inside the brain when somebody comes off antidepressants, having been on them for some months and certainly years. There are probably changes in the brain which takes some time to return to normal. And some people even fear that they might not return to normal at all, in a few cases where people have been taking antidepressants for many years.
Katie - So I think about one in 10 UK adults are currently being prescribed these drugs, is that about right?
Tony - Yes. In fact, the Public Health England survey suggested that, at any one time, more than 7 million people were taking antidepressants. Over a three year period from 2015 to 2018 it was getting on for a million who were taking it for longterm use.
Katie - Okay, so do we know how many of those people might struggle with coming off them?
Tony - The best evidence we have is that as many as one in two people, 50% of people will get some withdrawal symptoms. And of those around a half might find them quite troubling. That may be an overestimate because it's based partly on internet surveys and we know that the people who reply to internet surveys tend to be those who've had more of a problem. But it's certainly a good proportion of people and therefore it needs to be taken seriously. Antidepressants should not be stopped suddenly because the likelihood of withdrawal symptoms is much greater. They should be tapered off. And if people get problems, they should be able to discuss that with the prescriber, ask whether they need to go more slowly, or even go back up to the previous dose. And in some cases, probably a small minority, people find it quite hard to come off at all.
Katie - So do we know anything about the factors that might make that withdrawal more difficult? That half of the half of people you were talking about?
Tony - Some of the drugs have a what's called a shorter half life. They don't stay in the body for so long. So when you stop them, the level of drug in your bloodstream and in your brain drops quite quickly and that gives more withdrawal symptoms. So drugs like paroxetine and venlafaxine are well known to be more likely to cause withdrawal. So certainly by drug type. Probably by length of taking the antidepressant, the longer you've been on them, probably the more likely it is that you will get withdrawal. But as, we haven't done systematic studies of taking people off antidepressants at different intervals of time, we can't be sure about that. But certainly it does seem, and we advise caution when someone's been on antidepressants for certainly more than a few months, that the tapering should be carefully monitored in case they get withdrawal symptoms.
Katie - What is the motivation to come off? If you're feeling better, you may want to stay on them.
Tony - Yes. That's why we're getting so many people now who are taking antidepressants long term because they feel a certain fear that if they stop them, they might get depressed again. And they feel "well, if I'm okay on taking these, then I'll continue them". And their doctor may well go along with that as well. Neither the patient nor the doctor wants to risk having a relapse of depression, which can be catastrophic in somebody's life. And so the, kind of default position has been to continue them. But the problem with that is that we don't really know how long they're beneficial for. And we also are starting to recognise more and more side effects, some of which can be quite serious.
Katie - So how easy is it to tell if someone's ready to come off them or not?
Tony - Well, the current guidance is rather grey. The current recommendation from NICE (the National Institute for Care and Health Excellence) is for the first episode ever of depression that's treated with antidepressants, you'd probably come off after feeling well for about six months. So if it takes a few months to get better and then you continue them for six months, you probably should come off after about nine months, or certainly within the first year, and try doing without them. With recurrent depression, the recommendations are that antidepressant should be continued for two years in the first instance, before then reviewing them and possibly trying to come off them. But the evidence behind that two years is not very strong. More research is needed. But what we do know is that more than half the people on antidepressants have been on them for more than two years, and some of them have been on them for decades, and we really don't know that that's doing them any good. The reason for continuing them for two years is that we want to try and prevent them getting depressed again and studies up to two years have shown that if you stop them, you are more likely to get more depression. But many people can stop them without getting more depression. The worry is, that with longer and longer use you'll get more side effects and the type of antidepressant that's mostly in use these days - the Prozac type antidepressants - we've had them since the late eighties early nineties and it's only in recent years that we've started to see more and more side effects emerge. And some of those side effects can be relatively serious in a small minority of people.
Katie - From my conversation with Tony, there seemed to be two problems coming to the fore. One, a significant number of people experience difficulties coming off these drugs, and two, perhaps some people are on them without getting benefit because they're worried about coming off. Tony is part of a study trying to better this situation. The "reviewing longterm antidepressant use by careful monitoring and everyday practice study", luckily termed REDUCE for short, is based at the University of Southampton, and it's asking whether internet and telephone based psychological support for patients stepping down from antidepressants, as well as internet guidance for the GPs supporting them, could be of benefit.
Tony -So the support for patients is 2 fold, it's internet support - we have a new programme we've developed with patients, called Adviser, which is advice about antidepressants. And we have put cognitive therapy, mindfulness based therapy, and commitment and acceptance based therapy-type interventions into that online support. Psychological interventions can help people come off antidepressants and reduce the risk of relapse.
The second type of support for patients is phone calls from a psychologist to ask them how they're doing while they come off antidepressants. And to check if they're having symptoms of withdrawal or depression coming back. And encouragement to continue with the withdrawal as long as all is well. And then also support for the doctors - there's a separate programme called Adviser for Health Professionals. That's internet guidance on different schedules for tapering off the drugs, advice on timing the start of reduction. And information about the advice and telephone support for patients so that the GPs can direct patients to the support.
Katie - It sounds like quite a lot of this includes education for healthcare professionals on this topic. Is it fair to say that's been a bit lacking, so far?
Tony -To be fair to the health professionals, the guidelines have been inadequate. We are currently updating NICE guidance. There's been more guidance coming out of other countries like Holland, the Netherlands and Australia. Different countries are developing more guidance, so there's been a lack of clear guidance on how best to take people off long term antidepressants. Also, these days, general practices are so busy, as you will know if you've tried to make an appointment recently, the extra work involved in taking someone off antidepressants. Unfortunately the easiest thing to do is to continue to prescribe the antidepressant. And if the patient feels that they don't want to try coming off and the doctor doesn't want to rock the boat, that tends to be the default position in many cases.
Katie - Do you have any promising results? How confident are you that these strategies will work?
Tony - We don't have any results in terms of how effective this strategy is. We have done a feasibility trial. We engaged 50 patients and their GPs in that, and we showed that it was acceptable to patients. They liked getting involved, they liked having the internet support and the telephone support. Therefore, the method is acceptable and feasible. We have to continue the trial for the next three years and involve all together about 400 people before we'll know whether it's really more effective than simply prompting the GP to review the patient.
Katie - Understandably, we've got a UK focus in this conversation, but the podcast is a global one and the problem is a global one as well, isn't it? So do you think your study might have applications beyond the UK?
Tony -It is a global issue. Certainly in all the developed countries where people have looked at this, the number of people on antidepressants is increasing. There's an even greater proportion in America taking antidepressants, but it's also an issue in Holland, Australia, all the Western countries where it's been studied. There's a team that we're working with in Melbourne who are doing something similar to us with nurse led intervention in general practice to help people come off. There's a Dutch group that's doing a lot of work on it as well. Anywhere where people speak English could potentially benefit from our internet support. Telephone support would obviously have to be developed in each country.
Katie - Antidepressant drugs are just one way of treating depression. There's talking therapies, lifestyle medicine might be another. Do you think generally we've got the balance right, in terms of drugs compared to other strategies?
Tony - No, and I don't think many people would think we've got it right. 80% of people who are diagnosed with depression of significant severity get antidepressants in general practice. Really it's not the recommended first treatment by any means. NICE recommends guided self help and psychological treatments before drug treatment. Unfortunately it's often a long wait to get this sort of help. What we'd urge our students and trainees and GPs generally to do is to try and hold off from prescribing antidepressants, give people a chance to recover, through talking it over, getting some support from their family, from the community and from their doctor, maybe from the pharmacist, and hold off for some weeks if possible. It's more difficult if people have had depression before, they've had antidepressants before when they come asking for them again. But even then it's worth checking back and thinking "did they really need to have the antidepressants in the first place?" If we can put fewer people on antidepressants, that would be a good thing generally, because many of those people will benefit from other types of support and can improve without drug treatment. If we are starting drug treatment, we should warn them about the possibility of problems when they try to stop them.