Not very long so full text here: The importance of minimising long-term antidepressant use We recently argued that patients prescribed antidepressants should undergo regular review to consider whether continued prescribing or deprescribing is indicated.1 The evidence supporting continued treatment is flawed since discontinuation trials showing that continuation of antidepressants prevents relapse are likely to be confounded by withdrawal symptoms. This applies to the Geddes meta-analysis, mentioned by Looi et al,2 in which antidepressants were typically stopped abruptly or over only a few days. Such rapid discontinuation is well recognised to produce withdrawal symptoms that overlap with relapse measures, fundamentally undermining confidence in estimates of relapse prevention.3 Alongside doubtful evidence of benefit, there is clear evidence of harm with continuing antidepressants long term including emotional numbing, sexual dysfunction, weight gain, diabetes and, in older adults, increased risks of falls, fractures and possibly premature mortality. Looi et al agree that antidepressants should be reviewed regularly and discontinued when harms outweigh benefits. However, they do not address our central argument regarding the methodological limitations of discontinuation trials concerning their confounding by withdrawal symptoms. Looi et al also provide no evidence supporting their assertion that antidepressants remain beneficial for long-term treatment of recurrent moderate-to-severe depression. Long-term antidepressant use may only be beneficial in preventing withdrawal symptoms. Recent Australian data indicate that antidepressants are overwhelmingly prescribed by general practitioners (91%), unchanged from 2007 to 2011.4 Looi et al question whether evidence on antidepressant withdrawal symptoms from a UK National Health Service cohort is generalisable to Australia. There is no biological reason why withdrawal phenomena should differ between British and Australian patients. There is a growing body of international literature showing that patients can experience severe and prolonged withdrawal symptoms, particularly after long-term antidepressant use.5,6 Whether antidepressants should be continued long term and how to help patients who wish to stop taking antidepressants are important clinical questions. Reliable evidence supporting maintenance treatment is lacking, while there is evidence of harm.

The Australian Journal of General Practice from @RACGP published out letter today titled 'The importance of minimising long-term antidepressant use'. Given there is no robust evidence of benefit (discontinuation trials are confounded and not reliable) but evidence of harm we should be aiming to minimise long term use of these medications. Link below.

I do think it is important for people to understand that the average psychiatrist is open to learning about safe withdrawal and that the ideologically committed extremists on this platform are not representative. Otherwise the cynicism shown by these people can lead to unnecessary demoralisation. So I submit the feedback to a lecture on withdrawal and deprescribing I gave at the Nevada Psychiatric Association earlier this year (which is after the APA conference the second biggest psychopharmacology meeting of the year). Most of the other speakers at the conference were prominent key opinion leaders talking about the latest drugs released onto the market and psychiatrists come for a one stop shop to update their knowledge of psychopharmacology (in other words far from a selected group of critically minded psychiatrists). At the risk of being self-congratulatory (I assure you I am a monotonal, wooden and uncharismatic presenter and so this speaks to the material and not me) here are the main bits of feedback: -61% of 1500 psychiatrists rated it as ‘excellent’ and 86% as ‘very good’ or ‘excellent’ "This presentation probably changed my practice more than any other presentation at this conference." “As a psychiatrist who prides himself in his routine deprescribing, I entered this lecture with tepid interest, and found it breathtaking. What a beautiful, shocking, and deeply empathic presentation. Although I have found myself doing many of the things you've described over the years, I always always heard my colleagues' criticisms that I was being soft with people, or buying into their psychopathology, and enabling them by acting in this way. I learned in this lecture that I hadn't gone far enough! Shocking, invigorating. Thank you so much. Of all the lectures in this series, I found this the single most impactful for how I wish my practice to change.“ “This is the standard of care we should all practice. Extremely useful lecture." "Changed my thinking about how to taper off meds and discuss with patients the risk of withdrawal effects with stopping meds." "Very informative and eye opening. Goes against much of what I was taught about psychopharmacology but actually makes a lot of sense." "How is this information not more widely disseminated? I feel like my entire career and education was all a lie. How many patients have I inadvertently hurt?" "I'm glad this topic was included... I learned a lot on deprescribing and will change my practice." "Game changer." "One of the best presentations of the week. I learned so much. THANK YOU." “This is the lecture I will most remember as outstanding. I learned so much that I didn't know.” “This made sense and I'm glad I learned this info because I have been fairly casual when taking people off meds. Generally a slow titration but I will go slower now.” And just for balance: “I cannot possibly express the degree of my criticism of the material he presented (call me if you want specifics). I understand the difficulty challenging the speaker on-stage after the talk, but I'm concerned with what the audience took from this talk. I'm even more horrified seeing the young people sitting around with him in the "expert's area". More feedback in pictures