Invited response to article ‘Continuing antidepressants or not: Evaluating the potential benefits and harms’
Refer to the associated article by Horowitz et al, which is also published in this issue of AJGP.
We agree that antidepressants should be reviewed regularly, but are concerned if the default position for general practitioners (GPs) becomes stopping long term treatment, because this might create problems for the management of moderate-to-severe relapsing depression. Deprescribing is an endpoint rather than a framework for clinical assessment to determine whether a patient is depressed and might therefore benefit from an antidepressant. If patients are experiencing harms, such as adverse effects, from antidepressants, it is reasonable to consider whether or not they require ongoing antidepressant pharmacotherapy. This requires an assessment to ascertain whether or not a patient continues to suffer depression or is at risk of severe relapse, and therefore might need further treatment.
Where we particularly differ from the authors of this article is how they have interpreted and presented their evidence: we critique some references as examples. Horowitz et al have cited a reference for the statement, ‘General practitioners prescribe 92% of the antidepressants in Australia, sometimes when clinical guideline criteria are not met…’, citing a study of 789 patients in Victorian general practices from 2007–11.1 This study’s findings might not necessarily be able to be generalised to general practice in Australia, especially as the study endpoint is 15 years ago. The authors cite an antidepressant discontinuation study of 301 patients in a UK National Health Service (NHS) primary care psychological therapy program as support for the severity of withdrawal effects.2 Whether such a study is generalisable to an Australian general practice population, or those taking antidepressants in general, is also unclear. The authors also cite a systematic review as evidence that withdrawal symptoms can be severe.3 However, there was criticism regarding its validity as a systematic review in the same journal in which it was published.4 In our reading of a 2003 review paper cited,5 the authors might have overestimated the likelihood of a drug withdrawal effect on outcomes. Space limits do not permit citation of further similar examples in the paper.
We therefore encourage readers to carefully scrutinise the references cited as evidence, and also assess the validity of argumentation by the authors, before considering the clinical relevance thereof.
Authors
Jeffrey CL Looi MBBS, MD, DMedSc, FRANZCP, AFRACMA, FAMA, Associate Professor of Neuropsychiatry, Old Age Psychiatry and Psychiatry, Social Psychiatry and Epidemiology Research Unit, School of Medicine and Psychology, College of Science and Medicine, The Australian National University, Canberra, ACT; Coordinator, Consortium of Australian-Academic Psychiatrists for Independent Policy and Research Analysis (CAPIPRA), Canberra, ACT
Stephen Allison MBBS, FRANZCP, Member, The Consortium of Australian Academic Psychiatrists for Independent Policy Research and Analysis (CAPIPRA), Canberra, ACT; Associate Professor of Psychiatry, College of Medicine and Public Health, Flinders University, Adelaide, SA
Tarun Bastiampillai BMedSc, MBBS, FRANZCP, Member, The Consortium of Australian Academic Psychiatrists for Independent Policy Research and Analysis (CAPIPRA), Canberra, ACT; Professor of Psychiatry, College of Medicine and Public Health, Flinders University, Adelaide, SA; Clinical Professor of Psychiatry, Department of Psychiatry, Monash University, Melbourne, Vic
Steve Kisely MD, PhD, DMedRes, FRANZCP, FRCPsych, FAFPHM, FFPH, FAChAM, Member, The Consortium of Australian Academic Psychiatrists for Independent Policy Research and Analysis (CAPIPRA), Canberra, ACT; Professor of Psychiatry, Princess Alexandra Hospital Southside Clinical Unit, Greater Brisbane Clinical School, Medical School, The Faculty of Health, Medicine and Behavioural Sciences, The University of Queensland, Brisbane, Qld; Consultant Psychiatrist, Metro South Addiction and Mental Health Service, Brisbane, Qld; Professor, Departments of Psychiatry, Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada; Member, Australian Society of Psychiatrists, Sydney, NSW
Paul A Maguire MBBS, PhD, FRANZCP, Clinical Associate Professor in Psychiatry, Academic Unit of Psychiatry and Addiction Medicine, The Australian National University, Canberra, ACT; Member, The Consortium of Australian Academic Psychiatrists for Independent Policy Research and Analysis (CAPIPRA), Canberra, ACT
Luke S-C Woon MD, DrPsych, Lecturer in Psychiatry, Department of Psychiatry, Faculty of Medicine, The National University of Malaysia, Kuala Lumpur, Malaysia; Postgraduate Researcher, Academic Unit of Psychiatry and Addiction Medicine, The Australian National University School of Medicine and Psychology, Canberra, ACT; Clinical Observer, Canberra Hospital, Canberra, ACT
Katrina Anderson BMed, FRACGP, MTh, SFHEA, Clinical Professor of General Practice and Director of General Practice Education, Academic Unit of General Practice, School of Medicine and Psychology, The Australian National University, Canberra Hospital, Canberra, ACT
Competing interests: JCLL declares that he is a Fellow of the Australian Medical Association (AMA). LS-CW declares payments from Lundbeck Malaysia and Eisai Malaysia for lectures, presentations and meeting support. TB declares payments from CSL Sequiris for lectures and is an AMA South Australia Board Member. The remaining authors have no competing interests to disclose.
References
1. Davidson SK, Romaniuk H, Chondros P, et al. Antidepressant treatment for primary care patients with depressive symptoms: Data from the diamond longitudinal cohort study. Aust N Z J Psychiatry 2020;54(4):367–81. doi: 10.1177/0004867419898761.
2. Horowitz MA, Buckman JEJ, Saunders R, Aguirre E, Davies J, Moncrieff J. Antidepressants withdrawal effects and duration of use: A survey of patients enrolled in primary care psychotherapy services. Psychiatry Res 2025;350:116497. doi: 10.1016/j.psychres.2025.116497
3. Davies J, Read J. A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence- based? Addict Behav 2019;97:111–21. doi: 10.1016/j.addbeh.2018.08.027.
4. Jauhar S, Hayes J. The war on antidepressants: What we can, and can’t conclude, from the systematic review of antidepressant withdrawal effects by Davies and Read. Addict Behav 2019;97:122–25. doi: 10.1016/j.addbeh.2019.01.025.
5. Geddes JR, Carney SM, Davies C, et al. Relapse prevention with antidepressant drug treatment in depressive disorders: A systematic review. Lancet 2003;361(9358):653–61. doi: 10.1016/S0140-6736(03)12599-8.