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The waiting game

NICE antidepressant withdrawal guidance ‘misleading’ and ‘without evidence’

The current NICE guidance on antidepressant withdrawal is ‘misleading doctors’ about the severity of effects on patients, researchers have claimed.

According to current guidelines, withdrawal symptoms when stopping antidepressants are ‘usually mild and self-limiting over about one week’.

But an analysis of existing research, including NICE’s own evidence base, concluded the claims about the length and severity of withdrawal symptoms were not supported.

Instead, the study comparing 23 UK and international studies found that more than half (56%) of people who attempted to come off antidepressants experienced withdrawal effects, and nearly half of these (46%) – i.e. a quarter of all patients – described them as severe.

The systematic literature review, published in Addictive Behavioursalso found it was not unusual for the effects to last several weeks, or even months.

Having obtained NICE’s evidence base for the 2009 guideline via a freedom of information request, the researchers found it was ‘derived, at the time, from only two pieces of research’, which had ‘not been updated since 2004’.

And the researchers, from the University of Roehampton and University of East London, concluded that neither piece of evidence cited a single source to support NICE's claim that withdrawal symptoms last just one week.

They said: ‘NICE's current position on antidepressant withdrawal was not only originally advanced on weak evidence, but is 14 years out of date and countered by subsequent evidence, as can be seen in this review.’

The team warned that current guidelines are 'misleading doctors on the nature and management of withdrawal' and could lead to patients who experience lengthy withdrawal symptoms being misdiagnosed with relapse, or with a failure to respond to treatment.

This could result in antidepressants mistakenly being reinstated, switched or the dose increased, they added.

In the paper, NICE admitted that its 'current statement on antidepressant withdrawal was inherited’ from 2004 guidance which said 'if symptoms are mild, reassure the patient that these symptoms are not uncommon after discontinuing an antidepressant and that they will pass in a few days'.

NICE announced last week that it will re-consult on a new adult depression guideline for a third time, admitting the evidence base for previously released draft recommendations ‘needs updating’.

This means that the final adult depression guidelines will come nearly two years after initially intended.

A NICE spokesperson declined to comment further.

The news comes as the All-Party Parliamentary Group for Prescribed Drug Dependence released a report claiming many GPs fail to warn patients about the potential side effects of anti-depressant withdrawal.

Its survey of 319 users who were stopping medication showed 64% were given no information about the potential risks and side effects by their doctors, and 25% reported getting no advice on how to give up the drugs.

Nearly half also said they experienced withdrawal symptoms for more than a year, and 30% claimed they gave up work due to withdrawal.

But Professor Clare Gerada, a GP in southwest London and medical director for the national GP mental health service, said: ‘As a GP, I have prescribed antidepressants for the best part of 35 years. Some patients do have issues with withdrawing, the majority don’t.

'However, antidepressants used properly are an effective treatment for depression and save lives.’

Public Health England is including antidepressant prescribing in an ongoing prescription drug addiction review which is also looking at benzodiazepines, z-drugs, gabapentinoids and opioid pain medicines. It is expected to report early next year.

Readers' comments (13)

  • Is it not time that NICE were held to account concerning their inaccurate and misleading recommendations across a range of conditions? Their reviews cost a fortune to perform, not infrequently causing confusion rather than lending clarity. Of course their remit is cost effectiveness and not clinical excellence so maybe they should just change their name.

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  • National Hopeless Service

    Today I gave a patient the wrong advice. Yesterday I prescribed something that isn't available. What was the outcome?...Nothing because despite being paid to do a specific job I am not actually accountable to a parallel universe.

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  • From the National Institute of Clinical ECONOMY.

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  • AlanAlmond

    We do need some proper clarification about the role of NICE guidance. So often these guidelines are held up as a straight jacket, lawyers, commissioners and wider society use them as a means to control and punish Drs without real understanding of their limitation. Every time a lawyer gets involved in a complaint they slavishly and lazily refer to NICE guidelines as if they are compulsory and akin to the law itself. NICE states they are simply there to guide and are not compulsory but this is not how they are being used. Is it an impossible ask that this spirit be recognised in wider society? The biggest problem with NICE is not the guidance itself but its inappropriate use by non medics, primarily the legal profession. NICE is not the sole arbiter of medical practice but alas in the UK it is treated as such. It isn’t. Nobody in the rest of the world is getting sued for not following debatable state sponsored medical rules. Why are we doing this in the U.K.?

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  • Vinci Ho

    OMG, is there a day where this establishment not subjecting itself to criticism? The layman question of ‘how much taxpayers’ money is being paid to these guys?’ always remains( call it populism against establishment if you want )😡

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  • Well there’s a surprise! Which only begs the question, as already indicated, how much more NICE ‘guidance’ is both misleading and based on lack of evidence? And then we run the risk of being litigated for being expected to follow such guidance.
    Isn’t it wonderful working in such a system!

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  • Alan almond
    Well said. I fully agree.

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  • Professor Gerada has been consistent in minimising the potential for antidepressants to result in dependence and withdrawal effects. I do not understand why Professor Gerada is neither accepting evidence such as this and why she is choosing not to listen to evidence of experience.

    Dr Peter J Gordon

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  • Dr Gordon- Very true. Quoting personal experience versus multi centre studies shows a real lack of insight

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  • If you prescribe antibiotics for a sore throat/cough/cold we know patients will represent for the same treatment the next time they have a similar problem
    Why are we surprised that if we prescribe antidepressants for an episode of life stress/anxiety then patients will represent for the same treatment at the next time
    The scandal is what proportion of patients will spend most of their life on antidepressants because of an early in life GP presentation and prescription and lack of alternative routes to treatment

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  • What does NICE call an Antidepressant?
    Amitriptyline and Dothiepin are antidepressants. They have a fairly well known set of withdrawal effects, which do not last very long. Unfortunately they also have some fairly well-known side effects, so we are not supposed to use them.
    Fluoxetine can be used for depression, anxiety, OCD, etc. It has fairly well-known side effects and often quite marked and long-lasting withdrawal effects.
    Citalopram is wierd, and possibly addictive: Mirtazepine is wierd and highly addictive, but they are 'modern' and fashionable.
    Quetiapine is clearly an extremely addictive antipsychotic, and not an antidepressant at all (except in the way heroin and crack are!), yet it is heavily promoted for depression!
    Now some experts are recommending Pregabalin and Gabapentin for depression - so why not Coke, Heroin, Crystal and Hemp extract too?

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  • Re: Acute, sub-acute, chronic, legacy neurotoxicity of SSRIs/SNRIs.

    Induction, dose increase/decrease, SSRI/SNRI drug change, and SSRI/SNRI-withdrawal induced akathisia.


    FDA - Highlights of Prescribing Information. Fluoxetine.
    Ref. 2927282. U.S.A.

    24. - 17 -2.

    "Patients, their families and care givers should be alert to emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, AKATHISIA (my emphasis)
    other unusual changes in behaviour, worsening of depression and suicidal ideation -
    Especially during antidepressant treatment when the dose is adjusted up or down".

    "Families and care givers should be advised to look out for the emergence of such symptoms on a day to day basis , since such changes may be abrupt".

    "Such symptoms should be reported to the patient's prescriber or health professional, especially if they are severe, abrupt in onset, or not part of the patient's presenting symptoms".

    "Symptoms such as these may be associated with an increased risk in suicidal thinking and behaviour ---".


    AKATHISIA has been "disguised" in ghost-written, pharmaceutical industry-funded clinical trials by the use of terminology such as "hyperkinesia" and "emotional lability".

    Akathisia is a common, but commonly unrecognised, SSRI/SNRI severe neurotoxicity.

    It is vulnerable to misdiagnosis as emergent severe mental illness yet:

    "Depressive psychoses are vanishingly rare compared to treatment induced akathisia".

    Will revised guidelines, heavily influenced by ghost-written, industry funded "science", at last begin to reduce the prevalence of this common, prescription drug induced, life threatening ADR?

    If they do not, then one set of questionable guidelines will simply have been replaced by another.

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  • Good thing I don't follow nice guidelines for this then

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