Changing the conversation about health

BEYOND PILLS CAMPAIGN: Coming off dependence-forming drugs for mental health problems can ‘up end’ your life, say psychiatrist and pharmacist who have authored new guidelines for safe deprescribing

The Maudsley Deprescribing Guidelines by Dr Mark Horowitz and Professor David Taylor is the first clinical handbook on how to safely stop medications, reports Sarah Stacey

Until very recently, medical guidelines and textbooks have been influenced by short-term studies carried out by pharmaceutical companies, which reported that patients coming off medications such as antidepressants, benzodiazepines, gabapentinoids and z-drugs were unlikely to encounter difficult withdrawal effects.

That was untrue, as millions of patients have found. But invariably their doctors – the ones who prescribed the pills – had had little if any training in safe deprescribing. In fact, if patients came to them with symptoms of withdrawal, the doctors were likely to diagnose a relapse and put them back on the drug, sometimes at a higher dose.

Dr Mark Horowitz (pictured) is lead author on The Maudsley Deprescribing Guidelines, a clinical handbook designed for healthcare professionals to help patients to safely stop using antidepressants

The authors of The Maudsley Deprescribing Guidelines both have personal experience of the problems of withdrawal from antidepressants – the most widely prescribed psychiatric medication both in the UK and internationally.

Lead author Dr Mark Horowitz says: ‘Coming off antidepressants was the hardest thing I have ever done and it up-ended my life.’

He continues: ‘I felt like I was on the edge of a cliff, or being chased by an animal. I was just hanging on to life at that point.’

Searching for information, Mark, now 42, was ‘shocked to find that online peer support communities were more helpful to me in this process than some of the top psychiatrists in the world that I worked with at the time’.

His co-author Professor David Taylor, director of pharmacy and pathology at the Maudsley Hospital, London, explained that ‘for over a decade, I ran a helpline for people with questions about their psychiatric medications. At first, I found it hard to believe the variety and severity of symptoms people reported when stopping antidepressants.

It was only my personal experience that allowed me to understand just how grueling the process can be if not done in the right way.’ Professor Taylor has described his own experience of withdrawal as ‘strange and frightening and torturous’.

The evidence-based manual provides an overview of the principles to use in deprescribing, based on slow, staged withdrawal, using hyperbolic tapering (reducing by smaller and smaller amounts of the drug because of the way the drugs act on the brain), often with liquid forms of medication.

The book is written to inform healthcare professionals – psychiatrists, GPs, pharmacists, nurses and medical students – how best to support patients, as well as members of the public who are concerned about the problem. Latest figures show that a record 8.6 million adults in England were prescribed antidepressants in 2022/23, nearly double the figure in 2011.

Of those patients who try to come off their meds, about half will have some withdrawal symptoms; the extent depends on which drug and for how long they’ve been taking it. For many it is a living hell, as three patients explained in a short film shown at the launch of the Beyond Pills All Party Parliamentary Group in December 2023.

WATCH THE VIDEO BELOW: PEOPLE SPEAK ABOUT HOW PRESCRIBED DRUG DEPENDENCY HAS AFFECTED THEIR LIVES

When he first tried to cut down after ten years of taking antidepressants, prescribed initially when he was an unhappy medical student aged 21, Mark experienced appalling panic attacks.’

Dr Horowitz, a member of the Beyond Pills Alliance research cohort, believes there has been ‘a huge overmedicalisation of normal human emotion’. Periods of stress or unhappiness are quite normal, he says. But ‘over the past few decades, our society has been taught to see those things as medical illnesses requiring medical solutions’.

He was one of the signatories to a letter from members of the Beyond Pills APPG and others, published in the BMJ in December 2023, calling for an end to prescribing antidepressants for mild to moderate depression, and comprehensive support for safe withdrawal alongside the provision of comprehensive non-medical alternatives for mental health problems.

Professor Allen Frances, Professor Emeritus of Psychiatry at Duke University and head of the DSM-IV committee says: ‘Since we began using psychiatric medications 60 years ago, the focus has been on prescribing – with almost no attention to withdrawal symptoms and how often they’re confused with relapse. Any clinician can prescribe drugs; it takes art, science, and people skills to deprescribe them.’

 

The Maudsley Deprescribing Guidelines by David Taylor and Mark Horowitz is out now (Wiley-Blackwell, £44.99)