They were the wonder drugs of the 1990s. The new generation antidepressants, known as SSRIs (selective serotonin reuptake inhibitors), made a huge difference to many people suffering from depression, without seriously diminishing their ability to function. But this week doctors have been advised by the regulator that the drugs, such as Seroxat and Prozac, are often overprescribed for patients suffering from mild depression and that they should warn patients about potential problems before prescribing them and if patients decide to stop taking them.
For some people, this advice comes a good deal too late. Andrew took Prozac for five years, during which he received no supervision, only repeat prescriptions. Like many people, he felt unhappy about the prospect of being dependent on medication for life. “When I started taking Prozac I felt great. But who wants to be on medication for ever, or fill in ‘Prozac’ on every form for life insurance, a driving licence, a job application? You think people will take it as a sign of mental weakness. If you have been taking the pills for some time, and the depression seems like a distant memory, you want to know if you’re still suffering from depression.”
He could get no consistent advice about when, or how, to stop taking Prozac, so he just stopped. It was the wrong thing to do. “I started having those black, circular, negative thoughts again, I felt awful. I thought, ‘I want my pills back’. You never know whether it’s withdrawal from the drug or the return of depression.”
Doctors are now being advised to follow patients closely and to spend time with anyone thinking about coming off SSRIs, to discuss whether it’s the right thing to do. Steve Pilling, the co-director of the National Collaborating Centre for Mental Health, counsels anyone worried by the current news stories not to throw the pills away. “If you’ve had moderate to severe depression and you’ve had a good response to the drug, it may be that you should stay on it,” he says.
David Nutt, professor in psychopharmacology at Bristol University, believes that there are some people who should stay on the drugs for ever — but cases vary. “If it’s a 35-year-old man who has had repeated episodes of depression, who is under pressure with work, if he stops taking SSRIs, the chance of his suffering another episode is, I would say, 100 per cent. I would advise him to stay on them till he retires. If it’s a 25-year-old woman who has been through a messy divorce, I would say take them for six to nine months, get herself well, then tail off, and maybe she’ll never need them again. If they’re feeling fine on the drugs, they shouldn’t be rushing to stop taking them. If you’re feeling well, you should have a chat with your GP, have about it. There’s no need to do anything sudden.”
Most people who have suffered from depression would be understandably apprehensive about stopping their medication, for fear of a relapse. Professor Nutt believes there are ways of knowing whether someone is ready. “First, you get rid of the symptoms; second, you need evidence that they are functioning again in the real world. Someone who says that they are better but is not back at work is probably not better. If they are not fully recovered and they stop taking the drugs, the feelings of depression will come back very quickly.” He adds that anyone stopping the drugs should plan ahead to make sure that there is no life crisis looming, such as moving house.
Sarah Jane’s first attempt to come off Prozac coincided with a personal tragedy and led to a big setback. She had been prescribed Prozac for post-natal depression in her mid-forties, and had decided that she didn’t want to be on it any more. “I felt infinitely better, but I was in a fog. I felt so passive, floating along perfectly happily. I cut down very gradually like you’re supposed to, though I had no help from my GP.
Unfortunately my first attempt to come off Prozac coincided with my father dying. A month later I was in bits; that weepy loneliness and black-hole stuff came back. So I went back on Prozac.”
For those who do feel ready to stop, and their GP agrees, the importance of tapering the drugs off slowly is now strongly emphasised. Pilling points out that although withdrawal symptoms can be mild, patients should be aware of what they might expect. “The symptoms might include nausea, anxiety and agitation, and some unusual sensations a bit like electric shocks. They will pass. The important thing is not to think that you are getting a recurrence of depression. Without careful advice, some people might understandably misinterpret the symptoms.”
Seroxat is much more associated with withdrawal symptoms because it has a short half-life, which means that it comes out of the body fast. According to Professor Nutt, Prozac, which has a long half-life, has never been associated with withdrawal reactions and anyone experiencing withdrawal might be suffering a psychosomatic reaction. “If you’re scared of a withdrawal reaction, you might have one anyway.”
One feature of depression is waking at 4am, full of anxieties, and anyone thinking of coming off SSRIs must worry that those dark nights of the soul will come back. Professor Jim Horne, at the sleep research centre at Loughborough University, says there is more of a risk of wakefulness with short-acting SSRIs like Seroxat.
Anyone coming off the drugs needs a strong support network, an exercise routine and a good diet, says Amanda Geary, the founder of the Food and Mood project (www.foodandmood.org), which promotes innovative approaches to mental health issues. She points out that mood can be affected by excessive consumption of caffeine, refined carbohydrates, sugar or additives. At the same time, there are problems associated with insufficient protein, essential fats, vitamins, minerals and water. “Food sensitivities, most commonly to foods containing wheat or dairy foods, can also influence mood in some people.”
Acupuncture can help with the physical symptoms of withdrawal and alleviate anxiety. Garry Trainer, a complementary therapist, says: “Chinese medicine uses something called ‘nerve tonic’: they put needles in the big nerve junctions which stimulates the release of endorphins. Acupuncture can be used for depression, but it’s not the whole answer.”
Sarah Jane tried various alternatives to Prozac. “I had therapy which helped for a while; it felt great to have someone who was on my side. I did try St John’s wort, which I had read was ‘nature’s Prozac’, but it made me feel violently angry. I eventually came off Prozac gradually.”
Andrew, too, managed a gradual withdrawal. “At the second time of asking, the doctor said to step it down slowly. I started dropping one in four, and seeing how that felt, and so on, gradually. That was nearly two years ago, and I never think about it now. ”
