The dark side of halting antidepressants
As long-term use grows, withdrawal can become harsh
Victoria Toline would hunch over the kitchen table, steady her hands and draw a bead of liquid from a vial with a small dropper. It was a delicate operation that had become a daily routine — extracting ever tinier doses of the antidepressant she had taken for three years, on and off, and was desperately trying to quit.
“Basically that’s all I have been doing — dealing with the dizziness, the confusion, the fatigue, all the symptoms of withdrawal,” said Toline, 27, of Tacoma, Wash. It took nine months to wean herself from the drug, Zoloft, by taking increasingly smaller doses.
“I couldn’t finish my college degree,” she said. “Only now am I feeling well enough to try to reenter society and go back to work.”
Long-term use of antidepressants is surging in the United States, according to a new analysis of federal data by The New York Times. Some 15.5 million Americans have been taking the medications for at least five years. The rate has almost doubled since 2010, and more than tripled since 2000.
Nearly 25 million adults, like Toline, have been on antidepressants for at least two years, a 60 percent increase since 2010.
The drugs have helped millions of people ease depression and anxiety. Many, perhaps most, people stop the medications without significant trouble. But the rise in longtime use is also the result of an unanticipated and growing problem: Many who try to quit say they cannot because of withdrawal symptoms they were never warned about.
‘Discontinuation syndrome’
Some scientists long ago anticipated that a few patients might experience withdrawal symptoms if they tried to stop — they called it “discontinuation syndrome.” Yet withdrawal has never been a focus of drugmakers or government regulators, who felt antidepressants could not be addictive and did far more good than harm.
The drugs initially were approved for short-term use, following studies typically lasting about two months. Even today, there is little data about their long-term effects.
“Most people are put on these drugs in primary care, after a very brief visit and without clear symptoms of clinical depression,” said Dr. Allen Frances, a professor emeritus of psychiatry at Duke University. “Usually there’s improvement, and often it’s based on the passage of time or placebo effect.
“But the patient and doctor don’t know this and give the antidepressant credit it doesn’t deserve.”
Still, it is not at all clear that everyone on an open-ended prescription should come off it. Most doctors agree that a subset of users benefit from a lifetime prescription but disagree over how large the group is.
The Times analyzed data gathered since 1999 as part of the National Health and Nutrition Examination Survey. Overall, more than 34.4 million adults took antidepressants in 2013-14, up from 13.4 million in the 19992000 survey.
“What you see is the number of long-term users just piling up year after year,” said Dr. Mark Olfson, a professor of psychiatry at Columbia University. Olfson and Dr. Ramin Mojtabai, a professor of psychiatry at Johns Hopkins University, assisted The Times with the analysis.
A creeping unease
Antidepressants are not harmless; they commonly cause emotional numbing, sexual problems like a lack of desire or erectile dysfunction and weight gain. Long-term users report a creeping unease: Daily pill-popping leaves them doubting their own resilience, they say.
Drug manufacturers do not deny that some patients suffer harsh symptoms when trying to wean themselves from antidepressants.
“The likelihood of developing discontinuation syndrome varies by individuals, the treatment and dosage prescribed,” said Thomas Biegi, a spokesman for Pfizer, maker of antidepressants like Zoloft and Effexor. He urged that patients work with their doctors to “taper off ” — to wean themselves by taking shrinking doses — and said the company could not provide specific withdrawal rates because it did not have them.
Drugmaker Eli Lilly, referring to two popular antidepressants, said in a statement the company “remains committed to Prozac and Cymbalta and their safety and benefits, which have been repeatedly affirmed by the U.S. Food and Drug Administration.” The company declined to say how common withdrawal symptoms are.
The few studies of antidepressant withdrawal that have been published suggest that it is harder to get off some medications than others. This is due to differences in the drugs’ half-life — the time it takes the body to clear the medication once the pills are stopped. Brands with a relatively short half-life, like Effexor and Paxil, appear to cause more withdrawal symptoms more quickly than those that stay in the system longer, like Prozac.
“The truth is that the state of the science is absolutely inadequate,” said Dr. Derelie Mangin, a professor in the department of family medicine at McMaster University in Hamilton, Ontario. “We don’t have enough information about what antidepressant withdrawal entails, so we can’t design proper tapering approaches.”