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Consultant psychiatrist Dr Ron Alcorn looks at the problems
some people experience when stopping taking drugs used to treat
depression and anxiety
There have long been concerns about difficulties people
experience in stopping taking tranquillisers such as Valium. More
recently there has also been a lot of talk about whether
anti-depressants, and particularly some of the newer classes of
anti-depressants, can cause similar problems. People are wondering
whether they can become addicted to (doctors normally say 'dependent
on') anti-depressants and whether they might have trouble coming off
them. To answer these questions we need to take a closer look at
these drugs: at what they are and what they are used for.
anti-depressants
Anti-depressants are mainly used to treat depression that is
diagnosed as being in the moderate or severe categories. But these
drugs are only one of a number of treatments for depression: others
include psychological treatments ('talking therapies') and steps to
resolve the stresses or conflicts that can make you depressed in the
first place. Modern treatments for depression often involve a
combination of drugs and other approaches.
Perhaps rather confusingly, anti-depressants can also be used to
treat anxiety, panic attacks and obsessional states, to help with
binge eating (bulimia), to relieve pain, and to dampen down the
psychological reactions to severe trauma (post-traumatic stress
disorder).
Anti-depressants differ in a number of ways. Firstly, different
types work on different chemical systems in the brain (different
neurotransmitters) — those to do with serotonin and those to do with
noradrenaline. We don't know exactly how anti-depressants work, but
we do know that they boost activity in these two neurotransmitter
systems, which can relieve some of the most distressing symptoms and
improve a person's mood.
Secondly, anti-depressants can have quite different side-effects,
and this can be important when a doctor is choosing an appropriate
drug for you. Some side-effects can be helpful: for example, an
anti-depressant that is sedative (helps you sleep) is useful for
people who get very restless and sleepless when they are depressed.
But others when depressed are sluggish and oversleep, so they might
be prescribed a different drug. See general
guidelines for more about unwanted side-effects.
Thirdly, anti-depressants differ in how dangerous they are in
overdose. Many of the older anti-depressants, such as Lentizol
(Triptafen), clomipramine (Analfranil) and dothiepin (Prothiaden),
can be dangerous if you take too many, particularly if you take them
with other drugs, including alcohol.
The newer anti-depressants, particularly the selective serotonin
re-uptake inhibitors (SSRIs, which include fluoxetine (Prozac),
paroxetine (Seroxat), sertraline (Lustral) and citalopram
(Cipramil), are much less dangerous in overdose and they have fewer
troubling side-effects. However, some people trying to stop taking
the newer anti-depressants have had problems. This can happen even
after taking such a drug at a normal dose for an average length of
time. A standard course of treatment for these drugs lasts for
between four to six months, and some people need them in the long
term.
anti-depressants and 'discontinuation syndrome'
So are anti-depressants addictive ('dependence-forming')? Despite
the problems mentioned above, and despite the fact that some people
feel they are dependent on them, experts say that strictly speaking
these drugs do not lead to dependence. This is because doctors
define dependence as a 'syndrome', involving various features, and
certain features of that syndrome don't apply to anti-depressants.
For example, unlike with benzodiazepines, people don't develop
tolerance to anti-depressants (in other words they don't need to
take more and more to get the desired effect). Also, they tend not
to crave for the drug and put it before everything else in their
life. Finally, people don't use anti-depressants for non-medical
reasons, because anti-depressants don't give you a 'buzz' or 'high',
or an immediate sense of relief — in fact they take weeks to start
working.
So doctors talk not about anti-depressant dependence and
withdrawal but about a 'discontinuation syndrome'.
It's important to realise that this is nothing new.
Discontinuation problems have been recognised since anti-depressants
were first introduced. But the fact that they are happening in a new
group of medications, the SSRIs, has thrown the problems into relief
again.
So how might this affect you personally? See general
guidelines.
tranquillisers (benzodiazepines)
In the middle of the last century, a group of compounds called
benzodiazepines, commonly know as tranquillisers, took over from
barbiturates as the main class of drug for treating anxiety, calming
you down and helping you sleep. Two lesser-known uses are to stop
fitting and to relax muscle tone. Benzodiazepines were a revolution
at the time both because they were very effective and because they
were a lot safer than barbiturates, particularly in overdose.
These drugs work on a neurotransmitter system called the GABA
(gamma amino butyric acid) system, which is the major inhibitory
system in the brain — in other words, it dampens down brain
activity.
Examples of benzodiazepines used for anxiety include diazepam
(Valium), chlordiazepoxide (Librium), lorazepam (Ativan) and
alprazolam (Xanax). Benzodiazepines used to help with sleep include
temazepam, nitrazepam and flunitrazepam (Rohypnol).
A lot of people have used benzodiazepines occasionally at
difficult times in their lives, and it is important to say that for
some people with some medical conditions these drugs are still the
best treatment available. Drug prescription is always a question of
weighing up the benefits against possible problems.
In the case of benzodiazepines, those problems include the
discovery that tolerance develops — in other words you need higher
doses to achieve the same effect. You may also get withdrawal
symptoms (see general
guidelines) if you try to come off these drugs too quickly.
That's the physical side of the equation. Some people also come
to believe that they cannot live without these drugs and start to
organise their lives around obtaining and using them. These features
add up to a 'dependence syndrome'.
With benzodiazepines used to help you sleep, the early stages of
tolerance can occur after taking the normal prescribed dose for more
than a couple of weeks. If they are taken long term, stopping may
cause a withdrawal reaction. Doctors are advised that this type of
benzodiazepine should only be used for people who are acutely
distressed, and that the drug should be prescribed at as low a dose
and for as short a time as possible (usually not more than two
weeks). People should be informed about the longer-term risks. Also,
ways of improving sleep without drugs should be investigated.
With the anti-anxiety benzodiazepines, the story is similar. The
advice to doctors is to use them only for the short-term relief of
anxiety if it is severe and disabling. 'Short-term' in this case
means between two and four weeks.
Some people, either appropriately or inappropriately, are
prescribed higher-than-average doses or go on taking benzodiazepines
for longer than is normal, in which case the process of stopping
them needs to be gradual and carefully thought through. If you think
you might have been taking a benzodiazepine for too long, or you're
not sure why you've been prescribed one, talk about your concerns
with your doctor. There are also support groups who may be able to
help (see help
and info).
general guidelines
There are various reasons you might want to stop taking a drug
you have been prescribed. For example, you might think that the
original problem has gone away, or you might be worried about
dependence, or you might be experiencing unwanted side-effects.
But remember that a lot of people are helped by these drugs, and
though benzodiaepines should be prescribed only in the short term,
anti-depressants, as we have seen, are used over a matter of months
rather than weeks, and may be required for even longer periods. If
you're using an anti-depressant, don't feel under pressure to stop
taking it prematurely.
The side-effects for different drugs vary very widely, and
different people react to different drugs in different ways, so if
you're experiencing unwanted side-effects, talk to your doctor.
Depending on the drug, there may be various options in these
circumstances, including varying the dose, changing to another drug,
and opting for a form of treatment that doesn't involve drugs.
Benzodiazepines and anti-depressants not only have different
side-effects, the factors involved in discontinuing them are
different. Moreover, within these classes of drugs, some individual
medications are associated with more problems than others. However,
despite all the differences, there are some useful guidelines that
apply to the discontinuation of all these drugs.
The experience can be strongly influenced by:
- whether or not you know what to expect, so you don't get
surprises
- the speed at which you do it: the advice is generally to come
off these drugs slowly, allowing the mind and body to adjust. Talk
to your doctor about the right length of time for your
circumstances and the particular drug you're taking
- the amount of support and help you get from others (including
your doctor)
- whether or not the underlying problem has gone away.
Four main things might happen:
- nothing at all — many people stop taking these drugs without
any problems at all
- a short period of re-adjustment whilst the brain and body
adapts. For example, you might find that your sleep patterns are a
little disturbed and that there is some fluctuation in your mood
and levels of anxiety. These symptoms are lot less worrying if
you're prepared for them.
- in a minority or people, more severe, unpredictable or
prolonged symptoms. These can seem quite scary, though again they
will be less so if you know they are a possibility in advance.
With anti-depressants, such symptoms include stomach problems,
disturbed sleep and nightmares, anxiety and irritability,
dizziness, numbness and other unusual sensations. With
tranquillisers, they include anxiety, mood swings, muscle
tension/pain and, in rare cases, seizures. If you experience such
symptoms, talk to your doctor.
- the re-emergence of the problem for which the drug was
prescribed in the first place.
Bear in mind that sometimes symptoms caused by stopping taking a
drug can be mistaken for the symptoms of the original problem. If
you haven't been told about ways of managing possible symptoms of
discontinuation, you might be tempted to go straight back on to the
drug and so get stuck in a vicious circle. So, again, you need to
discuss these problems with your doctor, both in advance and when
they occur.
Who might have a harder time coming off these drugs?
- people who aren't getting much support from their doctor, or
family and friends, or other sources (see help
and info)
- people who are by nature more anxious or have a tendency to
rely on support from prescription drugs or other drugs, including
alcohol
- people who have been on doses that are higher than average and
for longer than is normal
- people who believe that their underlying problem was cured by
the drug, as opposed to the drug being used to manage the problem
- people who choose the wrong time to try and stop the
medication: ideally it should be done at a quiet, unstressful
time.
What is being done to address these problems
generally?
- Doctors now have guidelines for how to prescribe these drugs
and inform their patients better about the risks.
- Treatment guidelines also stress the importance of looking for
ways to treat problems without using drugs.
- The organisations that regulate the prescribing of these
drugs, for example the government and your local health authority,
have initiatives to check that doctors are not over-prescribing.
(The number of prescriptions for benzodiazepines has gone down
dramatically over the last few decades. On the other hand, the
prescription of anti-depressants has risen a lot.
- The pharmaceutical companies are trying to find drugs that
don't cause these problems.
What can you do about them specifically?
- If you are on a tranquilliser or an anti-depressant and you're
worried that you've been taking it for too long or you want to
stop taking it for other reasons, talk to your doctor about
whether it's appropriate for you to stop taking the drug — and if
it is, about how to do so safely and when you should start.
- Never stop a drug suddenly (especially from a high
dose) without talking to your doctor first. Generally you should
come off these drugs by gradually reducing the dose.
- Educate yourself (see help
and info).
- Seek the support you need — from your doctor, from your family
and friends, and from self-help groups (see help
and info).
help and info
See the mind
magazine for more information about mental health.
See the stress
magazine for information about stress relief.
See the abc
of drugs in the drugs room for information about the
non-medical use of benzodiazepines.
organisations
Most of the self-help organisations listed here are devoted to
the problems of tranquillisers, but some cover anti-depressants and
other drugs. Read the descriptions of services carefully to find an
appropriate organisation.
Battle Against Tranquillisers (BAT)
PO Box
658
Bristol BS99 1XP
Tel: 0117 966 3629 (every day
9am-8pm)
Website: http://www.bataid.org/
Aims to help people who
wish to withdraw from tranquillisers or sleeping pills. Provides
individual counselling and local support groups.
BENZACT
Tel: 01670 504155 (Mondays to Fridays
9am-5pm)
Website: http://www.benzact.org.uk/
Campaigning
organisation that can provide information on the adverse effects of
benzodiazepines, including the effects of taking benzodiazepines
during pregnancy. Cannot provide counselling but will refer.
CITA (Council for Involuntary Tranquilliser
Addiction)
Cavendish House
Brighton
Road
Waterloo
Liverpool L22 5NG
Helpline: 0151 949 0102
(Mondays to Fridays 10am-1pm)
Website: www.liv.ac.uk/~csunit/community/cita.htm
Advice and support for people addicted to tranquillisers and
sleeping tablets. Information, advice and leaflets available on
anxiety, tranquillisers and anti-depressants. Training offered for
professionals.
Depression Alliance
35 Westminster Bridge
Road
London SE1 7JB
Recorded information line: 0870 240
2822
E-mail: information@depressionalliance.org
Website: http://www.depressionalliance.org.uk/
Information and support for people affected by depression. The
website includes information about symptoms and treatments plus
details of self-help groups and correspondence schemes. Contact the
phone number above to request an information pack, or write
(enclosing an SAE if possible) or e-mail.
First Steps to Freedom
7 Avon Court
School
Lane
Kenilworth
Warwickshire CV8 2GX
Helpline: 01926 851
608 (every day 10am-10pm)
E-mail: mailto:info@firststeps.demon.co.uk
Website: http://www.firststeps.demon.co.uk/
Help for
anyone experiencing tranquilliser addiction. Also offers help to
people suffering from general anxiety, phobias, panic attacks,
obsessive compulsive disorder, anorexia and bulimia. Offers
counselling, listening, advice, support and information.
Mind
15-19 Broadway
London E15 4BQ
Info line:
08457 660 163 (Mondays to Fridays 9.15am-5.15pm)
E-mail: contact@mind.org.uk
Website: http://www.mind.org.uk/
Mental health charity
covering England and Wales. Works towards a better life for everyone
with experience of mental distress. Has a network of over 200 local
associations. Also produces a range of publications: see the website
for further details.
The National Phobics Society
Zion Community Resource
Centre
339 Stretford Road
Hulme
Manchester M15
4ZY
Helpline: 0870 7700 456 (Mondays to Fridays
10am-4pm)
Website: http://www.phobics-society.org.uk/
Support and
advice for people affected by phobias and anxiety disorders,
including those experiencing problems with tranquillisers. The
organisation is run by sufferers and ex-sufferers of anxiety
disorders. Produces factsheets, including one on tranquillisers.
Contact the helpline for more details about a specialist phone-in
service for people affected by tranquilliser problems.
No Panic
93 Brandsfarm Way
Telford
Shropshire TF3
2JQ
Helpline: 01952 590545 (Every day 10am-10pm); from 1
January 2002: 0808 808 0545
E-mail: ceo@no-panic.co.uk
Website:
http://www.no-panic.co.uk/
Supports people
suffering from panic attacks, phobias, obsessive compulsive
disorders and other related anxiety disorders, including
tranquilliser withdrawal, and supports their families and carers.
Provides advice, counselling, listening, befriending and can make
referrals. Runs local self-help groups and produces a range of
leaflets, information, audio and video cassettes.
Prozac Survivors Support Group
26 Fox
Street
Oldham
Lancashire OL8 3ST
Helpline: 0161 682 3296
(Mondays to Fridays 10am-4pm)
E-mail: Pssguk@aol.com
A group of people
who have come together following their own experiences of the severe
side-effects of prescribed mind-altering drugs. Although the group
does not provide a counselling service, the helpline is staffed by
volunteers who have basic counselling skills and have survived their
own experiences.
Sane
1st Floor
Cityside House
40 Adler
Street
London E1 1EE
Saneline: 0845 767 8000 (every day
12pm-2am,)
E-mail: sane@saneline.org
Website:
http://www.sane.org.uk/
Saneline is a national
mental health helpline providing information and support for people
with mental health problems and those who support them. They can
provide information on illnesses and symptoms, local and national
mental health services, medication, treatments and therapies.
Tranquilliser Withdrawal Support (West
Suffolk)
Blomfield House Health Centre
Bury St
Edmunds
Suffolk IP33 1HE
Helpline: 01284 702550 (24 Hour
Answerphone)
E-mail: helpdesk@trawisup.freeserve.co.uk
Website: http://www.trawisup.freeserve.co.uk/
Provides
advice and support for people with problems with tranquillisers,
anti-depressants or painkillers, and their families. Runs self-help
group meetings, and offers home visiting by appointment. Can provide
training and advocacy. Can take calls from around the UK.
Tranx-Release Helpline
Mike — tel: 0151 930 4287
(Mondays to Fridays 10am-3pm)
Gwen — tel: 0115 978 1612 (Mondays
to Fridays 9.30am-12pm)
Nigel — tel: 0115 981 3586 (Mondays to
Fridays 9am-9pm, Saturday 11am-3pm)
Confidential telephone
support for people addicted to tranquillisers, sleeping tablets and
anti-depressants.
UKPPG Medication Helpline
Helpline: 020 7919 2999
(Mondays to Fridays 11am-5pm)
Website: http://www.ukppg.co.uk/
The UKPPG (UK
Psychiatric Pharmacy Group) exists to ensure best treatment with
medicines for people with mental-health needs. Offers confidential
advice and information on prescription drugs for patients, carers
and families. Has leaflets on common psychiatric medicines.
websites
Adverse Psychiatric Reactions Information Link
http://www.april.org.uk/
Aims to raise
awareness of adverse psychiatric drug reactions. Features extensive
information, personal experiences and links.
All About Depression
www.mentalhealth.org.uk/html/content/bkdepress.cfm
Published
by the Mental Health Foundation, this online booklet is aimed at
those wanting to know more about depression, including its causes
and treatments.
American Academy of Family Physicians
www.aafp.org/afp/20000401/2121.html
Includes an
article called Addiction: Benzodiazepines — Side Effects, Abuse
Risk and Alternatives.
Antidepressant Discontinuation Reactions
www.uea.ac.uk/~wp276/antidepressant.htm
Personal
site by a researcher interested in antidepressant discontinuation
reactions. Includes a message board.
Antidepressant Discontinuation Reactions
http://www.bmj.com/
British Medical
Journal editorial by Peter Haddad, Michel Lejoyeux, and Allan
Young.
Antidepressants Facts
http://www.antidepressantsfacts.com/
An
extensive source of information on the side-effects and safety of
SSRIs. Features research, articles, studies, personal experiences,
views of doctors plus a range of links to further sources of
information.
Back to Life
http://www.backtolife.uk.com/
Information
about the long-term use of antidepressants and benzodiazepines. Set
up as a subsidiary to CITA (see organisations).
BBC Health: The A-Z of Drugs
www.bbc.co.uk/health/mental/help_drugs.shtml
A
list of the most commonly used drugs in the treatment of mental
health problems, explaining what they are used for and listing
important facts.
Benzo
http://groups.yahoo.com/group/benzo
Online
support group network for those who want to end benzodiazepine
addiction.
Benzo Awareness Network
www.geocities.com/benzowebsites
A range of
websites on the subject of benzodiazepines and how to withdraw from
them.
Benzodiazepine.org
http://www.benzodiazepine.org/
UK-based site
featuring a personal account of benzodiazepine addiction, with
information and resources on benzodiazepines, prescription drug
addiction, withdrawal and recovery.
Benzodiazepine Addiction, Adverse Reactions and Withdrawal
Symptoms
www.spacehoppa.com/april/pages/benzo.html
Part
of the Adverse Psychiatric Reactions Information Link website, with
information on adverse effects and withdrawal, details of websites
and support groups, and other resources.
Benzodiazepine Addiction, Withdrawal and Recovery
http://www.benzo.org.uk/
Comprehensive resource
for information on benzodiazepine addiction, featuring articles,
news stories and personal accounts. Includes frequently asked
questions.
British National Formulary
http://www.bnf.org/
Authoritative information
on the selection and clinical use of medicines aimed at UK
healthcare professionals but available to all.
International Coalition for Drug Awareness
http://www.drugawareness.org/
A group of
doctors, researchers, journalists and concerned citizens dedicated
to educating others about the dangers posed by some prescription
medicines.
Mental Health Foundation
http://www.mentalhealth.org.uk/
Information and
literature on all aspects of mental health, including where to get
help.
Panorama: The Tranquilliser Trap
http://news.bbc.co.uk/hi/english/audiovideo/
programmes/panorama/
tranquillisers/newsid_1312000/1312741.stm
Details of the BBC Panorama programme investigating
tranquilliser dependency.
Quick Guide to Antidepressants
www.sane.org.uk/About_Mental_Illness/Antidepressants.htm
Part
of the Sane website, this is a brief look at antidepressants, their
effectiveness, effects, and a description of how they work. Includes
links to recommended websites and reading.
The Royal College of Psychiatrists: Antidepressants
www.rcpsych.ac.uk/info/factsheets/pfacanti.htm
Informative
factsheet on antidepressants, dealing with how they work, their side
effects, and other frequently asked questions.
Social Audit
http://www.socialaudit.org.uk/
This site is
built around two interwoven themes: how medicines are used to treat
depression, and what this says about the way health care is
provided.
publications
The Accidental Addict by Di Porritt and Di Russell
A
resource for people experiencing problems discontinuing
benzodiazepines, and their families and friends. Further information
at http://www.benzo2000.com/.
Addiction by Prescription: One woman's triumph and fight for
change by Joan E. Gadsby (Key Porter Books Ltd, 2000)
£16.99
A personal account of addiction to benzodiazepines,
discussing the physical, cognitive and emotional side-effects of the
drugs, and the author's fight for a change in the health
industry.
Alive and Kicking by Peter Ritson (Casa Publishing, 1989)
£4.95
A personal account of how one man came to terms with and
eventually kicked his benzodiazepine addiction.
Back to Life by Pam Armstrong (Print Origination, 1998)
£4.95 including p+p
How tranquillisers work and the problems of
tranquilliser withdrawal. Available from the CITA helpline (see
organisations).
Benzodiazepines: How they Work and How to Withdraw (The
Ashton Manual) by Professor C Heather Ashton 2001.
A manual
based on the author's 12 years of experience in running a
benzodiazepine withdrawal clinic. Further information about the book
and ordering can be found at www.benzo.org.uk/bzmono.htm
Complete Guide to Psychiatric Drugs by Ron Lacey
(Mind/Ebury Press, 1996) £9.99
Discusses the benefits,
side-effects and hazards of prescribed psychiatric drugs, with
advice on use in pregnancy, childhood and old age.
Consumer's Guide to Psychiatric Drugs by John Preston,
John H O'Neal and Mary C Talaga (New Harbinger Publications, 1998)
£14.99
Provides information on the purpose, dosage, side effects,
interactions, and long-term effects of psychiatric drugs.
Making Sense of Treatments and Drugs: Major
Tranquillisers
Making Sense of Treatments and Drugs: Minor
Tranquillisers
Making Sense of Treatments and Drugs: Anti
Depressants
Making Sense of Sleeping Pills
Each of
these booklets is published by Mind and costs £3.50. For further
details visit www.mind.org.uk/shopping/shopping.asp.
Power and Dependence by Charles Medawar (Social Audit,
1992) £10
Discusses the safety of medicines from a consumer
perspective, focusing attention not so much on the properties of
molecules as on the conduct of the medical profession, government
agencies and the drug companies.
(December 2001)
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