coming off antidepressants and tranquillisers

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 antidepressants, and particularly some of the newer classes of antidepressants, can cause similar problems. People are wondering whether they can become addicted to (doctors normally say 'dependent on') antidepressants 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.

antidepressants

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Antidepressants 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, antidepressants can also be used to treat anxiety, panic attacks and obsessive-compulsive disorder, to help with binge eating (bulimia), to relieve pain, and to dampen down the psychological reactions to severe trauma (post-traumatic stress disorder).

Antidepressants 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 antidepressants 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, antidepressants 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 antidepressant 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, antidepressants differ in how dangerous they are in overdose. Many of the older antidepressants, 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 antidepressants, 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 antidepressants 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.

antidepressants and 'discontinuation syndrome'

So are antidepressants 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 antidepressants. For example, unlike with benzodiazepines, people don't develop tolerance to antidepressants (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 antidepressants for non-medical reasons, because antidepressants 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 antidepressant dependence and withdrawal but about a 'discontinuation syndrome'.

It's important to realise that this is nothing new. Discontinuation problems have been recognised since antidepressants 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, antidepressants, 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 antidepressant, 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 antidepressants 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 antidepressants, 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 antidepressants 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 antidepressant 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

Channel 4 is not responsible for the content of third party sites.

You might like to check out the feature on depression which discusses the condition in detail and looks at various types of treatment. Also, see our stress section for information about stress relief and the abc of drugs 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 antidepressants 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: www.bataid.org
Aims to help people who wish to withdraw from tranquillisers or sleeping pills. Provides individual counselling and local support groups.

CITA (Council for Involuntary Tranquilliser Addiction)
Cavendish House
Brighton Road
Waterloo
Liverpool L22 5NG
Helpline: 0151 949 0102 (Mon-Fri 10am-1pm)
Website: www.liv.ac.uk/~csunit/community/careorgs/cita.htm
Advice and support for people addicted to tranquillisers and sleeping tablets. Information, advice and leaflets available on anxiety, tranquillisers and antidepressants. Training offered for professionals.

Depression Alliance
35 Westminster Bridge Road
London SE1 7JB
Tel: 0845 123 23 20
E-mail: information@depressionalliance.org
Website: www.depressionalliance.org
National network of self-help groups for people experiencing depression. Offers a newsletter, national pen friend scheme and correspondence service with advice, guidance, support and fellowship to people experiencing depression, and their carers. Produces booklets and leaflets on various aspects of depression.

First Steps to Freedom
1 Taylor Close
Kenilworth CV8 2LW
Helpline: 0845 120 2916 (every day 10am-10pm)
Tel: 01926 864473
E-mail: info@first-steps.org
Website: www.first-steps.org
A confidential helpline for people suffering from general anxiety, panic attacks, phobias, obsessive compulsive disorder, anorexia and bulimia, and their carers. Offers counselling, listening, advice, support and information.

Mind (National Association for Mental Health)
15-19 Broadway
London E15 4BQ
Mind Infoline: 0845 766 0163 (Mon-Fri 9.15am-4.15pm)
Tel: 020 8519 2122
E-mail: contact@mind.org.uk
Website: www.mind.org.uk
Campaigns for better mental health services in England and Wales, through its national office, regional offices and network of over 200 local branches, some of which also provide services. Publishes a range of helpful books and leaflets. Contact them for details of your nearest local group and for more information.

National Phobics Society
Zion CRC
339 Stretford Road
Hulme
Manchester M15 4ZY
Helpline (members only): 0870 7700 456 (Mon-Fri 10am-4pm)
E-mail: nationalphobic@btconnect.com
Website: www.phobics-society.org.uk
A membership-only organisation, run by sufferers and ex-sufferers of anxiety disorders, that provides support and advice to people affected by phobias and anxiety disorders. Offers one-to-one therapy (with home visits for those who are housebound through agoraphobia etc.) including CBT, clinical hypnotherapy and counselling.

No Panic
93 Brands Farm Way
Telford TF3 2JQ
Helpline: 0808 808 0545 (every day 10am-10pm, answerphone 10pm-10am)
E-mail: ceo@nopanic.org.uk
Website: www.nopanic.org.uk
Provides a range of services for people who suffer from panic attacks, phobias and OCD including literature, audio/ video cassettes, a membership scheme and "contact" service. Also offers telephone recovery groups for people who live in rural or isolated areas where access to local support is limited.

Tranquilliser Withdrawal Support (West Suffolk)
Blomfield House Health Centre
Bury St Edmunds IP33 1HE
Helpline: 01284 702550 (Mon-Fri 5-6pm; 24 hour answerphone)
E-mail: helpdesk@trawisup.freeserve.co.uk
Website: www.trawisup.freeserve.co.uk
Provides advice and support for people with problems with tranquillisers, antidepressants 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
Tel: 0115 978 1612 (Mon, Wed, Fri 9.30am-12pm)
Confidential telephone support for people addicted to tranquillisers, sleeping tablets and antidepressants.

UKPPG Medication Helpline
Helpline: 020 7919 2999 (Mon-Fri 11am-5pm)
Website: 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
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/page.cfm?pagecode=PBBFDP
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
www.bmj.com
British Medical Journal editorial by Peter Haddad, Michel Lejoyeux and Allan Young.

Antidepressants Facts
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
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/conditions/mental_health/drugs_az1.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.

BENZACT
www.benzact.org.uk
Campaigning organisation that can provide information on the adverse effects of benzodiazepines, including the effects of taking benzodiazepines during pregnancy.

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
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, Withdrawal and Recovery
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
www.bnf.org
Authoritative information on the selection and clinical use of medicines aimed at UK healthcare professionals but available to all.

Coming Off Psychiatric Medication
www.comingoff.com
Website that aims to give up to date information about psychiatric medication, how it functions and the withdrawal process.

International Coalition for Drug Awareness
www.drugawareness.org
A group of doctors, researchers, journalists and concerned citizens dedicated to educating others about the dangers posed by some prescription medicines.

Prozac Survivors Support Group
www.pssg.org
Informing and educating the public about the SSRI drug products such as Prozac, Paxil, Zoloft, Luvox, and Celexa.

Quick Guide to Antidepressants
www.sane.org.uk/public_html/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/.../depression/antidepressants.aspx
Informative factsheet on antidepressants, dealing with how they work, their side effects, and other frequently asked questions.

Social Audit
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.

reading

	Back to Life by Pam Armstrong (Print Origination, 1998) £4.95 inc p+p How tranquillisers work and the problems of tranquilliser withdrawal. Also available from the CITA helpline (see organisations, above). Get this book
	Benzodiazepines: How they Work and How to Withdraw by Prof C Heather Ashton (The Ashton Manual, 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) Discusses the benefits, side-effects and hazards of prescribed psychiatric drugs, with advice on use in pregnancy, childhood and old age. Get this book
	Consumer's Guide to Psychiatric Drugs by John Preston, John O'Neal and Mary Talaga (New Harbinger Publications, 1998) Provides information on the purpose, dosage, side effects, interactions, and long-term effects of psychiatric drugs. Get this book
	Power and Dependence by Charles Medawar (Social Audit, 1992) 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. Get this book
	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 - Antidepressants or www.mind.org.uk - Sleeping Pills.

(December 2001, resources updated January 2005)