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coming off anti-depressants and tranquillisers

 

this feature:

anti-depressants | anti-depressants and 'discontinuation syndrome'
tranquillisers (benzodiazepines) | general guidelines | help and info


Consultant psychiatrist Dr Ron Alcorn looks at the problems some people experience when stopping taking drugs used to treat depression and anxiety

talk to a doctor!

This information is intended only as a general guide and is not a substitute for professional medical advice. If you're worried about any prescription drug you're taking, talk to your doctor, explaining why you're concerned. Don't just stop taking the drug this can be dangerous.

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)