Antidepressant Prescribing in Australian Primary Care: Time to Reevaluate

In their critique of long-term antidepressant prescription for depression and the risks of medication discontinuation—concerns that we share—Wallis and colleagues [1] state that the Royal Australian and New Zealand College of Psychiatrists (RANZCP) guideline [2] does not suggest ‘any viable alternative’ to hyperbolic tapering. This is entirely incorrect. The guideline provides very specific instructions on the withdrawal of antidepressants (Recommendation Box 4) as well as sections discussing ‘Stopping antidepressants’, ‘Risk of discontinuation and withdrawal symptoms’ and ‘Strategies for dose reduction’. It also makes a specific recommendation that ‘a detailed review of ongoing pharmacotherapy should occur at 1 year’ (Recommendation Box 3). We are therefore puzzled by the authors' claim that ‘guidance in Australia for how to stop antidepressants remains unchanged and unhelpful’. This too is incorrect. Further, they comment that more women are prescribed antidepressants and for lengthy periods of time, but depression preferentially affects women [3] and is a chronic and recurrent illness. In addition, the authors' assertion that lack of awareness of withdrawal and discontinuation trammels informed consent seems somewhat speculative—especially given that the guideline recommends that when initiating antidepressants, patients should be informed of potential withdrawal symptoms and following collaborative discussions, many depressed patients choose to continue taking antidepressants [4]. On top of this, the guideline [2] holistically prioritises exercise and other lifestyle interventions such as diet and sleep and describes them as essential ‘actions’ that are mandated as the foundation of depression management. It also includes specific strategies for instituting these interventions (Boxes 4, 5 and 6) and where possible, clearly recommends that depression be treated by non-pharmacological means and that psychological therapies be actioned before prescribing antidepressants. However, we agree that not everyone needs antidepressants, but then, not all patients respond to lifestyle interventions and psychological treatments alone. In practice, withdrawal symptoms are distinguishable from those indicating a depressive relapse as they appear sooner, and can often be minimised by gradual antidepressant tapering. In sum, although the discontinuation of antidepressants is as important as initiating them, antidepressant deprescribing should not lead to their proscription, and when used judiciously, antidepressants do benefit depressed patients. Gin S. Malhi: conceptualisation, writing – original draft, writing – review and editing. Erica Bell: conceptualisation, writing – original draft, writing – review and editing. Kinga Szymaniak: conceptualisation, writing – original draft, writing – review and editing. Philip M. Boyce: conceptualisation, writing – original draft, writing – review and editing. Jeffrey C. L. Looi: conceptualisation, writing – original draft, writing – review and editing. The authors have nothing to report. Gin S. Malhi has received grant or research support from National Health and Medical Research Council, Australian Rotary Health, NSW Health, American Foundation for Suicide Prevention, Ramsay Research and Teaching Fund, Elsevier, AstraZeneca, Janssen-Cilag, Lundbeck, Otsuka and Servier; and has been a consultant for AstraZeneca, Janssen-Cilag, Lundbeck, Otsuka and Servier. He is the recipient of an investigator-initiated grant from Janssen-Cilag (PoET Study), joint grant funding from the University of Sydney and National Taiwan University (Ignition Grant) and grant funding from The North Foundation. Erica Bell has received joint grant funding from the University of Sydney and National Taiwan University (Ignition Grant), The North Foundation and the Greek Young Matrons' Association (GYMA) Foundation. Kinga Szymaniak has received grant funding from the GYMA Foundation. Philip M. Boyce has received speaker fees from Servier and Janssen, educational support from Servier and Lundbeck, is on an advisory board for Incite Health, has been a consultant for Servier, inhaleRx and Greenhorn industries, and has served as DSMC Chair for Douglas Pharmaceuticals. Jeffrey C.L. Looi is Editor-in-Chief of Australasian Psychiatry and a member of the Advisory Board of Australian and New Zealand Journal of Psychiatry. He is a Fellow of the Australian Medical Association (AMA) and formerly, AMA Federal Council Specialist Representative for Psychiatrists, and Board Member, AMA-ACT. The authors have nothing to report.