Last year, Prof John Read and Dr James Davies published a paper in the scientific journal ‘Addiction’ reviewing the withdrawal effects of antidepressants and suggesting these are worse than most people have been informed.

They raise concerns that symptoms of withdrawal are both more common, affecting nearly half of people trying to come off them, and last much longer, up to 4-6 weeks ( rather than the one or two suggested in the government guidelines ). They are also concerned that the symptoms of withdrawal people experience when trying to stop taking the medication may be mistaken for a relapse of their illness, causing them to go back onto the medication without good reason. Finally, they argue that the withdrawal symptoms are so severe that the clinical guidelines around their use should be revised.

Antidepressant medications are being used more and more, rising by 170% since 2000. As many as 16% of the UK population were prescribed antidepressants last year and half of all users have been taking them for more than 2 years. Looking further, 36% have been on antidepressants for more than 5 years and 26% expect to stay on them for life. Alarmingly, 65% had never had a discussion with the person who prescribed them about coming off and, perhaps in a connected way, 45% of those who had stopped the drugs had done so without consulting their doctor. Indeed, about 1 / 3 people taking antidepressants for more than 2 years have no clinical indications for taking them.

Depression is a horrible problem to have to suffer with and, if antidepressants are providing effective treatment, it may well be worth tolerating some side effects and withdrawal symptoms. The main problem is that it seems as though these downsides and side effects are being understated and people may not be being given full and accurate information about them. Nearly half of people experiencing withdrawal effects describe them as ‘severe’, and it is not uncommon for people to continue experiencing withdrawals for several months. This is quite different from the current guidelines which describe ‘discontinuation symptoms’ as ‘mild and self-limiting, resolving over 1-2 weeks’.

All of this is not to say that people should stop medications they are finding helpful or that others shouldn’t explore medications as a good treatment option but it does sound like the advice and management around medication needs a lot more care and attention. Firstly, people need more detailed advice about the difficulties they might experience when they try and stop their medication and secondly their cases need regularly reviewing to see if, when and how they might consider stopping.

Finally, it should be emphasised that although we are discussing some of the side effects of medications, many still find them extremely helpful. Also, there are a number of new medications for depression showing great promise so the outlook for sufferers will only improve in the coming years and maybe even months. We shall report on some of these new treatments in articles very soon.

References:

“A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based?”:

https://www.sciencedirect.com/science/article/pii/S0306460318308347

The CAGE alcohol questionnaire takes just four questions to diagnose alcohol problems:

1. Have you ever felt that you should cut down on your drinking?

2. Have people annoyed you by criticizing your drinking?

3. Have you ever felt bad or guilty about your drinking?

4. Have you ever had a drink first thing in the morning to calm your nerves or get rid of a hangover?

9/10 people answering yes to two or more questions have been found to have an alcohol problem and 9/10 people who answer yes to all four are diagnosed to have alcoholism. 

Research has shown the CAGE questionnaire is both reliable and valid as a tool to screen for alcohol problems. ( https://en.wikipedia.org/wiki/CAGE_questionnaire )

The great value of the CAGE questionnaire is that people in front line health positions can use it as a quick and reliable screen to include amongst other health questions and allow earlier identification of problems and hachance to get help sooner. 

Whether you have an addiction problem, care about someone with an addiction problem or even if you work with people who have addiction problems, I think it helps to step back for a minute and understand how this problem and it’s recovery unfolds. It’s too easy to get blinkered, judgemental of ourselves and others, and not see the overall patterns of what we are looking at.

Professor John Kelly, addiction professor at Harvard Medical has produced a slide which really neatly summarises how these problems evolve and how recovery ensues. Please bear in mind that we are talking about averages here and we are talking about severe addiction problems. When you have an average, of course, there are going to be people who have very different experiences but this shouldn’t stop us from looking at averages to get an understanding of the course of recovery.

Addiction Onset

The first period that Professor Kelly described was the ‘onset’ of the problem. From the point at which it could be said that the addiction was first recognisably a problem, there was an average of a 4-5 year period where people have tried a series of self-initiated cessation attempts before they ask for outside assistance or help.

Help-Seeking

The next period could be described as an average of 8 years of Help-Seeking after which they are able to achieve full sustained recovery for more than one year. When I first heard Professor Kelly describe this he was very quick to point out that this period had a lot of recovery time in it, it’s just that it was taking this time to achieve an average of one full sustained year abstinent. On average people may have 4 or 5 treatment episodes and engagements with Mutual Help organisations ( AA, SMART etc.. ) during this stage.

5 Continuous Years of Abstinence.

During the first 5 years of abstinence, there is a need for continued care and mutual help. At the end of this first 5 years, the risk of relapse drops below 15%. This is significant because 15% of the population will develop an addiction problem so Professor Kelly has argued this is like saying that after 5 years of recovery, people return to having the same risk of addiction that the rest of the population have.

Conclusions and lessons to be learned

So, standing back and looking at this data, what conclusions can we draw?

It takes time

From the point of view of having an addiction problem, I think it is helpful to see that it takes time to get into recovery. There is this frightening saying that ‘relapse is part of the process of recovery’ and it can be disappointing to hear this. Of course, there are many people who achieve sustained recovery ‘first time’ but equally, there are many who struggle longer. I don’t think this should be very surprising. Addiction problems are the tip of the iceberg, underneath and around are many other social and psychological issues that interplay and so it really can’t be any surprise that it takes practice to get all these elements into the right alignment for recovery. If you reflect on any other skill you have developed, I bet there were times when you felt your learning was going backwards instead of forwards. The important thing here is not to feel like you just can’t get it if you have a slip or a relapse.
Overwhelmingly in this research data you can see a pathway that people with severe addiction problems are taking to come into recovery and long term remission from their problems. It’s important for everyone involved to keep the faith that this is where you are all heading.

Early intervention

You can see from the first period that there is this long stretch of 5 years after addiction becomes a problem but before someone seeks outside assistance. If it is apparent to the sufferer then it must also be apparent to those around them. Why is it taking so long to start asking for help? Perhaps there is still some embarrassment and shame? Perhaps friends and families think it’s none of their business. Somehow we need to make asking for help an easier thing and we should also encourage friends and families to bring this subject up. The sooner someone can get started with this, the sooner they will recover.

Family and friends

Addiction brings with it a series of crisis and during these episodes, it is very easy for any and all of us to lose hope. Looking at this outcome data you can see the evidence that the long term prognosis is in fact very good. The period that everyone must find very stressful is that middle period, averaging 8 years, where people are trying to find that first year of continuous abstinence. This is the time when there can be such tremendous recovery and hope and then, terrible setbacks. It is understandable to lose hope and feel very frustrated during this phase but it is such a shame if people can’t see what lies beyond. Ultimately, people could have any number of possible medical or psychiatric problems, addiction is just one of these, but the recovery rates for addiction are very similar for nearly any other chronic problems, medical or psychiatric. One of the statistics that Professor Kelly quotes is an outcome study ( White 2013 ) which calculated that 60% of individuals with addiction will achieve full sustained remission. Perhaps it’s the continued shame and judgement that surrounds addiction as so many still consider it a moral or character problem rather than understanding it’s medical and psychiatric dimensions. This is the time to set our sights on the long term outcome and outlook.

Carers and professionals.

From the perspective of someone who helps people with addiction problems, there are quite a few lessons here. One is the importance to try and find ways of helping people access help at earlier points. There is that beginning 5 year period where people are attempting to stop on their own before asking for help. Why aren’t they asking for outside assistance when this will so massively increase their success? I have another article about this very point so I won’t elaborate on it now but it’s worth us all reflecting on this. I would also ask people to consider how the expectation of recovery is phrased. It’s clearly important to study and discover what was working for them vs what wasn’t, but I do hear people being highly critical of treatments/people or methods as if there was ‘one’ other simple key which this new person/clinic/treatment centre can now offer. I see this in self-help groups, I see it amongst professionals and I see it between clinics. I suggest it’s important that we help people see this as a process of coming into recovery rather than one singular. To this point, it is most important that we be sure to offer the widest range of evidenced treatments rather than just one based on ‘opinions’. Let’s focus on the research evidence and share a range of skills and let’s help sufferers be less punishing of themselves and let’s help others be less punishing of them also.

It will be the focus of another article I am writing to look at how to minimise relapse.

In summary, let’s help people by sharing with them the bigger picture of this process of the recovery ‘Lifecycle’.

How long should someone stay in Rehab?

I’m sure this is a million dollar question and of course depends on so many things, how many problems we have, how bad they are and so on, but still, some people come in for a very brief respite and others stay longer so it’s interesting to know if there is any evidence for different benefits for different lengths of stay.

People come to clinics with many different problems, depression, addiction, alcoholism, eating disorders and so on. Unfortunately we rarely only have just one problem and so treatment needs to be tailored to helping on all these fronts at the same time.

Equally, there are many different treatments, Psychiatry, medicine, psychology, psychotherapy and so on. Understanding exactly which one works best for each individual and in what combination, is a very complicated process and makes research quite tricky. To do any research then, we need to find one common measurable factor and see how it is affected by the combined treatments.

I this study I looked at how depressed people were when they arrive and how this changed through treatment. The Becks Depression Index was created by the co-founder of CBT, Dr Aaron Beck. Thankfully it’s a fairly brief questionnaire but it has the benefit that it has been used in so many different clinical situations that there is very good evidence for its ability to accurately measure depression.

The BDI scores different ranges for depression you can see here:

1-10____________________These ups and downs are considered normal
11-16___________________ Mild mood disturbance
17-20___________________Borderline clinical depression
21-30___________________Moderate depression
31-40___________________Severe depression
over 40__________________Extreme depression

I decided to look at the scores of all the patients in the last year who came in with a score greater than 31, indicating Severe Depression. I then wanted to compare the average score on admission with the average score before leaving depending on how long they stayed. I know this is a small sample group since the research was conducted in a small clinic and I only took the data from the last year, so I may be able to do further analysis and build up greater numbers but it was still an interesting first analysis.

What we found was that for those who only stayed one week, the average score on admission was 37, so close to extreme depression, and the score on discharge, after that one week, was 26, so in the middle of the range of moderate depression. Not a bad shift in just one week!

In the group who stayed two weeks, the scores were quite similar to those who stayed just one week, the admission score was a bit higher, this group were scoring an average of 41 which is categorized as Extreme Depression but after just two weeks the scores came down two categories to 25, described as Moderate Depression.

It is really interesting to note what happened in the next two groups. For the clients who stayed for 3 weeks, the average admitting score was 40, so still very close to the Extreme Depression category, but the score after three weeks of treatment came down to just 13, described as ‘mild’ mood disturbance. Equally, the group who stayed four weeks also had a very high average score on admission of 38 and were just 14 on discharge, four weeks later.

So what can we conclude from this? Again, as I said at the beginning, we have to be careful to draw too many conclusions from such a small sample of patients but it does seem as though, although a one week and two weeks stay is beneficial, it looks as though three and four week stays are where you will see much more significant shifts.

Drinking any amount of alcohol is harmful

Alcohol is the leading attributable cause of death amongst the adult population ( between the ages of 15-49 ) and yet the message people have heard from doctors and the media has been that drinking a small amount of red wine may be good for your health. This was never true but it led to a lot of vulnerable people being given a validation for their drinking by the medical profession. This week, the medical research journal “The Lancet” has finally exposed this myth and made clear it’s advice that drinking anything at all is harmful.

There is nothing wrong with doing harmful things of course. Riding horses is harmful, and yet, people make an educated decision that riding their horse is fun and it is what they choose to do. You could say the same about riding a motorbike or many other activities that people do to enjoy themselves. They are prepared to take the risks that they know go along with it.

The same might be said for alcohol. People drink and enjoy it and can do so knowing the risks involved. So what is the big fuss with this new report in the Lancet?

Well, there is a massive difference when half of the alcohol is consumed by people with a mental health problem which gives them a pathological dependence on alcohol. In this case, every bit of information needs to be as clear as possible.

If you do a quick Google for ‘red wine is good for your heart’ you will find a long list of articles that have come out over the years where people tried to make the case that drinking ‘one glass a day of red wine’ was good for your health, specifically, it was supposed to be good for your heart. Unfortunately, these studies were flawed because they compared moderate drinkers against abstainers without taking into account the health reasons that may have led people to abstain. When you take this factor out, there were never any health benefits to drinking even just one glass of wine per day ( https://www.jsad.com/doi/10.15288/jsad.2016.77.185 ) Every drink did some damage.

So, no health benefits, but on the other hand, among the population from 15-49, alcohol was the leading attributable risk factor in deaths! So there is a massive risk that needs to be communicated about heavy alcohol consumption even though, for some strange reason, it seems to be hard to have that message communicated clearly.

Of course, the average person who drinks just one glass of wine per day probably doesn’t care if they take it or leave it and probably doesn’t care about the minimal impact it might have on their health, positive or negative. Unfortunately, the group who paid most attention to the ‘supposed’ health benefits of alcohol were the group I mentioned earlier who were drinking substantially more than one glass of wine per day and who are experiencing devastating consequences from drinking on all fronts, not least health. Having information which was misleading had the terrible effect of reinforcing denial about the need to stop drinking.

Finally, the truth is made clear. Any drinking is harmful and excessive drinking is excessively harmful.
( https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31310-2/fulltext ) These are the facts. If you choose to drink moderately and accept those risks then that is great and absolutely your right, but please help us communicate more clearly with the 10% who are hurting themselves and others terribly.

Transcranial Magnetic Stimulation is an exciting treatment for depression using magnets to stimulate the dorsolateral prefrontal cortex at the front of the brain which is associated with mood.

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BBC World at One news programme has reported on poor and unsafe practice in the private rehab sector.
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Today is world sleep day and poor sleep is one of the most common difficulties people face when recovering from mental health problems.
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Philippe Cavaroz presented on behalf of the PROMIS French team at the prestigious iCAAD conference in Paris today. There were speakers representing all aspects of care for people with addiction problems.
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In this last couple of years, I have seen Dr John Kelly speak a few times and I am always impressed with what he has to say. I want to share a few ideas he has brought up and to begin with, I’d like to share his ideas about the language we use to describe addiction problems, both as lay people and professionals.

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