APPG-Guidance-for-therapists-drug Withdrawal PDF

for Prescribed
Drug Dependence
Guidance for
Psychological Therapists
Enabling conversations with clients taking or
withdrawing from prescribed psychiatric drugs
December 2019
© Council for Evidence-based Psychiatry 2019
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Citation of document
Guy, A., Davies J., Rizq, R. (Eds.) (2019). Guidance for psychological 4. Moncrieff, J. & Stockmann, T. (2019). What psychiatric drugs
therapists: Enabling conversations with clients taking or do by class. In: A. Guy, J. Davies, R. Rizq (Eds.) Guidance for
withdrawing from prescribed psychiatric drugs. London: APPG psychological therapists: Enabling conversations with clients
for Prescribed Drug Dependence. taking or withdrawing from prescribed psychiatric drugs.
London: APPG for Prescribed Drug Dependence.
Section citations: If you are quoting from individual 5. Read, J. & Davies, J., with Montagu, L., Spada, M.M. &
sections please use the following citations: Frederick, B. (2019). What do we know about withdrawal?
In: A. Guy, J. Davies, R. Rizq (Eds.) Guidance for psychological
1. Davies, J., Rizq., R & Guy, A. (2019). Introduction. In: A. Guy,
therapists: Enabling conversations with clients taking or
J. Davies, R. Rizq (Eds) Guidance for psychological therapists:
withdrawing from prescribed psychiatric drugs. London: APPG
Enabling conversations with clients taking or withdrawing from
for Prescribed Drug Dependence.
prescribed psychiatric drugs. London: APPG for Prescribed
6. Guy, A. with Frederick, B., Davies, J., Kolubinski, D., Montagu,
Drug Dependence.
L. (2019). The role of the therapist in assisting withdrawal from
2. Moncrieff, J. & Stockmann, T. (2019). Introduction for
psychiatric drugs: What do we know about what is helpful?
therapists on how psychiatric drugs work. In: A. Guy, J.
Davies, R. Rizq (Eds.) Guidance for Psychological Therapists:
Enabling conversations with clients taking or withdrawing from
Drug Dependence.
7. Guy, A. with anonymous experts by experience (2019).
3. Rizq, R., with Bond, T., Guy, A., Murphy, D., Sams, P., Spada, M.
Patient voices: Examples from real life. In: A. Guy, J. Davies,
M, & Whitney, G, (2019) Implications for therapeutic practice.
R. Rizq (Eds.) Guidance for psychological therapists: Enabling
conversations with clients taking or withdrawing from
Drug Dependence.
If you have problems reading this document and would like it in a different
format, please contact us with your specific requirements.
t: 0116 252 9523; e: P4P@bps.org.uk.
Contents
Acknowledgements 4 4.4 Antipsychotics 49
4.5 Lithium and other drugs referred to 57
Section 1: Dr James Davies, Professor Rosemary as mood stabilisers
Rizq & Dr Anne Guy
4.6 Stimulants 63
1. Introduction 7
4.7 Combined psychotherapeutic and 68
1.1 What are the aims of this guidance? 8 psychopharmacological intervention
1.2 Who is this guidance for? 9 in depression
1.3 The medical model and the emerging crisis 9 4.8 Conclusion: Understanding psychiatric 71
1.4 Glossary 11 medication
1.5 Scope 12
Section 5: Professor John Read & Dr James
1.6 How to use the guidance 12 Davies, with Luke Montagu & Professor
Marcantonio Spada
Section 2: Professor Joanna Moncrieff &
5. What do we know about withdrawal? 72
Dr Tom Stockmann
5.1 A general introduction to dependence 72
2. Introduction for therapists on how 14
and withdrawal
psychiatric drugs work
5.2 Evidence on the likelihood, range of 75
2.1 The place of prescribed drugs in Mental
possible experiences, duration and
Health Services 14
severity of withdrawal per drug class
2.2 How do psychiatric drugs work? 14
5.3 Overall impacts of withdrawal on 87
individuals
Section 3: Professor Rosemary Rizq, with
Professor Tim Bond, Dr Anne Guy, Dr David 5.4 The withdrawal process and terminology 88
Murphy, Paul Sams, Professor Marcantonio Spada
& Georgina Whitney Section 6: Dr Anne Guy, with Dr James Davies, Daniel
C. Kolubinski, Luke Montagu & Baylissa Frederick
3. Implications for therapeutic practice 17
6. The role of the therapist in assisting 92
3.1 The biomedical paradigm and its 17
withdrawal from psychiatric drugs –
relationship to different therapeutic
what do we know about what is helpful?
modalities
6.1 The combined wisdom approach 93
3.2 Key issues for therapists to consider 20
when working with clients who are 6.2 Psychiatrist led multidisciplinary models 96
taking or withdrawing from prescribed 6.3 How are UK therapists already working 97
psychiatric drugs with withdrawal?
3.3 Practice-related guidance for therapists 26 6.4 Conclusion 99
Section 4: Professor Joanna Moncrieff & Section 7: Dr Anne Guy (Ed.)

Dr Tom Stockmann 7. Patient voices – examples from real life 100
4. What psychiatric drugs do by class 35
4.1 Interpreting the evidence on 35 Appendix A – Resources 104
psychiatric drugs
4.2 Antidepressants 37
4.3 Benzodiazepines and related drugs 45
December 2019 1
A welcome guidance
BACP has been proud to be part of this The BPS fully endorses this guidance We are absolutely delighted to
important project to produce much- and is proud to have produced this endorse this guidance document,
needed guidance for our members. in collaboration with our partner which will be an invaluable resource
The increase in the prescription of organisations. to countless therapists both now and
psychiatric drugs means many of our We believe the official recognition for years to come. It’s commonplace
members are working with clients who of the increasing numbers of people for UKCP members to be working
are taking or withdrawing from them, being prescribed psychiatric drugs, with individuals taking psychiatric
and this can have an impact on their and the difficulties withdrawing from medication, yet many don’t feel
work. them, is a positive step in helping both properly equipped to discuss this
patients and psychological therapists. in therapy. This guidance not only
We know from a recent survey of
provides therapists with deeper
practising therapists that the majority Our members have consistently told us
knowledge of these medications, but
feel ill-equipped to deal with these that they need guidance, information
will enable them to discuss confidently
issues in a therapeutic setting. and training to help them work more
issues that are often central to the
This work will provide our members confidently with clients either taking or
emotional distress that people they
with up-to-date evidence and relevant withdrawing from prescribed drugs.
are working with are experiencing.
guidance to help clients deal with the The evidence reviewed in this guidance The importance of this cannot be
issues around taking or withdrawing provides an up-to-date summary of the underestimated. It constitutes yet
from such drugs and understand the main effects, adverse consequences another important step in improving
impact on clients and therapy. and possible withdrawal reactions for the care for the alarming number of
We fully support the guidance and each of the main classes of psychiatric people currently being prescribed
recommend it as a resource for our drug. psychiatric medication.
members and training providers. We strongly recommend this guidance
as a resource for our members. Professor Sarah Niblock
Hadyn Williams Chief Executive, UKCP
Chief Executive Officer, BACP Sarb Bajwa
Chief Executive, BPS
2 Guidance for Psychological Therapists

As a network led by people who The National Counselling Society fully I am delighted that the APPG for
experience long-term mental support this guidance, and commend Prescribed Drug Dependence has
distress, during the creation of this the authors and organisatons involved brought together the leading therapy
guidance NSUN helped to provide the in its compostion. The increase in organisations and relevant experts to
perspective of people directly affected psychiatric drug prescriptions should produce this guidance, which will help
by prescribed drug dependence. be viewed through a critical lens. The to tackle the problem of prescribed
This guidance is needed more than research laid out in this guidance drug dependence highlighted by Public
ever, given the widescale prescribing clearly indicates an urgent need for Health England’s recent report. It is
of psychiatric drugs continues to more education on the impact of clear that many people end up taking
increase. such prescribing, as well as critical unnecessary and potentially harmful
It is vitally important to support evaluation of the paradigm by which psychoactive drugs for years, and that
the prevention of drug harms and it is enabled. As medication is being there has been inadequate recognition
dependency by offering practitioners used in a wide variety of mental health of the problem and very little support
crucial information about withdrawal settings, our members will have for those wishing to withdraw. This
management, the monitoring of experienced the impact of these drugs guidance, along with the other
symptoms, while supporting regular upon clients and therapy. In many recommendations from PHE such as a
medication review and the limiting of cases, therapists may be unaware national helpline, are therefore part of
unnecessary long term use. Above all how medication, and psychaitric an overdue response to this important
people should have a choice about drug withdrawal itself, can subtly yet public health issue.
whether to take medication or not and significantly impact the therapeutic
Sir Oliver Letwin MP
have information and access to a range process. We would ideally like to see
all therapists and allied professionals Chair, APPG for Prescribed Drug
of alternatives.
develop greater awareness of the Dependence, October 2018–
NSUN welcomes the guidance
potential impact of prescribed drug November 2019
and hopes it will help to reduce
dependency. We strongly encourage
unnecessary long term use of
our members and training providers
psychiatric medication, while taking
to familiarise themselves with this
us closer to developing and using
guidance.
non-drug alternatives.
Vicky Parkinson
Sarah Yiannoullou
Chief Executive Officer, NCS
Managing Director, NSUN
for Prescribed
Drug Dependence
December 2019 3
Acknowledgements
Organisational roles
The All-Party Parliamentary Group for Prescribed Psychotherapy (UKCP) have collectively funded and
Drug Dependence (APPG for PDD) has facilitated steered the creation of the guidance in conjunction
the creation of this guidance by bringing together with members of the APPG for Prescribed Drug
key professional bodies representing psychological Dependence Secretariat (all members of the
therapists in the UK with relevant subject matter Council for Evidence-based Psychiatry (CEP)),
experts. and the National Survivor User Network (NSUN).
The professional bodies, including in addition the
The British Association for Counselling and
National Counselling Society (NCS), endorse the
Psychotherapy (BACP), British Psychological
guidance and will promote it to their members and
Society (BPS) and United Kingdom Council for
relevant training organisations.
Core steering group

Dr Anne Guy Adam Jones
Chair & Project Manager, Secretariat APPG for PDD Policy & Advocacy Officer, UKCP
Dr James Davies Dr Che Rosebert

Deputy Chair, Secretariat APPG for PDD Division Clinical Psychology, BPS
Luke Montagu Professor Peter Kinderman

Secretariat APPG for PDD Former President, BPS
Fiona Ballantine Dykes Dr Lewis Blair

Chief Professional Standards Officer, BACP Division of Counselling Psychology, BPS
Dr Naomi Moller Dr Esther Cohen-Tovee

Joint Head of Research, BACP Division of Clinical Psychology, BPS
Suzie O’Neill Dr Yetunde Ade-Serrano

Head of Communications, BACP Division of Counselling Psychology, BPS
Professor Sarah Niblock Rachel Dufton

Chief Executive, UKCP Director of Communication and Engagement, BPS
Jo Watson Stephanie Taylor-King

UKCP member Communications Co-ordinator, NSUN

Other acknowledgements
The editors are grateful for support from BACP, The following were officers of the APPG for PDD
UKCP and BPS in providing a variety of practical until November 2019:
resources to complete the guidance, including
Chair: Sir Oliver Letwin MP (Ind)
access to input from Rum Judy Communications.
Co-chair: Sir Norman Lamb (Lib Dem)
The guidance has been developed in conjunction Co-chair: Luciana Berger MP (Lib Dem)
with and reviewed by experts by experience Co-chair: Lucy Powell MP (Lab)
(clients, carers, therapists and campaigners). Co-chair: Baroness Masham of Ilton
Co-chair: Earl of Sandwich
The APPG for PDD will distribute the guidance and
Co-chair: Baroness Stroud (Con)
host a website for this purpose, seeking to make it
as widely available as possible both in the UK and, This is not an official publication of the House of
where appropriate, internationally. Commons or the House of Lords. It has not been
approved by either House or its committees. All-
Party Parliamentary Groups are informal groups of
Members of both Houses with a common interest in
particular issues. The views expressed in this report
are those of the editors and writing team.
Editors
Dr Anne Guy (UKCP, BACP, CEP) Professor Rosemary Rizq (UKCP, BPS)
Integrative Psychotherapist, APPG for PDD Professor of Psychoanalytic Psychotherapy,
Secretariat Co-ordinator University of Roehampton
Dr James Davies (CEP)

Reader in social anthropology and mental health,
University of Roehampton, Psychotherapist, APPG
for PDD Secretariat
Lead authors (section/s)

Professor Joanna Moncrieff (CEP) Professor John Read (BPS, CEP)
Consultant psychiatrist, Senior Lecturer in Professor of Clinical Psychology,
Psychiatry, University College London University of East London
Sections 2,4 Section 5
Professor Rosemary Rizq Dr Anne Guy

Section 3 Sections 6,7
Dr James Davies
Section 1
December 2019 5
Other contributors and specialist area
Professor Tim Bond (BACP) Professor Marcantonio Spada (BPS)
Professor Emeritus, Professional ethics, CBT Practitioner, Professor of Addictive Behaviours
University of Bristol & Mental Health, London South Bank University
Section 3 Section 3
Dr James Davies Dr Tom Stockmann

Sections 5,6 General Psychiatry Specialist Registrar
Sections 2,4
Dr Anne Guy
Sections 1,3 Georgina Whitney
Expert by experience
Baylissa Frederick
Section 3
Psychotherapist with specialist experience
of withdrawal Beverley Crouch (BACP)
Section 6 Psychotherapist
Appendix A
Daniel C. Kolubinski (BACP)
Researcher Karen Espley
Section 6 Appendix A
Luke Montagu (CEP) Marion Brown

APPG for PDD Secretariat Psychotherapist (retired)
Sections 5,6 Appendix A
Dr David Murphy (BPS) Thanks are also given to the additional members
Person-centred/experiential,
of the professional bodies, experts by experience,
Associate Professor carers, and specialist therapists, who contributed
University of Nottingham
to discussions or provided feedback on drafts of
Section 3 this guidance, including Katrina Ashton, Helen
Blythe, Jarka Hinksman, Harry Hogarth, Stevie
Professor Rosemary Rizq
Lewis, June Lovell, Dede-Kossi Osakonor, Cathy
Section 1
Perry, Andy Ryan, Harry Shapiro (APPG for PDD
Paul Sams Secretariat), Robyn Timoclea (Survivor Researcher
Expert by experience – Population Health Research Institute, St George’s,
Section 3 University of London) and Mohammed Zaman.

1. Introduction
Dr James Davies, Professor Rosemary Rizq & Dr Anne Guy
In September 2017 the All-Party Parliamentary In October 2019, NICE heeded calls by CEP, the
Group for Prescribed Drug Dependence (APPG APPG for PDD and the RCPsych to remove its
for PDD) met senior representatives from Public previous advice that antidepressant withdrawal
Health England (PHE) to present data and research is usually mild, self-limiting and resolving over
(including work undertaken by the British Medical 1-week, and acknowledge that, while many people
Association, 20161) revealing the mounting may experience only mild withdrawal, there is
social and individual problems associated with ‘substantial variation’ in people’s experience ‘with
prescribed drug dependency and withdrawal. symptoms lasting much longer (sometimes months
As a result, Steve Brine MP, then Under Secretary or more) and being more severe for some patients’.7
of State for Public Health and Primary Care,
While these changes largely relate to
commissioned PHE to undertake the largest review
antidepressants (and, in the case of PHE,
to date into prescribed drug dependency and
benzodiazepines, Z-drugs, GABA-ergic medicines
withdrawal. This comprehensive review has now
and opioid pain medications), they demonstrate
been published and has called for the following:
that thinking around psychiatric drug withdrawal
■■ A 24-hour national helpline and associated has shifted considerably since early 2018. Today,
website to provide advice and support for in the UK, it is now widely acknowledged that
those adversely affected by prescribed drug we previously underestimated the incidence,
dependency and withdrawal. severity and duration of withdrawal effects and
■■ Updated clinical guidance and improved the extent to which those people affected need
doctor training. support. Relevant organisations are therefore
now considering how best to support people who
■■ Provision for better patient-information about
have suffered harm. PHE has recommended a
drug risks and benefits, as well as alternatives
helpline, better training for doctors on appropriate
such as therapy and social prescribing.
withdrawal management, and more support for
■■ Further research into the nature and severity of
GPs; recommendations now supported by the Royal
withdrawal and its successful treatment.
College of General Practitioners, the Royal College
■■ Appropriate support from the NHS for patients, of Psychiatrists , the British Medical Association and
including dedicated support services.2 all the organisations involved in either the creation
In May 2019 the Royal College of Psychiatrists and/or endorsement of this current document (i.e.
issued a new position statement on antidepressant the APPG for PDD, CEP, the British Association for
withdrawal,3 following new research4,5 and Counselling and Psychotherapy (BACP), United
campaigning by people who have been harmed by Kingdom Council for Psychotherapy (UKCP),
psychiatric drugs, (also known as the prescribed- the British Psychological Society (BPS), and the
harm community), the Council for Evidence-based National Counselling Society (NCS)).8
Psychiatry (CEP) and the APPG for PDD. The In endorsing this document these organisations
Royal College’s statement acknowledged that are taking their share of responsibility for
antidepressant withdrawal is more widespread addressing the withdrawal problem, by equipping
than previously thought and can be more severe psychological therapists with the information and
and protracted than our current clinical guidelines guidance necessary to help them better inform
acknowledge.6 Joining the campaigners, the and support clients who are either taking or
Royal College also called for NICE to update its withdrawing from psychiatric drugs.
guidelines to better reflect the evidence base.
December 2019 7
1.1 What are the aims of this guidance?
Psychiatric drugs such as antidepressants and for clear guidance about how best to work with and
antipsychotics are more prescribed today than at support clients either taking or withdrawing from
any other time in our profession’s history. Around a psychiatric drugs. This guidance seeks to provide
quarter of the UK adult population was prescribed such support in two distinct ways:
a psychiatric drug last year, with around 16% being
Firstly, it aims to support therapists in deepening
prescribed antidepressants (2016–17) (DHSC 2018).9
their knowledge and reflection on working with
The steep rise in prescriptions (which have broadly
the said client group. The evidence reviewed in
doubled in the last 20 years10) means that most
this guidance means that therapists will now
therapists now work with clients who have either
have access to an up-to-date summary of the
taken or are taking psychiatric drugs. These drugs will
main effects, adverse consequences and possible
produce effects that may or may not be experienced as
withdrawal reactions for each of the main classes
positive by the individual in question. These drugs can
of psychiatric drug. Using this evidence base, the
also produce adverse effects, while many clients will
guidance aims to empower therapists to talk about
struggle to reduce or withdraw from them. To date, the
prescribed drugs with their clients (and where
lack of summarised evidence, information and training
appropriate with prescribers) as well as to identify
for therapists who work with such clients, constitutes
and work with the impact that psychiatric drugs
a growing problem for therapists whatever their
may exert on the process of therapy itself.
modality or setting in which they work.
Secondly, it invites therapists to familiarise
This lack of knowledge and training is reflected in
themselves with core issues relating to the role
data gathered from a 2018 survey of approximately
of psychiatric drugs in therapy. Many therapists
1,200 practising therapists – all members of BPS,
prefer to avoid discussing the client’s relationship
UKCP or BACP. While 96.7% of the therapists
to prescribed psychiatric drugs, assuming any
reported that they currently work with at least
consideration or discussion of this relationship
one client who is taking a psychiatric drug (e.g.
is best left to prescribers. This preference may
an antidepressant, anxiolytic or antipsychotic),
be rooted in feelings of anxiety about navigating
only 7.3% reported that their training equipped
alternative views on psychiatric drugs, not
them ‘very well’ in responding to questions about
having sufficient knowledge to engage other
withdrawing from or taking psychiatric drugs.
professionals, or feeling uncertain about managing
Additionally, 42.5% of therapists reported feeling
the boundaries of one’s professional competence
a lack of confidence in knowing where to find
or role. Indeed, while this guidance agrees that it is
appropriate information (or ethical or professional
not the role of the therapist to tell a client either to
guidance) on how to work in the most therapeutic
take, continue to take or withdraw from psychiatric
way with people taking or withdrawing from
drugs, nor to decide when, if or what drugs need to
psychiatric drugs. This lack of support, training
be withdrawn, this guidance actively encourages
and information may well explain why 93.1% of
therapists to support clients in whatever
the therapists surveyed reported they would find it
decisions they reach with their prescribers. It also
either ‘useful’ or ‘very useful’ to have professional
encourages them to engage with the views and
guidance to help them work more competently and
perspectives of other professionals whilst at the
confidently with such clients.
same time honouring the distinctive and important
It is therefore now essential for the therapeutic contributions therapists can make in supporting
professions to respond jointly to this growing need a client through withdrawal from psychiatric

drugs. Finally, it is also important to note that this in the light of new debates, disputes, interests and
guidance does not aim to disrupt or comment on evidence. For example, at the time of writing the
the NICE guidelines as used by medical doctors, guideline on depression (CG90) is undergoing an
which, for example, recommend drugs for many additional period of consultation in response to
conditions in addition to psychological therapies. criticisms from a coalition of stakeholders, which
However, it is also important to note that NICE’s includes many therapy organisations.
recommendations are continually being updated
1.2 Who is this guidance for?

This guidance aims to be relevant to a wide variety does not aim to be prescriptive nor attempt to offer
of theoretical models as well as professional and a set of therapeutic ‘competences’ or ‘guidelines’.
personal positions held by members of the main Rather, by using the available evidence base,
accrediting bodies. These are: BPS, BACP and UKCP therapists of all persuasions will be invited to
and NCS. It is clear that therapists’ professional consider a number of key questions and concerns
training as well as their personal and therapeutic relevant to their therapeutic work with clients who
experience means there are likely to be significant are either taking or withdrawing from prescribed
differences in how they think about and work with psychiatric drugs.
the various issues relating to prescribed drugs. Many
Therapists will also be invited to reflect on their
therapists will be highly critical of their use whilst
own professional background and training, their
others may believe prescribing privileges should
personal and practice-based experiences as well
be extended to therapists.11 It is also important to
as their relationship to and understanding of the
note that, in addition to holding different views,
‘medical model’ and its associated interventions.
therapists also operate within a variety of settings.
These may include NHS primary care, secondary While this guidance is therefore written for
care and specialist services; statutory or third sector therapists, much that is included may be of
services; private practice and other private sector professional interest to those working in allied
services and agencies. Different professional settings helping professions (e.g. nursing; occupational
will shape therapists’ decision-making as well as therapy; social work; and those in relevant caring
the opportunities available to them for working and medical roles). It is therefore hoped that allied
collaboratively with other healthcare professionals. professions might be able to make use of some
or all of these materials in ways that will serve
Given this rich diversity of professional
their clients’ interests while at the same time best
backgrounds, trainings and settings, this guidance
honouring their own professional and ethical values.
1.3 The medical model and the emerging crisis

Whatever an individual’s view regarding the best or organic pathology. It is important to note,
model with which to understand and respond to however, that such criticism has been advanced
emotional and mental distress, it is clear that since not only by non-medical professionals. Indeed,
the mid-2000s there has been growing professional many of its proponents stem from the medical and
and public criticism of the utility and validity of the psychiatric community itself, where today there is
‘biomedical’ model and associated interventions – a a diversity of views regarding the utility and validity
model in which distress has been assumed by some of this model. In short, the lines of debate cut
to be rooted in an underlying disease mechanism through all mental health disciplines, and so can
December 2019 9
no longer be framed in disciplinary polarised ways. within psychiatry and beyond, that psychiatric drugs
Furthermore, such debates now resonate beyond ‘cure’ mental ‘illnesses’ that are rooted in brain
the disciplines themselves, in ever larger sections pathologies. Rather, it takes the view that psychiatric
of the academic, political, media and service-user drugs, like all other psychoactive substances, alter
communities, and similarly stem from increasing states of mind in ways that may or may not be
concern that our mental health services are not experienced as helpful by the individual in question.
just failing due to lack of investment, but owing Also, like many other psychoactive substances,
to peoples’ emotional and behavioural difficulties psychiatric drugs can cause side, adverse and
being over, unduly and unhelpfully medicalised. withdrawal effects that can complicate a person’s
It has been argued that over-medicalisation has recovery, certainly if not acknowledged as such.
led, in turn, to the consequent over-prescribing of
The second influence concerns the language used
psycho-pharmaceuticals,12,13 rising mental health
in this guidance. Medical terms such as ‘illness’,
stigma,14 the proliferation of unnecessary and
‘disorder’, ‘pathology’ and ‘dysfunction’ do not
harmful long-term prescribing, and the crowding
merely describe the suffering they depict but shape
out of effective alternatives that people both need
how it is understood, managed and perceived.
and want.15,16 These arguments have dovetailed with
Medical language imports meanings that may
others that pertain to the medical model, such as
not always accord with how many psychological
the value or otherwise of psychiatric diagnosis more
therapists frame distress. A common view in the
broadly17–21; the role of conflicts of interest between
psychological community is that medical language
the pharmaceutical industry, prescribers and drug-
broadly assumes what it should rather demonstrate:
researchers22–24; the lack of biomarkers for ‘mental
that the suffering it describes is in fact medical
disorders’ or evidence for the chemical imbalance
‘illness’, ‘disorder’ or ‘pathology’. Rather than seeing
theory of mental distress 25,15; the evidence that
suffering as an illness, many therapists would
antidepressants may yield no clinically significant
understand it as a rational reaction to hurt, trauma
benefits over placebos for most people despite ever-
or impairment. In many cases it may be a call for
rising prescriptions30–33; the expanding knowledge
change or an instance of what may be termed ‘social
of withdrawal problems34,4,5, and the growing
suffering’ – namely, a non-pathological, distressing,
understanding that long-term use of psychiatric
yet understandable human response to harmful
drugs is often associated with poor outcomes and
social, political, relational and environmental
increased harms3. These concerns, criticisms and
conditions (past or present).
areas of debate have been articulated, advanced and
engaged with not only by psychologists, academics Given that medical language carries meanings
and therapists, but also by many psychiatrists that extend well beyond the way in which many
who have seen in the psychiatric perspectives and therapists understand psychological distress,
treatments once championed in the 1990s, many including meanings that assume, rather than
promises left unrealised. demonstrate the biological causes of mental
distress, this guidance will avoid medical
Each individual involved in the composition of
terminology where possible. Instead, it will
this guidance will have a particular view on these
adopt non-medical descriptors, such as those
separate debates and criticisms, as will its readers.
recommended by the British Psychological
As no guidance can ever be written in a vacuum,
Society.36 There are occasions, however, where
and as many contributors have been involved
the meaning of alternative words is not clear
in some of the above debates, it is important to
and so some language has been retained for the
be explicit about how these criticisms may have
sake of simplicity and readability, but this should
informed the content of this guidance.
not be taken as an acceptance of its full medical
The first obvious influence is that this guidance implications. Quotation marks have been used in
departs from the increasingly contested belief, both some places to denote a disputed term.

1.4 Glossary
In this guidance the terms below will be preferred avoids those connotations, which is why the
and used for the following reasons: prescribed-harm community, in general, prefers
the term, as it better captures the experience of
■■ Therapists – this term is used to denote the
becoming dependent by following a prescriber’s
range of different psychological therapists
recommendations. Secondly, and following
represented by the bodies endorsing this
Public Health England’s preferred language,
guidance (e.g. counsellors, clinical and
dependence refers to an adaptation to the
counselling psychologists, psychotherapists,
repeated exposure to a drug. This is usually
psychoanalysts). This term is used simply for the
characterised by tolerance and withdrawal,
matter of convenience, and its usage in no way
(though tolerance may not occur with some
intends to minimise or overlook the differences
drugs).2
that may exist between different therapeutic
■■ Psychiatric ‘drugs’ rather than psychiatric
professionals and modalities.
‘medication’ – this distinction is drawn since
■■ Psychiatric drugs – this term is used
the term ‘medication’ is defined as a substance
throughout to refer to all prescribed psycho-
that is used to cure or treat a disease or
pharmaceuticals including antidepressants,
medical condition, or to alleviate symptoms of
antipsychotics, stimulants, tranquilisers,
an illness.37 As it is contestable as to whether
anxiolytics etc. regardless of who has
psychiatric drugs either ‘cure’ or ‘treat’ a
prescribed them.
‘disease’ or a ‘medical’ condition or ‘illness’, the
■■ Client: this term is used throughout this term ‘drugs’ is preferred, in particular as the
guidance to refer to anybody meeting a definition for drugs (i.e. ‘a substance which has
therapist for therapy. a physiological effect’38), better captures the
■■ Dependence – this term is used throughout this evidence-base for how psychopharmaceuticals
guidance to denote physical dependence on a work.
drug. This is not to deny the relevance of meanings ■■ Drug-Centred vs Disease-Centred model of
and beliefs and the psychological effects of drug action – this distinction is drawn to clarify
taking and stopping psychiatric drugs, but only to how psychiatric drugs work: the disease model
specify that the research covered in the evidence assumes psychiatric drugs work by reversing or
sections of this guidance predominately relates to partially reversing an underlying ‘disease’, while
dependence in its physical form. the drug-centred model asserts that psychiatric
Also, this guidance draws the distinctions between drugs work by producing physiological and
the following terms: psychological effects, as all psychoactive
substances do, which may or may not be
■■ ‘Dependence’ rather than ‘addiction’ – this experienced as beneficial. This guidance prefers
distinction is drawn for two reasons: the the drug-centred over the disease-centred
term ‘addiction’ is generally associated with model, as it better captures the evidence-base
dependence on non-prescribed substances as to how psychopharmaceuticals work. This is
(such as illicit drugs and alcohol). As such it may further expanded on in section 2.
be read, rightly or wrongly as having negative
connotations. In contrast, ‘dependence’ largely
December 2019 11
1.5 Scope
This guidance relates to psychiatric drugs that have dependence and withdrawal). As important as
been prescribed in the course of clinical practice. these areas are, the number of variables involved
It does not tackle illicit or recreational drug use renders making any general statements unfeasible,
(nor prescribed painkiller/opioid use) and any beyond recommending that such adverse reactions
associated problems. Naturally, such hard and fast must always be discussed with the prescriber.
distinctions may belie clinical complexity, given
Finally, systemic, child and family therapies, as
some clients may present with multiple prescribed
well as social prescribing are not discussed in
and non-prescribed dependencies.
this guidance, although we clearly recognise the
A further area beyond scope is first, the impact vital contribution they make in this area. The
of other physical health conditions on both drug parameters of a project must be drawn somewhere,
and talking therapy, and conversely, the impact and ours reflect pragmatic constraints rather than
of prescribed psychiatric drugs on physical any implied grading of the relative importance of
health (beyond those problems associated with the topics omitted.
1.6 How to use the guidance

It is suggested that the sections giving general References
information should where possible be read in full, 1. BMA (2016). Supporting individuals affected by prescribed
whilst readers might selectively read information drugs associated with dependence and withdrawal. (Accessed
relating to specific classes of drugs in sections 4 July 2019.) Website: https://www.bma.org.uk/collective-
voice/policy-and-research/public-and-population-health/
and 5, depending on which they are most likely to
prescribed-drugs-dependence-and-withdrawal.
encounter, or on an as-needed basis. 2. Taylor, S., Annand, F., Burkinshaw, P., Greaves, F., Kelleher, M.,
Knight, J., Perkins, C., Tran, A., White, M. & Marsden, J. (2019).
This guidance aims to empower and support Dependence and withdrawal associated with some prescribed
conversations often already taking place between medicines: An evidence review. London: Public Health England.
3. Royal College of Psychiatrists (2019). Position statement on
therapists and their clients. Therapists will need
antidepressants and depression. (Accessed July 2019) Website:
to decide for themselves whether, and to what https://www.rcpsych.ac.uk/docs/default-source/improving-
extent, they wish to use this guidance in the care/better-mh-policy/position-statements/ps04_19---
context of their therapeutic work. These decisions antidepressants-and-depression.pdf?sfvrsn=ddea9473_5.
4. Davies, J., Read, J. (2018). A systematic review into the
will depend on their theoretical modality,
incidence, severity and duration of antidepressant withdrawal
practice setting and the individual needs of the effects: Are guidelines evidence based? Addictive Behaviors.
client. The client’s agency, as always, should be pii: S0306-4603(18)30834-7. doi: 10.1016/j.
supported and respected at all times. Clients addbeh.2018.08.027. [Epub ahead of print].
5. Horowitz, M.A. & Taylor, D. (2019). Tapering of SSRI treatment
should be encouraged to discuss withdrawal
to mitigate withdrawal symptoms. The Lancet Psychiatry.
from prescribed psychiatric drugs with a 6. National Institute for Health and Clinical Excellence (NICE)
knowledgeable prescriber who can give medical (2009). Depression in adults: Recognition and management.
advice, oversee and manage any withdrawal Website: https://www.nice.org.uk/guidance/cg90/resources/
depression-in-adults-recognition-and-management-
process appropriately. While this guidance
pdf-975742638037. (Accessed July 2018.)
advocates the importance of informed client 7. National Institute for Health and Clinical Excellence (NICE)
choice based on full information about potential Depression in adults: recognition and management (2009–
benefits and risks, it does not advocate therapists 2019 update) https://www.nice.org.uk/guidance/cg90/
chapter/1-Guidance#care-of-all-people-with-depression
telling their clients to take, not take, stay on or
8. APPG for PDD, (2019), Statement of Support. Available online:
withdraw from psychiatric drugs. These matters www.prescribeddrug.org/news/
should be left to the prescriber and client to decide.

9. Department of Health and Social Care (DHSC) (2018). Hansard: 25. Harrington, A. (2019). Mind fixers: Psychiatry’s troubled search
Prescriptions drugs – written question – 128871. Available for the biology of mental illness. New York: W.W. Norton and
online: https://www.parliament.uk/business/publications/ Company.
written-questions-answers-statements/written-question/ 26. Kondro, W. & Sibbald, B. (2004). Drug company experts advised
Commons/ 2018-02-21/128871/. (Accessed July 2018.) to withhold data about SSRI use in children. Canadian Medical
10. Kendrick, T. (2015). Long-term antidepressant treatment: Time Association Journal, 170, 783.
for a review? Prescriber, 26(19), 7–8. 27. Turner, E.H. et al. (2008). Selective publication of
11. Tomba, E., Guidi, J. & Fava, G.A. (2018). What psychologists antidepressant trials and its influence on apparent efficacy,
need to know about psychotropic medications. Clinical The New England Journal of Medicine, 17, 252–60.
Psychology & Psychotherapy, 25(2), 181–7. 28. Spielmans, G.I. & Parry, P.I. (2010). From evidence-based
12. Dowrick, C. & Frances, A. (2013). Medicalising and medicating medicine to marketing-based medicine: evidence from
unhappiness. BMJ,14(347). Website: https://www.bmj.com/bmj/ internal industry documents. Bioethical Inquiry, 7, 13–29.
section-pdf/750417?path=/bmj/347/7937/Analysis.full.pdf. 29. Angell, M. (2011). The Illusions of psychiatry. The New York
13. Rice-Oxley, M. & Fishwick, C. (2013). Medicalisation of misery to Review of Books, 58(12), 82–84.
blame for soaring use of antidepressants, say GPs. (Accessed July 30. Ioannidis, J. (2008). Effectiveness of antidepressants: An
2019). Website: https://www.theguardian.com/society/2013/ evidence myth constructed from a thousand randomized
nov/21/prescribing-culture-blame-rise-antidepressants. trials? Philosophy, Ethics, and Humanities in Medicine 3,14.
14. Loughman, A. & Haslam, N. (2018). Neuroscientific explanations 31. Kirsch, I. & Jakobsen, J.C. (2018). Correspondence: Network
and the stigma of mental disorder: A meta-analytic study. meta-analysis of antidepressants. The Lancet, 392(10152),
Cognitive Research: Principles and Implications 3(43). Published P1010. doi: https://doi.org/10.1016/S0140-6736(18)31799-9.
online 14 November 2018. doi: 10.1186/s41235-018-0136-1. 32. Hengartner, M.P. & Ploderl, M. (2018). Statistically significant
15. Bracken, P., Thomas, P., Timimi, S. et al. (2012). Psychiatry antidepressant-placebo differences on subjective symptom-
beyond the current paradigm. British Journal of Psychiatry, rating scales do not prove that the drugs work: Effect size and
201, 430–434. method bias matter! Front Psychiatry, 9, 517. Published online
16. Davies, J. (2013). Cracked: Why psychiatry is doing more harm 17 October 2018. doi: 10.3389/fpsyt.2018.00517.
than good. London: Icon Books. 33. Munkholm, K., Paludan-Müller, A.S. & Boesen, K. (2018).
17. Frances, A. (2013). Saving normal: An insider’s revolt against Considering the methodological limitations in the evidence
out-of-control psychiatric diagnosis, DSM-5, Big Pharma, and base of antidepressants for depression: A reanalysis of a
the medicalization of ordinary life. New York: William Morrow. network meta-analysis. BMJ Open, 9:e024886. doi: 10.1136/
18. Davies, J. (Ed.) (2017). The sedated society: The causes and bmjopen-2018-024886.
harms of our psychiatric drug epidemic. London: Palgrave 34. Fava, G., Gatti, A., Belaise, C., Guidi, J. & Offidani, E. (2015).
Macmillan. Withdrawal symptoms after selective serotonin reuptake
19. Johnstone, L. (2014). A straight talking introduction to inhibitors discontinuation: A systematic review. Psychotherapy
psychiatric diagnosis (Straight Talking Introductions). London: and Psychosomatics, 84, 72–81.
PCCS Books. 35. Whitaker, R. (2016). Rising prescriptions, rising disability: Is
20. British Psychological Society (2011). Response to the American there a link? All-Party Parliamentary Meeting for Prescribed
Psychiatric Association DSM-5 Development. Leicester: Author. Drug Dependence. Retrieved from the Council for Evidence
21. Allsopp, K., Read, J. & Kinderman, P. (2019). Heterogeneity in Based Psychiatry: http://cepuk.org/2016/05/27/video-now-
psychiatric diagnostic classification. Psychiatry Research 279, available-appg-event-link-rising-prescribing-disability/.
15–22. 36. British Psychological Society (2015). Guidelines on language
22. Campbell, E.G., Weissman, J.S., Ehringhaus, S. et al. (2007). in relation to functional psychiatric diagnosis. Available online:
Institutional academic-industry relationships. The Journal of https://www1.bps.org.uk/system/files/user-files/Division%20
the American Medical Association, 298(15), 1779–1178. of%20Clinical%20Psychology/public/Guidelines%20on%20
23. Cosgrove L., Krimsky, S., Vijayaraghavan, M. & Schneider, L. Language%20web.pdf. (Accessed January 2019.)
(2006). Financial ties between DSM-IV panel members and the 37. DHHS (2011). What is medication? Available online: https://
pharmaceutical industry. Psychotherapy and Psychosomatics, www.dhhs.nh.gov/dcbcs/bds/nurses/documents/sectionII.pdf.
75(3),154–60. (Accessed February 2019.)
24. Timimi, S. (2008). Child psychiatry and its relationship with 38. English Oxford Dictionary (2019). Available online: https://
the pharmaceutical industry: Theoretical and practical issues. en.oxforddictionaries.com/definition/drug (Accessed February
Advances in Psychiatric Treatment, 14, 3–9. 2019)
December 2019 13
2. Introduction for therapists on how
psychiatric drugs work
Professor Joanna Moncrieff & Dr Tom Stockmann
2.1 The place of prescribed drugs in Mental Health Services

Drugs have been the mainstay of psychiatric not simply as inducing useful but crude states of
treatment since the 1950s. Nowadays, most people sedation and passivity, like the older style drugs,
who receive specialist psychiatric services are but as acting to reverse underlying psychiatric
prescribed one sort of psychiatric drug, and often diseases.
several. General practitioners prescribe such drugs
The naming of psychiatric drugs reflects this
to millions of other people.
assumption; so ‘antipsychotics’ are thought to
Before the 1950s, drugs, especially sedatives, act on the biological abnormality that produces
were used extensively in psychiatric hospitals symptoms of psychosis or ‘schizophrenia’,
and prescribed to outpatients. However, they ‘antidepressants’ are thought to reverse the basis
received little attention because they were of depressive symptoms, ‘mood stabilisers’ are
generally regarded simply as a means of chemical thought to help rectify the process that gives rise to
restraint.1,2 However, during the 1950s and abnormal fluctuations of mood and ‘anxiolytics’ are
1960s new ranges of drugs were introduced thought to address the biological mechanism that
into psychiatry. Views about how they worked creates anxiety.
gradually transformed: they came to be seen
2.2 How do psychiatric drugs work?

The assumption that the major types of drug 2.2.1 The disease-centred model
used in psychiatry work by reversing or partially
The disease-centred model has been imported
reversing the underlying disease process may
from general medicine, where most modern drugs
be termed the ‘disease-centred’ model of drug
are correctly understood in this way. Although
action. There is little evidence to support this
most medical treatments do not reverse the
model, however. An alternative ‘drug-centred’
original disease process, they generally act on the
model states that psychiatric drugs produce
physiological processes that produce symptoms,
a global state characterised by a range of
or on specific physiological targets to reduce
physiological and psychological alterations,
symptoms via an identified mechanism. Thus,
which are superimposed on, and interact with, the
chemotherapeutic agents counteract the abnormal
‘symptoms’ of mental ‘disorders’ in ways that may
cell division that occurs in cancer, while analgesics
or may not be perceived as beneficial.
act on the physiological processes that produce
pain. Some anti-hypertensives (medications for
high blood pressure) relax blood vessels by acting
on specific receptors to lower blood pressure,
even though the cause of the hypertension may be
unknown.

The disease-centred model of drug action is closely be antidepressants have been shown to have
related to theories that mental health conditions equivalent effects to antidepressants in people
are caused by abnormalities in particular brain with depression, including anti-anxiety drugs like
chemicals, or a ‘chemical imbalance’. Chemicals diazepam (Valium), stimulants and antipsychotics.
that facilitate or inhibit the transmission of nervous Antipsychotics are not clearly distinguished from
impulses with the brain are called ‘neurotransmitters’. other sedatives in studies of people diagnosed
Following the observation that psychiatric drugs with psychosis or schizophrenia10, and lithium is
act on neurotransmitter systems, it started to be not superior to other drugs in studies in people
proposed that an abnormality in these systems might diagnosed with acute bipolar or manic states.11 In
be the cause of psychiatric disorders. The best-known addition, two studies that attempted to distinguish
example of this way of thinking is the dopamine between the effects of lithium and antipsychotics
hypothesis of ‘schizophrenia’, which followed from the in people with different diagnoses (bipolar or
discovery that early antipsychotics reduce dopamine affective disorder versus non-affective psychosis or
activity (dopamine is a brain-based neurotransmitter). schizophrenia) failed to do so.12,13
The idea that depression is caused by a deficiency
Even if the mechanisms of mental health difficulties
of the neurotransmitters serotonin or noradrenalin
could be identified, however, we would still be
is another example sometimes referred to as the
uncertain whether or not psychiatric drugs impact
‘monoamine theory’ of depression (serotonin and
symptoms by affecting those mechanisms. This is
noradrenalin are both classified as monoamine-type
because to draw this conclusion, we somehow need
brain chemicals or neurotransmitters).
to discount the effect of the general mental and
Some researchers still support the dopamine behavioural alterations that these drugs are known
hypothesis of ‘schizophrenia’3, and some to cause in anyone, regardless of whether or not they
antipsychotic drugs certainly affect dopamine have an identified neurochemical abnormality.
transmission, although others have only weak
The drug-centred model of drug action suggests it
effects on dopamine. However, evidence that
is these alterations that are significant.
there are dopamine abnormalities in people with
psychosis or ‘schizophrenia’ prior to starting drug
treatment is inconsistent.4,5 Few people now accept 2.2.2 The drug-centred model
the idea that depression is caused by a serotonin or This model highlights that psychiatric drugs can
noradrenaline abnormality, and again the evidence be considered to be ‘psychoactive’ drugs in the
is highly inconsistent.6 sense that they are substances that cross the
blood/brain barrier and affect brain functioning.
In fact, despite decades of intensive research on
By doing so they produce an altered global
all sorts of aspects of biological science including
state characterised by a range of physiological,
various neurotransmitters, genetics and neural
psychological and behavioural changes. There is
networks, definitive causes of mental health
no essential distinction, according to this view,
difficulties have not been established. Recently,
between drugs used for psychiatric treatment and
the former head of the US National Institute of
recreational psychoactive drugs like alcohol and
Mental Health admitted that $20 billion of funding
cocaine. All psychoactive drugs produce altered
for investigating the neuroscience and genetics
physical and mental states that can influence the
of mental disorders, had produced no benefit to
way people think, feel and act, with different sorts
people suffering from mental health difficulties.7
of substances having different sorts of effects.
There is also little evidence that drugs that are The effects of recreational drugs are experienced
meant to have specific effects in certain conditions, as desirable by at least some people, but some
according to the disease-centred model, are drugs produce mental and physical changes that
better than other sorts of drugs.8,9 For example, are generally experienced as unpleasant (e.g.
numerous drugs that are not considered to antipsychotics and lithium). The drug-centred
December 2019 15
model suggests that it is these psychoactive Much of the material in this section is a condensed
properties that explain the changes seen when and updated version of material contained in A
drugs are given to people with mental health Straight Talking Introduction to Psychiatric Drugs by
difficulties. Drugs like benzodiazepines and alcohol, Joanna Moncrieff, published by PCCS Books, and
for example, reduce arousal and induce a usually used with the publisher’s kind permission.
pleasant state of calmness and relaxation. This
state may be experienced as a relief for someone References
who is intensely anxious or agitated. But taking 1. Moncrieff, J. (1999). An investigation into the precedents of
a drug like this does not return the individual to modern drug treatment in psychiatry. History of Psychiatry
10(40 Pt 4), 475–90.
‘normal’, or to their ‘pre-symptom’ state. The drug-
2. Braslow, J. (1997). Mental ills and bodily cures. Berkley, CA:
induced state is superimposed on the ‘symptoms’ University of California Press.
and is found to be preferable, either by the sufferer 3. Howes, O.D., McCutcheon, R., Owen, M.J. & Murray, R.M.
themselves, or by others. (2017). The role of genes, stress, and dopamine in the
development of schizophrenia. Biological Psychiatry 81(1):
In psychiatry, an accepted example of a drug- 9–20.
centred treatment is the recognised benefits of 4. Kendler, K.S. & Schaffner, K.F. (2011). The dopamine
hypothesis of schizophrenia: An historical and philosophical
alcohol in social anxiety (also referred to as social
analysis. Philosophy, Psychiatry & Psychology, 18(1), 41–63.
phobia). Alcohol can help people with social 5. Moncrieff, J. (2009). A critique of the dopamine hypothesis of
anxiety because a state of mild intoxication is schizophrenia and psychosis. Harvard Review of Psychiatry,
associated with a lessening of social inhibitions. 17(3), 214–25.
6. Healy, D. (2015). Serotonin and depression. BMJ. 350:h1771.
Rather than reversing an underlying biochemical
7. Henriques, G. (2017). Twenty billion fails to ‘move the needle’
imbalance, alcohol works because it substitutes the on mental illness Thomas Insel admits to misguided research
alcohol-induced behavioural and emotional state, paradigm on mental illness. Psychology Today, 23 May
with its characteristic lessening of inhibitions, for 2017, https://www.psychologytoday.com/gb/blog/theory-
knowledge/201705/twenty-billion-fails-move-the-needle-
the previous anxious state.
mental-illness. (Accessed 7 July 2019.)
8. Moncrieff, J. (2008). The myth of the chemical cure: A critique of
The brain reacts to the presence of a drug in various
psychiatric drug treatment. Basingstoke: Palgrave Macmillan.
ways, and often adapts to the drug in ways that 9. Moncrieff, J. & Cohen, D. (2005). Rethinking models of
counteract the drug’s effects. Therefore, the effects psychotropic drug action. Psychotherapy and Psychosomatics
that a drug has when it is first taken may wear off 74(3), 145–53.
10. Wolkowitz, O.M. & Pickar, D. (1991). Benzodiazepines in the
and increasing doses may be required to sustain
treatment of schizophrenia: A review and reappraisal. The
the initial effects. Sometimes this is referred to as American Journal of Psychiatry 148(6), 714–726.
‘tolerance’. Biological adaptations to the presence 11. Prien, R.F., Caffey Jr., E.M. & Klett, C.J. (1972). Comparison of
of a drug are also responsible for withdrawal lithium carbonate and chlorpromazine in the treatment of
mania. Report of the Veterans Administration and National
symptoms. When a drug that has been taken for
Institute of Mental Health Collaborative Study Group. Archives
some time is stopped, the body’s adaptations are of General Psychiatry 26(2), 146–153.
no longer opposed by the presence of the drug 12. Braden, W. et al. (1982). Lithium and chlorpromazine in
and can give rise to unpleasant and debilitating psychotic inpatients. Psychiatry Research 7(1), 69–81.
13. Johnstone, E.C. et al. (1988). The Northwick Park ‘functional’
sensations and experiences.
psychosis study: Diagnosis and treatment response. Lancet
2(8603), 119–125.
Whereas the disease-centred model assumes that
psychiatric drugs help to restore normal brain
functioning, the drug-centred model stresses that
taking a drug creates an abnormal biological state.
Some effects associated with this altered state may be
perceived as worthwhile in certain situations. Often
however, by distorting normal bodily function, drugs
have an adverse impact. They may therefore do more
harm than good, particularly in the long term.

3. Implications for therapeutic practice
rofessor Rosemary Rizq, with Professor Tim Bond,
P
Dr Anne Guy, Dr David Murphy, Paul Sams,
Professor Marcantonio Spada & Georgina Whitney
Having introduced the broader context and the for working with clients at different stages of
different ways of viewing prescribed psychiatric their prescribed drug journey: those who are
drugs in sections 1 and 2 of this guidance, this considering taking prescribed drugs; those who
section considers the implications for therapeutic are considering withdrawing; and those who are
practice. It invites therapists to reflect on their already withdrawing and who may be experiencing
own position in relation to the biomedical withdrawal reactions. For ease of reference, brief
paradigm and to consider a number of key issues summaries of the evidence presented in sections 4,
in relation to prescription psychiatric drugs. 5 and 6 are included.
Practice-related guidance includes suggestions
3.1 The biomedical paradigm and its relationship to

different therapeutic modalities
From the outset, it is important to acknowledge centred model of practice. Therapists from all
some of the tensions that exist between the professional backgrounds draw from paradigms
biomedical model currently dominating healthcare that predominantly emphasise the psychological
and the psychological paradigm adopted by and psychosocial aspects of experience thought
therapists working with those in emotional distress. to underpin mental suffering, rather than on
models that emphasise notions of deficit,
As stated in the introduction, the growing
symptomatology and medicalisation. Indeed, there
medicalisation of distress in society reflects the
has been a growing professional movement in
widespread assumption that mental illness exists
the psychotherapeutic field away from a disease-
in the same way as physical illness and can be
centred model of practice and the use of prescribed
diagnosed and treated like flu or a virus. The idea
psychiatric drugs. For example, there have been
that psychological distress may be understood as
recent attempts to offer alternative ways of
the symptom of an underlying disease process or
understanding mental distress (e.g. the Power Threat
organic abnormality, to be treated with prescribed
Meaning Framework1). The BPS2, too, has stated that
psychiatric drugs, reflects a disease-centred model
‘clients and the general public are negatively affected
of practice in line with the biomedical approach to
by the continued and continuous medicalisation
science, policy and practice currently dominating
of their natural and normal responses to their
mental health services.
experiences; responses…which do not reflect illnesses
Of course, the prevalence of the biomedical so much as normal individual variation…This misses
approach does not exclude mental health services the relational context of problems and the undeniable
advocating better access to psychological therapies, social causation of many such problems’ (p2).
particularly where therapy is assumed to be Underpinning these and other critiques lies the call
complementary to the use of psychiatric drugs. for a ‘paradigm shift’ within mainstream psychiatry3
However, the majority of psychological therapists that takes account of the complex interplay of social,
hold a framework for understanding emotional cultural, economic and psychological forces that are
pain that conflicts with the prevailing disease- thought to result in much mental distress today.
December 2019 17
However, the continuing cultural dominance in the extent to which therapists feel they can or
of the biomedical approach means that it must adhere to a biomedical perspective. For this
is likely to shape the attitudes, beliefs and reason, it is important for therapists to reflect on the
values of therapists from all psychotherapeutic personal and professional ways in which they relate
backgrounds and to pervade their practice in to and engage with the ‘medical model’, as this is
both explicit and implicit ways. Whilst Elkins likely to influence significantly, if implicitly, their
(2009)4 suggests that the ‘medical model’ in the attitude towards people who are taking prescribed
psychological therapies is essentially an analogy: drugs, prescribers and the drugs themselves.
‘a descriptive schema borrowed from the practice
of medicine and superimposed on the practice of How do the main modalities relate
psychotherapy’ (pp67–71), it is clear that different
to the medical model?
psychotherapeutic disciplines will understand,
take up and respond to it in different ways. For The authority of the medical model means that
example, some have argued that the field of many therapists consider issues of prescribed
applied psychology is significantly permeated by psychiatric drugs to be the exclusive remit of
a biomedical perspective5, whilst others prefer doctors, psychiatrists and neurologists. However,
to adopt a critical position in relation to notions the specialist training of therapists means they
of ‘pathology’, ‘illness’ and ‘disorder’.6 Within all subscribe to a conceptual system of mental
the different theoretical traditions too there is distress that is primarily psychological rather than
considerable variation in philosophical stance biomedical. They are therefore well placed to help
and attitude, reflective of different tensions and their clients in ways that are additional to and
discourses within the field. Although therapists distinctive from medication.
principally draw from psychological paradigms The next section offers a brief summary of how the
that differ from the biomedical approach, it three main therapeutic modalities traditionally
is clear some psychotherapeutic frameworks position themselves in relation to the biomedical
actively recruit the ‘medical model’ by analogy, model of practice. It is clear that such a summary
borrowing language and classificatory systems cannot be exhaustive, nor can it do justice to
that give rise to an apparent alignment in practice. the variations that exist within and between
In the face of these and other complex debates theoretical orientations. Rather, it aims to offer
and professional differences, therapists using this a starting-point of reference for therapists who
guidance will need to consider carefully the degree wish to locate their practice on the continuum
to which they think a biomedical perspective discussed above.
currently influences their practice. Clearly there will
3.1.1 Humanistic models of training
be considerable differences here, depending on each
therapist’s professional background, professional and practice, including person-centred,
training, work context and personal preference. For experiential, existential and Gestalt approaches are
example, there will be some therapists whose work concerned with notions of subjective experience,
setting privileges a biomedical framework, requiring personal meaning and the development of potential,
them to use the language of psychiatric classification with therapy seen as inherently relational. The
and to incorporate standardised assessments client’s potential for actualisation, uniqueness,
and manualised ‘clinical’ techniques into their autonomy and authenticity contrasts with the
therapeutic work. By contrast, others may work in medical model’s focus on ‘illness’, ‘disorder’
settings that allow them to reject the language of ‘psychopathology’ and its use of standardised
medicalisation and symptomatology entirely and assessments, ‘objective’ outcome measures
to focus instead on the therapeutic relationship and and the specificity of ‘clinical’ techniques.
client self-determination. There are many possible Psychological distress is considered to be the
configurations here and many possible variations result of thwarted actualisation due to sub-optimal

social/environmental conditions. Humanistic 3.1.3 Cognitive-behavioural models
therapists seek to develop a therapeutic relationship
characterised by authenticity and transparency
of training and practice cover a number of
approaches including Beckian cognitive-behavioural
rather than by hidden agendas or ‘expert’ positions,
therapy (CBT), dialectical behaviour therapy (DBT) and
instead emphasising emotional engagement,
rational-emotive behaviour therapy (REBT) as well as
collaborative work, responsibility for the self and
those that would be considered under the heading of
the client’s freedom to self-direct. The fundamental
‘third wave’ approaches such as mindfulness-based
call for humanistic therapists to ‘be with’ rather
CBT (MBCBT), compassion-focused therapy (CFT) and
than ‘do to’ the client means they do not direct or
acceptance and commitment therapy (ACT). These
actively encourage clients to make changes in their
are all structured, focused approaches emphasising
lives. Instead, they prefer to support clients in taking
the use of specific techniques and strategies to
responsibility for themselves through a spirit of
promote measurable change. Whilst there is some
collaborative, empathic enquiry, exploration and
debate about the extent to which its proponents align
acceptance.
themselves with the ‘expert’ position characteristic of
3.1.2 Psychodynamic models of the biomedical model, the therapist stance endorsed
by most CBT practitioners is collaborative, seeking
training and practice range from long- to develop a helpful therapeutic alliance, a shared
term psychoanalytic and relational psychotherapy
formulation and therapy goals. Psychoeducation and
through to shorter term models such as brief,
self-monitoring may be used to help clients identify
psychodynamically oriented counselling and
unhelpful patterns of thought, behaviour and action
Dynamic Interpersonal Therapy (DIT). Whilst
that are seen as maintaining their current psychological
there are important differences between the
difficulties. This may be followed by therapeutic work
various psychoanalytic schools of thought, all
aimed at addressing underlying issues such as the
approaches emphasise the centrality of unconscious
impact of trauma. CBT is a common approach within
mechanisms and processes in relationships and
public sector services, where therapists routinely work
tend to focus on the emergence of transferential
within a multi-disciplinary team.
and countertransferential material within therapy.
The client is seen as ‘divided’, and therapeutic work In concluding this section, it can be seen that the
aims to bring unconscious material to the surface, different perspectives outlined above all carry very
allowing it to be experienced safely and to become different assumptions about the nature of emotional
available for thought and processing with the suffering. The biomedical paradigm sees much of
therapist. Psychodynamic therapists, like humanistic mental distress as an unproductive ‘disorder’ or
therapists, tend to reject the ‘expert’ position ‘symptom’ that is best removed with the help of
characteristic of biomedical approaches, although prescription psychiatric drugs. Within the humanistic
some schools of psychoanalytic thought adhere to and psychodynamic traditions, however, suffering is
diagnostic classifications that are closely linked with conceptualised as having potential value and purpose
medical psychiatry. Most therapists prefer to adopt a rather than something that is merely ‘pathological’ or
‘neutral’ stance that allows the client to project on to otherwise useless. Therapists from these traditions
the therapist feelings and fantasies deriving from his tend to see emotional distress as a signal that
or her early relationships. The traditional injunction there is something wrong in the individual’s life:
to keep the therapeutic space free for transferential suffering represents an opportunity for change and
work means that psychodynamic therapists may transformation if it can be explored and managed
vary in their willingness to offer direction or advice productively. By contrast, in approaches such as
to clients, and they are likely to consider carefully cognitive-behavioural therapy, the main focus is on
the unconscious implications of the therapist’s removing symptoms of distress by altering patterns
contact with prescribers or other people involved in of cognition, emotion and behaviour that are
the client’s care. understood to maintain emotional suffering.
December 2019 19
3.2 Key issues for therapists to consider when working with
clients who are taking or withdrawing from prescribed
psychiatric drugs
A general principle emerging from the evidence In the instances where prescribed psychiatric drugs
base in this guidance is that there is little to produce short-term relief, they do not change the
support a ‘disease-centred’ model of drug action. underlying causes of psychological distress and
Prescription psychiatric drugs act on the brain to may do some harm in the long term. It should
alter mood and consciousness. In general, they also be remembered, however, that psychiatric
control reactions to emotional distress by numbing, drugs can be prescribed for physical conditions
tranquilising or sedating a person, thereby such as migraine. As we will see from the evidence
producing subjective states that may or may not presented in sections 4–7, all prescription
be experienced as helpful to the individual. Where psychiatric drugs come with withdrawal costs to
psychiatric drugs produce effects experienced as some people. What follows is a brief summary of
helpful, they are best thought of as a temporary that evidence.
tool or coping mechanism that can be a helpful
precursor to psychological change.
Evidence box A: Summary of adverse effects and withdrawal reactions to broad classes of prescribed
psychiatric drugs
(For full details, including references, see sections 4 and 5)
Benzodiazepines (e.g. Diazepam) have sedative properties and are generally prescribed for anxiety and sleep disturbance. They
carry a significant risk of dependence if used for more than a month and for this reason should be prescribed for no longer than
that. Adverse effects include drowsiness and impaired cognitive ability and, at higher doses, slurring of speech, loss of balance
and confusion. Withdrawal effects are often severe and generally include an acute period over two weeks to two months with
symptoms such as anxiety, agitation, insomnia and muscle stiffness. There can also be tingling, numbness, electric shock-type
feelings, hallucinations, delusions and nightmares. Some people will experience longer-term withdrawal symptoms lasting a
year or more.
Antidepressants come in two main classes: Tricyclic antidepressants which are sedating, resulting in slowed reaction time,
drowsiness and emotional indifference. In high doses they can also cause heart arrhythmias; SSRIs/SNRIs can cause nausea,
drowsiness, but also sometimes insomnia. They usually have sedative effects and appear to numb emotions but may sometimes
cause anxiety and agitation. There is also some evidence that SSRIs may increase suicidal impulses and possibly also violent
behaviour in children and young people. Withdrawal effects can include nausea, dizziness, anxiety, depression, ‘brain zaps’,
insomnia, hallucinations, vivid dreams, agitation and confusion. These symptoms typically last a few weeks but may continue
for up to a year and occasionally for several years.
Stimulants (e.g. Ritalin) are generally prescribed for behavioural problems in children (and now often adults). They increase
arousal and improve attention in the short-term, but suppress interest, spontaneity and emotional responsiveness. Insomnia is
common. An important adverse effect for children is growth suppression. There may be rebound effects on withdrawal as well as
tearfulness, irritability and emotional lability (rapid often exaggerated changes in mood).
Mood stabilisers (e.g. Lithium) are most commonly prescribed for those who have been given a diagnosis of bipolar disorder. All
have a sedative effect, suppressing physical activity and reducing or flattening emotional responses. There is decreased ability
to learn new information, prolonged reaction times, poor memory, loss of interest and reduced spontaneous action. Weight gain
is common. Withdrawal from Lithium does not result in the physical withdrawal symptoms typical of other drugs but can cause a
relapse of mania if undertaken too quickly.
Anti-psychotics (e.g. Olanzepine) all produce a sedative effect, dampening or restricting emotional reactions and making it
difficult to take the initiative. There are a number of adverse neurological and metabolic adverse effects, including muscle
stiffness, tremors, slowness in movement and thought, and akathisia (restlessness). Weight gain, increased risk of diabetes and
cardiovascular disease are also common, and long-term use leads to shortened life span. Suicidality and sexual dysfunction
are common adverse effects. Tardive dyskinesia or involuntary movements of the face, tongue, arms and legs is common, and
may become evident, or be exacerbated, after withdrawal, reduction or switching medication. Withdrawal effects typically start
within four days and may include symptoms such as nausea, headache, tremor, insomnia, decreased concentration, anxiety,
irritability, agitation, aggression and depression. Rebound psychosis may also occur.

For ease of reference, the following table
summarises the main adverse effects and
withdrawal reactions for each class of prescribed
psychiatric drug. For fuller lists and a review of the
evidence (including references), please see sections
4 and 5.
Evidence box B: Summary of psychiatric drug effects by class.
Drug class Effects that may be perceived as adverse Possible withdrawal reactions
Benzodiazepines and Z-drugs ■■ Sedative ■■ Sweating, nausea, dizziness,

■■ Significant risk of dependence abdominal cramps
E.g. Temazepam, Diazepam,
Pregabalin, Gabapentin, ■■ Drowsiness and impaired cognitive ability ■■ Anxiety, agitation, insomnia,
Zoplicone muscle stiffness
■■ Tingling, electric shock type
feelings. Risk of epilepsy
■■ Panic attacks, poor memory
■■ Hallucinations, delusions
■■ Nightmares
Antidepressants ■■ Sedative ■■ Anxiety

E.g. Fluoxetine, Paroxetine ■■ SSRIs/SNRIs: nausea, drowsiness, insomnia ■■ Nausea, dizziness, insomnia.
■■ Sexual dysfunction ■■ Mood changes
■■ Anxiety and agitation ■■ Hallucinations
■■ Emotional blunting ■■ Vivid dreams
■■ Suicidality ■■ Confusion
Stimulants ■■ Insomnia ■■ Rebound effects, including

■■ Growth suppression in children tearfulness, irritability, emotional
E.g. Ritalin
lability
Mood stabilisers ■■ Sedative ■■ No physical withdrawal effects

E.g. Lithium ■■ Drowsiness, tremor, lethargy, decreased ability ■■ Relapse or rebound of mania
Tegretol to learn new information, prolonged reaction
time, poor memory, reduced spontaneity
■■ Weight gain
■■ Reduced emotional responses
■■ Toxic state: levels have to be regularly
monitored
Anti-psychotics ■■ Sedative ■■ Nausea, headache, tremor

E.g. Chlorpromazine, ■■ Dampened emotional responses and ■■ Sleep disturbance, irritability,
Haloperidol, Olanzapine, motivation aggression, depression.
Risperidone ■■ Dizziness, sexual dysfunction, weight gain ■■ Possibility of ‘supersensitivity’,
■■ Cardiovascular effects psychosis, particularly when
withdrawing from clozapine
■■ Akathisia and extra-pyramidal effects
■■ Rebound psychosis.
■■ Tardive dyskinesia
■■ Anticholinergic effects: dry mouth, blurred
vision, constipation
■■ Restlessness
■■ Suicidality
For fuller lists of possible drug effects and withdrawal reactions, please refer to sections 4 and 5.
December 2019 21
3.2.1 Potential effects of taking Given the above evidence for a range of effects
and adverse reactions to taking or withdrawing
prescribed psychiatric drugs on from prescription psychiatric drugs, therapists
therapeutic work may wish to consider a number of key issues
The evidence detailed in section 4 suggests that when working with those who are currently
research aimed at demonstrating the superiority taking, have previously taken or have now been
of a combination of psychiatric drugs and advised to take these drugs. The following section
psychotherapy over either intervention alone is invites therapists to consider questions relating to
not conclusive. Indeed, given the predominantly reflexivity, evidence, context and ethics.
sedative effects of many prescribed psychiatric
drugs, it is not unrealistic to suggest they can 3.2.2 Reflexivity: where am I in this?
significantly and unhelpfully affect therapeutic
Therapists will need to consider their personal
work.7 Therapists may find that prescribed
position in relation to the medical model, reflecting
psychiatric drugs act in ways that limit their
on their own beliefs, values and attitudes towards
emotional access to clients and the problems for
prescribed psychiatric drugs together with any
which they are seeking help. Clients may feel ‘out
relevant personal or professional experiences
of reach’ or emotionally cut off and their difficulties
that might have contributed to their stance. A
may seem vague or difficult to define. In addition,
complicating factor is that the widespread use
prescription psychiatric drugs have the potential
of prescription drugs means it is possible, even
to significantly alter the way clients think, feel and
likely, that therapists themselves will have been
behave.
prescribed psychiatric drugs at some point in
Effects on thinking may include: loss of memories; their lives. They may also have witnessed family
poor recall; poor concentration; confusion; losing members, partners or friends taking psychiatric
track of ideas; difficulties in making links; difficulties drugs. Where this is the case, they may also
in structuring thought; problems staying focused; wish critically to reflect on their own and others’
and an inability to retain insights over time. experiences of such drugs and to consider how
and to what extent this might impact on their
Effects on feeling may include: emotional therapeutic stance.
withdrawal; being uninvolved, distanced or ‘not
really there’; inability to reconnect with feelings
Question box 1: What do I feel about
relating to past experiences; suppressed anger,
prescribed psychiatric drugs?
sadness or fear; and a lack of emotional congruence.
■■ What do I understand by the term ‘medical
Effects on behaviour may include: passivity with
model’?
the therapist; passivity outside therapy sessions;
■■ How does the medical model ‘sit’ with my
uncooperativeness or over-compliance; denial
preferred therapeutic modality?
of responsibility; absences due to lateness,
cancellations or missed appointments; apparently ■■ What position do I take up in relation to the
poor motivation; repetitive speech or behaviour; medical model? Where do I locate myself?
and disengagement from work or social activities. ■■ How does my professional training and
clinical experience influence the way I
These effects will vary according to the particular
understand and work with issues relating
drug, its dosage and the period of time over which
to taking or withdrawing from prescribed
it has been taken as well as the individual taking it.
psychiatric drugs?
A picture will build up over time of how and in what
■■ Do I have any experience of taking
way the client’s life has been affected and shaped by
prescribed psychiatric drugs myself? Am
taking prescription psychiatric drugs, bearing in mind
I aware of any family members or friends
that no-one is likely to display all of the above signs.
who have taken prescribed drugs?

■■ If so, what do I think and/or feel about 3.2.4 Context: what are the key
these drugs, based on my own knowledge
and experience?
influences on my work and me?
Other issues will need to be considered in the light
■■ How might this facilitate or hinder a
of each therapist’s theoretical framework, work
discussion with the client?
setting and personal and professional judgment.
■■ Do I need to reflect on any of these issues
in my own personal therapy? Do I need to It is important that therapists use the evidence
discuss in supervision? base included in this guidance to develop their
therapeutic understanding and skills in the light
of their particular modality and professional
3.2.3 Evidence: what do I know? context, as well as the particular needs of the
Therapists will find it helpful to develop a basic client. As an example, therapists working within
understanding of the evidence relating to the public sector services such as the NHS are likely
possible effects of the main classes of psychiatric to be expected to liaise where appropriate with
drugs, together with their withdrawal effects. This prescribers, other mental health professionals and
includes being aware of general information about in some cases with partners, carers and relatives as
tapering, such as the need to avoid any sudden well. Therapists working in independent practice
cessation of psychiatric drugs when withdrawing. may have less opportunity for such collaboration.
They may also find it useful to understand the Different theoretical models will also take diverse
likely impact of prescribed drugs on therapeutic perspectives on the likely impact of collaboration
work and how some withdrawal reactions can on the therapeutic relationship. In these and other
be mistaken for relapse back into psychological situations, therapists may wish to draw on the
distress. evidence-base to tailor their support of clients in
ways that are appropriate to the particular model
Question box 2: What evidence do I need to and context within which they are working.
consider?
Question box 3: What contextual issues do I
■■ Which drugs do I most commonly hear
need to consider?
about from my clients?
■■ Am I familiar with the main classes of ■■ How does my preferred theoretical
psychiatric drugs and what they are used framework enable me to think about the
for? (See section 4). role and function of prescribed drugs in my
client’s life?
■■ Am I familiar with their common effects and
withdrawal symptoms? (See sections 4 ■■ Given my preferred therapeutic model,
and 5). what position do I take up in relation to
working with other health professionals if
■■ What do I know about the evidence for the
requested by the client?
impact of prescribed psychiatric drugs on
therapy? (See section 4 per drug, and 3.2.1). ■■ Should I consider liaising with the client’s
prescriber? Given my current workplace,
■■ Do I understand the importance of slow
what are the possible channels of
withdrawal or tapering strategies?
communication with other people involved
(See section 5.4).
in the care of my client?
■■ What knowledge and skills do I need to best
■■ How does my preferred framework
support my client?
influence whether I signpost information
where this is in the best interests of the
client?
December 2019 23
■■ Might it be helpful to find out more about The latter places the therapist in the position of
multidisciplinary models of work in cases ‘expert’ and may risk undermining the client’s
of prescribed psychiatric drug withdrawal? autonomy and decision-making capacity. In
(See section 6.2) the same way, the therapist who offers general
■■ What is the likely impact of contact information about the effects of psychiatric drugs is
or collaboration with others on the not offering any specific advice about ‘what to do’
therapeutic relationship? but is rather providing information on the ethical
basis of ‘informed consent’. Clients can then decide
■■ Should I consider signposting the client to
for themselves how best to proceed.
further relevant information or evidence
about their drugs? Clearly, this process is not always straightforward,
■■ Should I consider referring the client and will be dependent on a number of factors:
to specialist agencies or other forms of
■■ The skill of the therapist in engaging the client
support?
in ways that support them to make informed
■■ What is the likely impact of such a referral
decisions i.e. decisions based on understanding
on the therapeutic relationship?
the benefits and risks of any proposed
psychiatric drug treatment.
3.2.5 Ethics: what are the principles ■■ The capacity of the client to engage in decision-
that might apply to this issue? making processes, which will vary according
Finally, working with issues of prescribed drug to their personal circumstances, history of
dependence raises legal and ethical questions psychological problems and current level of
relating to the importance of therapists working distress.
within the boundaries of their professional ■■ The tendency of clients to favour interventions
competence and role. It may be useful here that claim immediate relief for their emotional
to clearly distinguish between medical advice distress, rather than longer-term interventions
and medical information. Whilst it is clear that whose future outcome may appear less certain.
psychological therapists are neither trained to This bias arguably skews the entire informed
issue medical diagnoses nor to prescribe medical consent process, no matter how conscientiously
or pharmacological treatment, they may frequently implemented.
be asked by clients for medical information. ■■ Additional processes and care will be required
Discussing facts, scientific evidence or information where a client lacks the mental ability to make
where appropriate with clients differs substantially informed decisions about what is best for them.
from offering a diagnosis, prescribing drugs or
advising withdrawal. It is important to be clear It remains the case that there is currently no
about this distinction with clients. specific legal or ethical guidance on how therapists
should respond to issues relating to taking or
Let us consider the difference between offering withdrawing from prescribed psychiatric drugs.
information to clients (sometimes called psycho- This means that general ethical principles provided
education) and giving them advice. As therapists, by all the main professional accrediting bodies
we may prefer to talk with clients about the will remain an important touchstone for their
common features of – and helpful reactions to – a therapeutic practice and therapists may need
panic attack rather than telling them what they to consider which principles are likely to be
should or should not do. The former is a common particularly relevant when working with those
therapeutic strategy that enables therapists to who are taking or withdrawing from prescribed
help clients think about and understand the range psychiatric drugs.
of options available. It allows the client to decide
what they feel is best or most helpful for them.

For example, BACP’s Ethical Framework (2018)8 All psychological therapists should be aware
covers the following areas: that working with issues of prescribed drug
dependence is becoming an increasingly
■■ Working on the basis of informed consent.
contested and fast-moving field of practice. The
Helping the client to understand the potential
rapid growth of scientific knowledge can make
impact of their prescribed psychiatric drugs
it difficult for professional guidance, including
on the therapeutic process can be seen to be
medical guidelines, to keep pace with the speed
part of the therapist’s responsibility to ensure
of change, leading to the potential for significant
the client’s informed consent within therapy.
differences of opinion between those who are
This should be clearly distinguished from the
caring for the client. Where therapists disagree
prescriber’s responsibility to inform the client
with a prescriber’s medical advice to the client
about the physiological and psychological
(e.g. which they believe to rest on erroneous or
effects of their prescribed drugs. However,
out-dated medical information), they may, with
it may be helpful for therapists to support
client consent where possible, consider contacting
this process where appropriate, for example
the prescriber to raise their concerns. However,
by directing clients to relevant sources of
differences in professional expertise, as well as
information.
variations in how a patient presents can also
■■ Respecting the client’s best interests. This lead to well-founded disagreements within or
includes supporting the client to take action, across teams and disciplinary divides and practice
or where necessary, for therapists to consider settings. Therapists will need to be mindful of the
doing so themselves, in order to prevent need to communicate thoughtfully, sensitively
significant harm to the client or others. and courteously with other professionals whilst
■■ Keeping knowledge and skills up to date. prioritising the best interests of the client at all
This may include therapists referring to the times (see Note in 4.3 below).
evidence-base included in this guidance and
supplementing their competence in the areas
Question box 4: What ethical and legal issues
proposed.
do I need to consider?
■■ Demonstrating accountability and candour. This
■■ Am I aware of the distinction between
includes being open and honest with clients
medical advice and medical information?
about the potential problems or risks associated
with dependence on or withdrawal from ■■ How might I ensure that my client does not
prescribed psychiatric drugs. interpret any information giving as advice?
■■ Working respectfully with colleagues. Whilst it ■■ Am I aware of the relevant principles
is important that therapists do not undermine and ethics of professional practice
a client’s relationship with other colleagues or recommended within my current
prescribers, they may need to be prepared to professional accrediting body? E.g.:
support clients where they have had unhelpful –– working on the basis of the client’s
experiences or advice. informed consent
–– respecting the client’s best interests
Although the ethical frameworks of the UKCP, BPS
and NCS also endorse these ethical principles, –– taking steps to keep my knowledge
therapists will need to reflect on and apply them and skills up to date
to their own particular therapeutic practice and –– demonstrating accountability
professional work setting, as well as taking any and candour
associated organisational policies into account. –– respecting the client’s autonomy
and self-determination.
December 2019 25
3.3 Practice-related guidance for therapists
It is not possible for this guidance to address all the no hard and fast rules here about the best course
possible implications of taking or withdrawing from of action where therapists are concerned about
prescribed psychiatric drugs, for all therapeutic a client’s use of or withdrawal from prescribed
practice, in all contexts. Rather, the intention is to psychiatric drugs, and in many cases therapists may
promote critical thinking and awareness of the impact decide against such contact. The decision to get in
of prescribed psychiatric drugs, and for therapists touch with a prescriber will inevitably be a function
to extend their competence by considering issues of multiple, overlapping factors: whether contact
particular to their own clients and practice settings. is at the request of and in the best interests of the
client; whether the client has consented to the
This part of the guidance is divided into three
therapist making contact; the therapist’s preferred
main sections for ease of reference. Each section
therapeutic model and rationale for communicating
addresses issues that are relevant to the client’s
– or not – with the prescriber concerned; the work
drug ‘journey’, i.e. where the client is in relation to
context in which therapy is taking place; and
taking prescribed psychiatric drugs. The sections
the therapist’s own confidence in and previous
are as follows: a) clients who are considering a
experience of initiating contact with prescribers and
prescription for psychiatric drugs; b) clients who
other medical professionals.
are already taking prescribed psychiatric drugs; c)
clients who are considering withdrawing from their Where contact with the prescriber is considered
prescribed drugs; and, d) clients who are currently appropriate and where the client has given consent, a
withdrawing from prescribed drugs and who may short email to request a discussion or meeting can be
be experiencing withdrawal effects. helpful, followed up where necessary by a telephone
call or message. For therapists working in public
In each section, a number of key information areas
sector services like the NHS, such communications
are highlighted alongside links to relevant sections
are usually straightforward, particularly where
in the guidance that provide further material,
therapists are working side-by-side with prescribers.
resources and/or evidence for therapists to consult.
Where it proves difficult to contact prescribers, it
Implications for the client and for therapy are also
may be necessary for the therapist to discuss their
discussed. At the end of each section there are a
concerns with colleagues and/or supervisors. Where
number of practice-related questions for therapists
appropriate, they may wish to consider bringing
to consider. These are designed to help therapists
their concerns to a multidisciplinary team meeting
think critically about their therapeutic work and
for discussion (details of models for supporting
its particular context, and are not necessarily to be
withdrawal in multidisciplinary teams can be found
asked of clients. Given the considerable differences
in 6.2). In other settings such as independent practice,
within and between theoretical frameworks, these
communication with prescribers is frequently
questions are intentionally broad, aiming to help
more complex and will be dependent on therapists
therapists reflect on their personal knowledge,
obtaining the GP or prescriber contact details. Where
skills and experience in working with clients who
possible, therapists can email or write to request a
have issues relating to taking or withdrawing from
conversation or meeting, indicating their professional
prescribed psychiatric drugs.
qualifications and role together with their reasons
for being concerned about the client. Following
Note 1: Working with prescribers initial contact, therapists may need to be prepared to
and family members or carers maintain communication particularly where the client
Throughout the guidance, therapists are encouraged is withdrawing from prescribed drugs.
to consider if, when and how it might be appropriate Therapists are also encouraged to consider whether
to contact prescribers. It is clear that there can be it might be appropriate, with the client’s consent,

to be in contact with carers or family members such expectations about prescribed psychiatric drugs
as partners or other relatives. In the case of some that prevent the client from accepting an alternative
older adults, or those with learning disabilities or view of their difficulties, which would in turn enable
communication difficulties, carers, partners and therapy to be of more benefit.
families are likely to be involved in supporting
The relationship that clients have with their
the client. In some work settings, particularly
prescribed psychiatric drugs becomes more
within public sector services, collaboration with
complex where drugs are taken as a consequence
family members and carers is seen as a relatively
of being detained under the Mental Health Act
straightforward element in therapeutic work. In other
or being treated under a Community Treatment
settings, such as independent practice, there is less
Order (CTO). In these circumstances, therapists
opportunity or need for contact and collaboration.
will need to be alert to the way in which
Therapists will need to consider carefully, from the
pharmacological treatments are likely to impact
perspective of their preferred therapeutic framework
on the therapeutic relationship, working with
and practice setting, the range of issues and
clients to support them within the limitations
implications associated with contacting and working
imposed by legal frameworks. Difficulties are also
with carers and/or family members.
likely to arise where clients rely on prescription
psychiatric drugs to demonstrate eligibility
Note 2: Working with the beliefs for benefits such as Employment and Support
clients hold about prescribed Allowance (ESA). In these situations, therapists
psychiatric drugs will need to explore sensitively and with care the
extent to which anxiety about any possible loss
Therapists may also wish to explore the beliefs
of benefits underpins the client’s understanding
clients hold about taking prescription psychiatric
of the causes of their emotional distress and
drugs, as well as the psychological ‘message’ that a
drives any decision about withdrawing from
pharmacological intervention inevitably carries. For
prescribed psychiatric drugs. Therapists should
example, some people believe, or have been told,
also bear in mind the extensive debates in the
that depression, anxiety and other psychological
field about the overprescribing of psychiatric
problems are caused by biochemical changes to
drugs in marginalised groups, including those
the brain, while others believe there are genetic
from black and ethnic minority backgrounds. For
factors underlying their emotional distress. In these
further information about this, it may be helpful to
cases, prescription psychiatric drugs carry a strong
consult the British Psychological Society’s (2017)
psychological message for the individual that they
Understanding Psychosis document.
are ‘ill’ and require medical ‘treatment’ in order to
manage. Indeed, where clients believe that they are
‘weak’ or have failed to live up to social expectations 3.3.1 Working with clients who
and norms, it may be preferable for them to treat are considering a prescription for
what they believe to be the physical or biochemical
psychiatric drugs
causes of their distress rather than to explore painful
Useful information for therapists to know:
life experiences or interpersonal dynamics that may
be contributing to the problem. Clients may also ■■ Main effects of the proposed psychiatric drug
believe that it is not good for them to experience (section 4).
strong feelings of distress, and that prescribed ■■ The potential risks of drug dependence
psychiatric drugs will quickly and effortlessly get (sections 4 and 5).
rid of feelings of sadness or anger. In these and
■■ The likely impact of the proposed prescribed
many other situations, therapists will need to take
drug on therapy (section 4 by drug and 3.2.1
into account the beliefs and meanings held by the
above).
client, exploring any unrealistic or over-optimistic
December 2019 27
a) Implications for the client prescriber has recommended, and should always
refer the client back to their prescriber for medical
■■ Based on the principle of informed consent,
advice, remaining alert to any reluctance on the
therapists may wish to enquire whether the
part of the client to question their prescriber. Acting
client’s prescriber has discussed with them the
on the principle of informed consent, therapists
possible effects of or potential for dependence
may wish to explore any concerns the client may
on the proposed psychiatric drug. If not, they
have about their prescribed drugs and where
can encourage the client to discuss this further
appropriate direct them to relevant available
with their prescriber. Therapists may also need
sources of information (e.g. BNF) or evidence in a
to ensure the client is aware of the potential
sensitive and non-leading manner (see 3.2.5).
impact of taking the proposed drug on the
process and progress of therapeutic work. c) Practice-related questions for therapists to
■■ Therapists should be aware of the implications consider
of prescribed psychiatric drugs for working with
Question box 5
particular groups of clients. For example, older
adults who have diminished physical or cognitive ■■ What does the client think and feel about
capacities may be at increased risk of falling whilst taking prescribed psychiatric drugs?
taking prescribed drugs. Clients who are pregnant ■■ Why might the client wish, or feel they
or planning a pregnancy may incur risks to the need, to accept (or not) a prescription?
unborn child. In these and other cases, therapists ■■ What is the likely impact of the proposed
are well-placed to encourage the client, where drug on the client’s ability to engage in
appropriate, to discuss the potential impact of psychological therapy?
prescribed psychiatric drugs with their prescriber
■■ Is the client directly requesting advice
in order to ensure they are making an informed
about drugs? If so, can I support their
choice about the use of such drugs.
agency in relation to the prescription?
b) Implications for therapy Do they need more information?
■■ How can I best support the client’s choice
■■ Therapists will need to explore sensitively and
either to start their prescribed drugs or
with care the client’s perception of his or her
to revisit the GP/prescriber to consider
psychological problems. It is important to judge
alternatives to drugs?
whether the client wishes, or is ready, to talk
about any issues associated with their planned ■■ Is therapy appropriate for the client
use of prescribed psychiatric medication. at this time, or is referral to another
service required?
■■ Therapists should consider whether and to what
extent the client’s planned use of prescription
psychiatric drugs is likely to affect therapy. Where
possible, it is helpful to address issues around
3.3.2 Working with clients who
psychiatric drug use at an early point in the have already started taking
therapeutic relationship in order to better assess prescribed psychiatric drugs
its likely impact on successful therapeutic work. Useful information for therapists to know:
■■ Where clients directly ask therapists for advice
■■ Main effects of client’s prescribed psychiatric
concerning prescribed drugs, therapists will need
drug (see section 4).
to ensure they do not offer any personalised
suggestions about the advisability or otherwise of ■■ Impact of prescribed drugs on therapy (section
taking prescription psychiatric drugs. They should 4 by drug and 3.2.1 above).
not be drawn into discussions about the type, ■■ Risks of abrupt discontinuation, reduction or
dosage or frequency of any drugs that the client’s switching prescribed drugs.

a) Implications for the client c) Practice-related questions for therapists
to consider
■■ Clients may experience a range of effects whilst
taking their prescribed psychiatric drugs. If Question box 6
therapists are familiar with some of the adverse
■■ If the client’s prescribed drug use was not
effects of the main classes of psychiatric drugs
raised at the start of therapy, why has it been
(e.g. benzodiazepines and antidepressants) they
raised now?
may be able to help the client identify if and
when they might be experiencing them. ■■ Why might the issue of prescribed drugs
be significant within the therapy at this
■■ Taking prescribed psychiatric drugs may have
particular time?
significant implications for the client’s partner,
family, carers or other people involved in their ■■ What are the implications of taking
care. This may be of particular relevance for prescribed drugs for the progress of therapy?
older adults and those with learning disabilities ■■ What is the client’s relationship with their
or communication problems. Therapists will prescriber?
need to consider carefully, from the perspective ■■ How can I support the client to contact
of their work setting and preferred therapeutic their GP, psychiatrist or other prescriber?
framework, the range of issues associated with Might it be helpful for me to do so?
contacting and working with carers and/or ■■ Does the client want me to contact any
family members (see Note 1, 3.3). family members, carers or others who may
b) Implications for therapy be involved in the client’s care? What are
the implications of this for the therapeutic
■■ Therapists will need to explore sensitively and relationship?
with care the extent to which the client wishes, or
is ready, to talk about any issues associated with
their use of prescribed psychiatric drugs. In some
cases, therapists may decide that it is not in the
3.3.3 Working with clients who
client’s best interests to start therapy and instead are considering withdrawing from
may choose to refer the client to alternative prescribed psychiatric drugs
sources of help and support. However, given the
lack of currently available services, therapists This guidance aims to empower and support
should remain cautious about assuming other conversations often already taking place
professionals are better able to offer emotional between therapists and their clients. Therapists
or psychological care. Depending on the type and will need to decide for themselves whether, and
level of prescription psychiatric drugs taken by to what extent, they wish to use this guidance
the client, therapists are generally well-placed in the context of their therapeutic work. These
to offer support, though it may be necessary to decisions will depend on their theoretical
adjust therapeutic expectations of what kind of modality, practice setting and the individual
work will be possible. needs of the client. The client’s agency, as
■■ Clients may make a ‘late reveal’ in therapy that always, should be supported and respected
they are or have been taking prescribed drugs at all times. Clients should be encouraged to
for some time but have not previously been able discuss withdrawal from prescribed psychiatric
or willing to discuss this. In some cases where drugs with a knowledgeable prescriber who
the client’s prescription drug use is known can give medical advice, oversee and manage
but has not been discussed, the therapist may any withdrawal process appropriately. While
make a decision to raise it as an issue where this guidance advocates the importance
previously it had not been part of the work, of informed client-choice based on full
if in the interest of the therapy. information about potential benefits and risks,
December 2019 29
it does not advocate therapists telling their ■■ The process and possible experiences of
clients to take, not take, stay on or withdraw withdrawing from prescribed psychiatric drugs.
from psychiatric drugs. These matters should ■■ Awareness of the importance of planning for
be left to the prescriber and client to decide. withdrawal: preparation, timing, knowledge
and support.
During the course of therapeutic work, clients may ■■ Understanding the likelihood of withdrawal effects.
consider withdrawing from their psychiatric drugs
■■ Understanding the potential impact of withdrawal
and either moving to therapy alone or ending all
on the client’s family and other social networks.
interventions if they are feeling better. In these
■■ Understanding the importance of the client
cases, it will be helpful if therapists are aware of
having informed medical support and
the following:
supervision during withdrawal.
■■ Key definitions about relapse and withdrawal.
Box C: Evidence summary – useful information for therapists to know
Although there is a lack of formal research into the effectiveness of therapeutic strategies aimed at supporting withdrawal, the
theoretical, experiential and anecdotal evidence from those working in this field nonetheless offers useful suggestions. What
follows is a summary of the ‘combined wisdom’ from these sources (for full details, including references, see section 6).
There are five relevant factors that have been found to be helpful in supporting withdrawal. These are:
1. Access to accurate information about withdrawal.
2. The involvement of a knowledgeable prescriber to devise, help monitor and manage, a tapering programme that is tolerable
and agreeable to the client.
3. Access to client-centred, non-authoritarian support.
4. Access to information about and help with engaging with useful coping strategies and/or supportive lifestyle changes.
5. Awareness of the need to suspend customary assumptions about sources of distress and their associated interventions
(i.e. emotional processing or analysis) for the duration of withdrawal.
The ‘combined wisdom’ approach

The combined wisdom of those therapists who have worked in depth with this client group describes three stages of support:
Stage 1: Preparation before withdrawal is started
Preparation is essential to successful withdrawal. Understanding the withdrawal process, alongside a stance of non-judgmental
acceptance, allows the therapist to engage the client in a discussion about the advantages and disadvantages of withdrawal.
Ten areas to consider reviewing with the client are:
■■ Exploring whether a client feels ready to begin the withdrawal process.
■■ Exploring who is going to provide medical support, and their relationship with their prescriber.
■■ Signposting and discussing relevant information on withdrawal (*see list of examples below).
■■ Discussing the possibility and general nature of withdrawal effects so clients know what to look for.
■■ Clarifying the high-level definitions of relapse, rebound, recurrence and withdrawal and how they might be mistaken (e.g.
adverse withdrawal reactions that result from reducing or discontinuing a drug might be mistaken as ‘relapse’, a term which
refers to the gradual return of the original issue, at the same intensity, for which the drug was initially taken – see 5.4.2).
■■ Addressing any potential fears about the withdrawal process.
■■ Identifying possible ways the attempt might be inadvertently sabotaged.
■■ Identifying potential support networks.
■■ Discussing the idea of the client using a diary or log to keep track of drug reductions and experiences.
■■ Discussing the availability of extra sessions or other contact if needed in between scheduled meetings, being clear about the
limits of what can be provided.
* Examples of information about withdrawal that may be shared with the client if appropriate (see 5.4.1 for fuller information):
■■ Withdrawal from prescribed psychiatric drugs should be carefully planned and carried out under the supervision of an
informed prescriber.
■■ Withdrawal should never be sudden or abrupt; people’s experience can vary significantly, with some experiencing no
withdrawal reactions whilst others can experience severe and protracted withdrawal.
■■ Schedules should be flexible and the reduction rate based on the individual’s withdrawal reactions, intensity of reactions,
their ability to cope and whether there is sufficient support available. Drugs may need to be tapered very slowly over months
or beyond.
■■ Where reactions to withdrawal are severe, it is sometimes possible for a client to get a liquid prescription from the GP/
prescriber. This helps to ensure accuracy in making small reductions to the prescribed drug.
Further details about the ‘combined wisdom’ approach, including references, can be found in section 6.

a) Implications for the client c) Practice-related questions for therapists
to consider
■■ Clients may not have considered the possibility
of withdrawal reactions, nor of the need to Question box 7
prepare for withdrawing from their prescribed
■■ If the client wishes to withdraw from their
psychiatric drugs. Indeed, where clients are
prescribed drugs, why now? What has
planning to finish therapy and subsequently to
precipitated their decision?
withdraw from their prescribed drugs because
they feel better, they may not have considered ■■ Has the client discussed their decision to
how a therapist could support them in the withdraw with his or her prescriber?
withdrawal. ■■ What is the client’s relationship with their
■■ Withdrawing from prescribed psychiatric prescriber?
drugs may have significant implications for ■■ Does the client have a plan for withdrawal?
the client’s partner, family, carers or other ■■ How can I support the client to contact
people involved in their care. This may be of their GP, psychiatrist or other prescriber?
particular relevance for older adults and those Might it be helpful for me to do so?
with learning disabilities or communication ■■ Does the client want me to contact any
problems. family members, carers or others who may
b) Implications for therapy be involved in the client’s care? What are
the implications of this for the therapeutic
In addition to reviewing the information outlined in relationship?
box C:
■■ Therapists should be aware that withdrawing 3.3.4 Working with clients who
from prescribed drugs requires planning and are currently withdrawing from
preparation and may take some time. The
process of withdrawal itself can take months
prescribed psychiatric drugs
or years, not days or weeks. A rushed or Clients may already have started to withdraw from
unplanned withdrawal process is less likely their prescribed drugs before starting work with
to succeed. a therapist. Some may not wish to tell a therapist
that they are doing so. In these cases, it may be
■■ While it is beyond the professional remit
useful for the therapist to consider the following,
of psychological therapists to give direct,
in addition to the information given in section 3.3.3:
personalised withdrawal or tapering advice,
therapists may wish to consider in advance a) Implications for the client
their position on giving or signposting relevant
information to clients. This may be particularly
■■ If a client has chosen to start withdrawing
important if the relationship between client and without talking to a prescriber or researching
prescriber is problematic or has broken down. how to taper, any information given may come
as a surprise. Discussing the helpfulness of
■■ Adopting a stance of non-judgmental
informed medical support and supervision
acceptance allows the therapist to engage the
during withdrawal will need to be done in such a
client in a discussion about the advantages and
way as to not undermine the client’s agency.
disadvantages of withdrawal.
■■ Clients may have a range of experiences when
■■ Where relevant, therapists will need to consider
withdrawing from prescribed psychiatric drugs
carefully, from the perspective of their work
(summarised in section 3.2, full information in
setting and preferred therapeutic framework,
section 5). Withdrawal reactions such as anxiety,
the range of issues associated with contacting
agitation or insomnia, especially those that
and working with carers and/or family members
continue past the acute stages are commonly
(see 3.3, note 1).
December 2019 31
Evidence box D: Summary – useful information for therapists to know
The ‘combined wisdom’ approach

As introduced in 3.3.3 the combined wisdom of those therapists who have worked in depth with this client group describes three
stages of support. The second and third stages are as follows:
Stage 2: During withdrawal – support
Therapists are likely to have more regular contact with a client than a prescriber. They are therefore in a strong position to offer
the client ongoing support for the withdrawal process. Possible areas for therapeutic work may include:
■■ Helping clients to identify withdrawal reaction and offering reassurance that they will pass. It is important to assume that
any reactions that emerge during the transition are due to withdrawal unless proven otherwise.
■■ Encouraging clients to make sense of their experiences and to accept them as normal to the withdrawal process. For
example, clients may experience intense anxiety and fluctuating levels of physical and mental pain.
■■ Helping clients to manage withdrawal reactions that can come and go. This is sometimes referred to as ‘waves’ and
‘windows’, where the ‘waves’ of reaction slowly decrease in intensity, interspersed with ‘windows’ of reduced or very limited
reactions. Some clients may only experience ‘waves’ within ‘waves’.
■■ Helping clients to identify supportive practices which enable them to manage and tolerate withdrawal experiences while
they last. These may include coping strategies such as: acceptance; maintaining a non-resisting attitude to withdrawal
experiences, or breathing exercises. (For the full range of potential coping tools, see 6.1.1.1).
Stage 3: After withdrawal is complete

■■ At the end of withdrawal, therapists may find it useful to review the client’s experience and to determine with them what
further therapeutic needs they have. In addition:
■■ If the client has experienced any cognitive problems as a part of their withdrawal experience it may take a while for
confidence in decision making to rebuild (including the ability to say ‘no’ to others).
■■ If the clients’ withdrawal was experienced as traumatic this might need to be considered in any further therapeutic work.
■■ Both client and therapist should be aware that post-withdrawal reactions can occur for some time after stopping taking
prescribed psychiatric drugs.
Working in multidisciplinary teams

■■ There are examples in the theoretical and research literature of psychiatrist-led models to support withdrawal that may be
of interest for further reading if a therapist has an opportunity to suggest this in a multidisciplinary team setting (see 6.2).
Further details about withdrawing from prescribed psychiatric drugs, including references, can be found in sections 5 and 6.
assumed by clients and their prescribers to signal b) Implications for therapy

a return of the client’s psychological problems
In addition to those elements described in Box
and to require further medication. In such cases,
D, and always dependent on the therapist’s
therapists will need to work with clients to help
theoretical framework, therapists should also
them understand their experiences of withdrawal
consider the following elements that may form part
as physiological rather than psychological
of therapeutic work over the withdrawal period:
in origin, and to agree what is realistic
therapeutically during the process. ■■ If there was no opportunity to work with the
■■ If a client experiences protracted or severe client to prepare for withdrawal, therapists
withdrawal reactions they will naturally need should consider the list of 10 areas listed in Box
to adjust their expectations of the withdrawal C to see if any would be still helpful to address.
process and how long it might take. They may ■■ If clients experience ‘waves and windows’
also need to consider more fully what support during the withdrawal process (see Box D)
is available to them from family and friends, or where reactions fluctuate over time, therapists
from a continued relationship with a therapist. can help monitor the course of these episodes if
■■ Withdrawing from prescribed psychiatric drugs they happen, providing the client with support
may have significant implications for the client’s and information and tailoring therapeutic work
partner, family, carers or other people involved appropriately.
in his or her care. ■■ Whilst it is clear from Box D that any reactions
■■ Where clients have been sedated and inactive that emerge during the transition should be
due to long periods of drug use, they may treated as a result of withdrawal unless proven
need to find new and more satisfying ways of otherwise, it is possible that new emotions
occupying themselves. may also emerge. The therapist may need to

consider these feelings carefully together with ■■ Is the client aware of the potential impact
the client, deciding whether they are further of withdrawal from drugs on existing
material for therapeutic work and if so, when relationships such as family, partners and
they might be best addressed. colleagues?
■■ Where the client is unable to process emotional ■■ What might I need to do or change in my
material due to high levels of anxiety or therapeutic practice to accommodate the
physical/mental pain or discomfort, it will client’s withdrawal reaction distress?
be necessary for the therapist to revisit any ■■ What additional relevant tools or strategies
previously agreed therapeutic aims in order to might be helpful, and how might these
provide support, guidance and reassurance. impact the therapeutic relationship?
■■ The therapist will need to anticipate, discuss Which do I know enough about to provide
and work through potential problems, feelings information on, and which would I need to
or setbacks with the client. It is important to simply signpost for the client?
maintain an accepting and non-judgmental ■■ Do I need to consider additional
therapeutic stance, identifying risks in the event therapeutic support for the client?
of the client becoming emotionally unsafe. Where would this come from?
■■ If there are concerns about prolonged or adverse
reactions during withdrawal, therapists should
consider discussing with the client the advantages This guidance aims to empower and support
and disadvantages of seeking advice from the conversations often already taking place
prescriber and/or other mental health professional. between therapists and their clients. Therapists
■■ Therapists will need to encourage the client’s will need to decide for themselves whether, and
sense of responsibility and autonomy whilst to what extent, they wish to use this guidance
remaining clear about the support they are able in the context of their therapeutic work. These
to provide. decisions will depend on their theoretical
■■ As for 3.3.3, therapists will need to consider modality, practice setting and the individual
carefully, from the perspective of their work needs of the client. The client’s agency, as
setting and preferred therapeutic framework, always, should be supported and respected
the range of issues that arise when asked to at all times. Clients should be encouraged to
contact and work with carers and/or family discuss withdrawal from prescribed psychiatric
members (see 3.3, note 1). drugs with a knowledgeable prescriber who
can give medical advice, oversee and manage
c) Practice-related questions for therapists any withdrawal process appropriately. While
to consider this guidance advocates the importance
of informed client choice based on full
Question box 8
information about potential benefits and risks,
■■ Am I aware of the ‘combined wisdom’ it does not advocate therapists telling their
approach in relation to withdrawal clients to take, not take, stay on or withdraw
strategies? (Boxes C & D). from psychiatric drugs. These matters should
■■ Does the client want me to contact his or be left to the prescriber and client to decide.
her GP, psychiatrist or other prescriber?
■■ It may not be possible to distinguish
between withdrawal symptoms and any
re-emergence of the client’s presenting
psychological problem. Can I tolerate my
own and the client’s uncertainty about this?
December 2019 33
References
1. Johnstone, L. & Boyle, M. with Cromby, J., Dillon, J., Harper, D., 5. Wampold, B. (2001). Contextualising psychotherapy as a
Kinderman, P., Longden, E., Pilgrim, D. & Read, J. (2018). The healing practice: Culture, history and methods. Applied &
Power threat meaning framework: Towards the identification Preventive Psychology, 10, 69–86.
of patterns in emotional distress, unusual experiences and 6. Strawbridge, S. & Woolfe, R. (2010). Counselling psychology:
troubled or troubling behaviour, as an alternative to functional Origins, development and challenges. In: R. Woolfe, S.
psychiatric diagnosis. Leicester: British Psychological Society. Strawbridge, B. Douglas & W. Dryden (Eds.) Handbook
2. British Psychologial Society (2011). Response to the American of Counselling Psychology, 3rd Edition. London: Sage
Psychiatric Association DSM-5 Development. Publications, pp.3–22.
3. Bracken, P. et al. (2012). Psychiatry beyond the current 7. Hammersley, D. (1995). Counselling people on prescribed
paradigm. (Pat Bracken, Philip Thomas, Sami Timimi, Eia drugs. London: Sage.
Asen, Graham Behr, Carl Beuster, Seth Bhunnoo, Ivor Browne, 8. BACP (2018). Ethical framework for the counselling professions.
Navjyoat Chhina, Duncan Double, Simon Downer, Chris Evans, Lutterworth: British Association for Counselling and
Suman Fernando, Malcolm R. Garland, William Hopkins, Psychotherapy.
Rhodri Huws, Bob Johnson, Brian Martindale, Hugh Middleton, 9. British Psychological Society (2017). Understanding psychosis
Daniel Moldavsky, Joanna Moncrieff, Simon Mullins, Julia and schizophrenia (revised). A report by the Division of Clinical
Nelki, Matteo Pizzo, James Rodger, Marcellino Smyth, Derek Psychology. Ed. Anne Cooke.
Summerfield, Jeremy Wallace and David Yeomans). The British
Journal of Psychiatry, 201, 430–434.
4. Elkins, D. (2009). The medical model in psychotherapy: Its
limitations and failures. Journal of Humanistic Psychology,
49(1), 66–84.

4. What psychiatric drugs do by class
Professor Joanna Moncrieff & Dr Tom Stockmann
4.1 Interpreting the evidence on psychiatric drugs

The most robust evidence for the use of psychiatric 4.1.2 Ignoring drug-induced
drugs is generally agreed to come from randomised
controlled trials that compare a particular drug or
alterations
intervention with a standard or ‘control’ condition, Since most research is premised on the disease-
such as a placebo. Randomisation is important centred model of drug action, the general
because it allows the effects of the intervention alterations that drugs produce on physical
being tested to be distinguished from the effects and mental functioning are often ignored and
of other things, such as the natural history of the interpreted as changes in the underlying ‘disorder’.
condition and general factors that might produce Yet these alterations may change people’s
improvement like seeing a specialist. To further experience and behaviour without affecting the
reduce the risk of bias, the investigators and underlying problem.
participants may be ‘blinded’, or made unaware
of who receives the drug and who the control 4.1.3 ‘Publication bias’
treatment or placebo. Studies that find positive effects of drugs are
more likely to be published than studies that find
Combinations of the results of several different
they have no benefits or cause harm.8 In addition,
trials of the same treatment, called meta-
published reports of studies often emphasise the
analyses, are also regarded as providing high
measures that show the drug in the best light.8
quality evidence. However, a meta-analysis is
Measures that show no benefit or that indicate
only as good or as poor as the trials it combines.
harmful effects may not be published or may be
A meta-analysis of poorly conducted trials
concealed in the small print of the article.
summates their deficiencies or biases and so
the result may be more misleading than the Some pharmaceutical companies have been
original studies. shown to withhold data that do not show their
drug in a favourable light.9 But doctors, researchers
Randomised controlled trials were developed to
and editors have also played a part in focusing
test the outcomes of interventions for physical
on research that highlights the positive and
medical conditions. Translating them into the
plays down the negative effects of drugs. There
area of mental health is not straightforward and
are extensive financial relationships between
there are various difficulties with interpreting
these groups, that have been shown to bias the
the results.
undertaking, interpretation and reporting of
research.
4.1.1 The validity of measurements
Emotional states and behaviours are properties
4.1.4 Unblinding
of living human beings and cannot be described
The use of a placebo is meant to prevent
and quantified in the same way that we measure
participants and researchers from knowing
the properties of physical objects. Therefore, the
whether they are getting the real drug or not. This
meaning and validity of measurements of mental
is why studies using a placebo are referred to as
symptoms is not clear-cut.
‘double blind’. However, it is often quite easy for
people in trials to tell whether they are taking the
December 2019 35
drug or the placebo, due to the mental and physical 4.1.5 Drug withdrawal effects in trials
alterations drugs produce independently of any
Most trials of long-term treatment, and many trials
effect they might have on the underlying disorder.
of short-term treatment too, involve people who
The chance that people will detect whether they
are already taking the drug that is being tested, or
are taking a drug or a placebo is heightened
something similar. The people who are randomised
because people who take part in trials are given
to placebo are then taken off their existing treatment
detailed information about the ‘side’ effects of the
and may therefore be vulnerable to adverse effects
drug being tested.
related to the withdrawal of the prior treatment.11
What this suggests is that many trials that are This is especially problematic because the
supposed to be double blind are not. Many of the withdrawal and transfer to placebo is usually done
participants and some of the professionals involved abruptly. Therefore, many studies, particularly those
are likely to be able to work out who is taking assessing long-term treatment, may assess the
the real drug and who is on the placebo. Trials in effects of withdrawing from prescribed drugs rather
which people are asked to guess what they are than the impact of starting on it in the first place.
taking show that in most cases people can detect
This array of potential problems suggests that
the nature of the pill they have been given.10 If
care must be taken when interpreting research on
people taking part in trials believe that drugs are
psychiatric drugs, and the clinical guidelines based
likely to help them, they may have a heightened
upon them.
expectation of improvement if they suspect they
are taking the real drug. Conversely, they may
have lowered expectations if they believe they are References
1. Melander, H., Ahlqvist-Rastad, J., Meijer, G. & Beermann, B.
on the placebo. Any differences in the outcome
(2003). Evidence b(i)ased medicine: Selective reporting from
of treatment may be due to these different studies sponsored by pharmaceutical industry: Review of
expectations, rather than the effects of the drug. studies in new drug applications. BMJ 326(7400), 1171–3.
2. Jureidini, J.N., McHenry, L.B. & Mansfield, P.R. (2008). Clinical
trials and drug promotion: Selective reporting of study 329.
International Journal of Risk and Safety in Medicine 20(1–2), 73–81.
3. Fisher, S. & Greenberg, R.P. (1993). How sound is the double-
blind design for evaluating psychotropic drugs? The Journal of
Nervous and Mental Disease 181(6), 345–50.
4. Moncrieff, J. (2006). Why is it so difficult to stop psychiatric
drug treatment? It may be nothing to do with the original
problem. Medical Hypotheses 67(3), 517–23.

4.2 Antidepressants
4.2.1 History term physical health condition, or has ongoing

life stressors. In such cases, antidepressants are
During the 1950s, certain drugs were tried out
recommended to be continued for a minimum of
on people who were depressed, which started
two years2, but increasingly people end up taking
to be called antidepressants. One group of these
these drugs for multiple years and beyond.
drugs, which are similar in structure to some of
the early antipsychotics, is known as the tricyclic They are also prescribed for individuals who have
antidepressants. Another group is the monoamine received a diagnosis of a variety of other mental
oxidase inhibitors or MAOIs. These were the main health difficulties, including anxiety, obsessive
types of antidepressant used until the late 1980s. compulsive disorder, panic disorder, phobias,
Prozac was launched in 1988 and was the first bulimia and post-traumatic stress disorder. Tricyclic
of a series of new antidepressants introduced antidepressants are sometimes also used to treat
during the 1990s called the ‘selective serotonin chronic pain, particularly pain of a neurological
re-uptake inhibitors’ (SSRIs). These were joined by origin, or insomnia, usually at lower doses than
a variety of other sorts of drugs also branded as those recommended for depression.
antidepressants (including venlafaxine, duloxetine
and mirtazapine). 4.2.3 Theories of action
From the beginning of the 1990s, industry The traditional view of antidepressant action,
advertising campaigns and professional publicity based on a disease-centred model (outlined in
increased the prescribing of these drugs section 2), suggests that antidepressants help
substantially. Antidepressants are now by far the correct a chemical imbalance presumed to be
most commonly prescribed class of psychiatric present in depression. They are said to increase the
drug, and their use continues to rise. In 2016 in availability of certain neurotransmitters that are
England, over 65 million prescriptions were issued thought to be deficient in depression. Older drugs,
for antidepressants, a 6% increase on the previous like the tricyclic antidepressants and the MAOIs
year and over 500% increase since 1992.1 are thought to act by increasing the availability of
the neurotransmitter noradrenalin. The SSRIs are
Antidepressants are regarded as useful treatments
still generally believed to improve depression by
for depression and a range of other conditions and
correcting a deficiency of serotonin.
their use is recommended in various situations by
official guidance. Although the idea that depression is caused by
a chemical imbalance has entered the public
4.2.2 Common short-term uses consciousness, the ‘monoamine’ theory of
depression is not supported by evidence or expert
Antidepressants are recommended for what is judged
opinion.3,4 Studies of serotonin receptors, for
to be moderate or severe depression, and for less
example, show contradictory findings, with some
severe depression that is not helped by psychological
showing that receptor numbers are reduced in
interventions1. SSRIs are usually the first choice.
people with depression, compared to people
People diagnosed with depression who recover without, some showing no difference, and some
after being prescribed an antidepressant for the showing they are increased. Studies that aim to
first time, are generally advised to continue the induce a lowering of serotonin levels through
drug for at least six months.2 Antidepressants are dietary means do not show any association
usually prescribed for a longer period if the patient with the onset of depression in people with no
has suffered several episodes, the symptoms have history of depression, although some studies
not disappeared entirely, the person has a long- show a deterioration of mood in people with a
December 2019 37
previous history of depression who have been type of antipsychotics. They are strongly sedating
treated with SSRI antidepressants. Evidence on drugs. They increase sleep and cause drowsiness
noradrenaline is also contradictory.5 In addition, during the day. Studies with healthy volunteers
numerous randomised trials have shown that show that taking tricyclic antidepressants makes
drugs that are not thought of as antidepressants, people slower in their reactions and impairs
and have actions on other neurotransmitter intellectual abilities such as attention and memory.
systems, including benzodiazepines, opiates, Taking them is usually an unpleasant experience
stimulants and antipsychotics, are as effective for volunteers (it is associated with ‘dysphoria’ in
as recognised antidepressants in people with volunteer studies).14,15
depression.5 Leading psychopharmacologists
SSRIs have more subtle effects in volunteer
have concluded that direct evidence for the
studies apart from their effects on the gut (most
monoamine hypothesis is lacking.6,7 Indeed, the
of the body’s serotonin is present in the gut). They
whole ‘chemical imbalance’ theory of depression
commonly cause nausea and sometimes diarrhoea
is now dismissed as overly simplistic by academic
and vomiting. SSRIs also commonly produce
psychiatry.8 Some official sources continue to
mild drowsiness but can also cause insomnia.
suggest that antidepressants work by increasing
They can induce a state of emotional numbing or
‘levels of chemicals in the brain’ that are linked
restriction.13 In addition, they can cause lethargy,
with depression8, but others, such as the Royal
reduced libido and sexual impairment. They
College of Psychiatrists public information leaflet,
also occasionally produce an unpleasant state
no longer mention reduced serotonin as a potential
of agitation and tension, especially in young
cause of depression.9
people.14,16 These effects can be difficult
The drug-centred model as outlined in section to recognise.
2, suggests that antidepressants produce
mental and physical alterations, which interact 4.2.5 Evidence of efficacy
with the symptoms of depression. These may
potentially account for certain differences between 4.2.5.1 Short-term use in depression
antidepressants and placebo in randomised trials. Antidepressants are one of the standard
For example, the sedation produced by older recommended treatments for depression and
antidepressants may be experienced as helpful many people regard them as useful. Their use is
by some people with anxiety and insomnia, based on evidence from hundreds of placebo-
while the emotional numbness induced by some controlled trials, which show that antidepressants
antidepressants may reduce the intensity of are slightly better than a placebo in terms of scores
negative feelings for some. The mental and physical on a depression rating scale, the principle outcome
alterations may also reveal to people participating measure of these trials. Studies are inconsistent,
in randomised trials that they are taking an active however, and differences are small, especially
drug, increasing the placebo effect. when unpublished trials are included.
The small difference between antidepressants

4.2.4 Drug effects and placebo raises questions about whether the
There has been little effort to characterise how effects are, indeed, worthwhile. For example, in
antidepressants alter normal physical and mental an analysis, which combined the results of several
functioning. American trials of SSRIs and other new drugs, the
difference between the drugs and the placebo
Antidepressants come from many different
was less than two points on the commonly used
chemical classes, and therefore can be expected
Hamilton Rating Scale for Depression (HRSD).17
to vary in the effects they produce. Tricyclic
Other meta-analyses, including the largest ever
antidepressants, for example, appear to be
conducted, published in 2018, report similar small
pharmacologically similar to some of the older

differences between antidepressants and placebo.18 and various statistical issues may have artificially
The HRSD usually has 17 items and scores up to 54 inflated differences between antidepressants and
points. When a difference of around two points is placebos in randomised trials and meta-analyses
compared to ratings on a commonly used global of these trials.23
measure of people’s overall condition, the Clinical
Additionally, antidepressants may produce
Global Impressions Scale19, it does not register as
alterations that reduce depression-related
showing any difference at all. Indeed, a difference
symptoms without actually acting on depression
of eight points on the HRSD would be required to
itself. Depression often involves insomnia or
register as a ‘mild’ level of improvement on the
sleeping difficulties and sometimes involves
Clinical Global Impressions Scale, a difference that
anxiety and agitation. Any drug with sedative
is way above that found in any combined analysis
properties will improve this aspect of the problem.
of placebo controlled antidepressant trials.20 An
The HRSD, for example, contains three items on
analysis of trials conducted by the (then) National
sleep alone and these items can score up to six
Institute of Clinical Excellence21 also found that
points. So, any difference between drugs and
the difference in depression scores between
placebo may reflect the sedative qualities of
people randomised to antidepressants and people
some commonly used antidepressants (tricyclic
randomised to placebo was so small that it was, in
antidepressants and mirtazapine, for example).
the words of the Institute’s report, ‘unlikely to be of
clinical significance’.21 Any drug that alters our consciousness may also
obscure or suppress depressive feelings. SSRIs
Although depression rating scales scores are the
appear to dull or numb emotions, which could
principle outcome measures of placebo-controlled
reduce the intensity of depressive feelings.16,24
trials, results are often presented in terms of the
Tricyclic antidepressants may also promote a state
proportion of people who show a ‘response’ to the
of emotional indifference, given their affinity with
antidepressant compared with the proportion that
antipsychotic drugs that are known to have this
respond to the placebo. The largest antidepressant
property. All these effects may reduce scores on
meta-analysis reported, for example, that people
depression rating scales.
randomised to take antidepressants were one and
a half to two times more likely to show a ‘response’ These and other alterations also mean that people
than people allocated to placebo.18 There is no involved in antidepressant trials are sometimes
objective marker of ‘response’, however. It is able to detect whether they are taking the active
simply defined, quite arbitrarily, as a certain level drug or the placebo. This may produce an unequal,
of reduction in depression measurement scale amplified placebo response in people who are taking
scores. When scores are categorised in this way, antidepressants in randomised trials. If people can
however, the difference between the groups can be improve by taking an inert placebo, what is known
inflated, so that small absolute differences in scores as the ordinary placebo effect, then people who
become quite large differences in response rates.22 take a drug that has noticeable effects may have
Therefore the depression scores are the most an amplified placebo response. Conversely, people
reliable measure of the outcome of these trials. who take the placebo may realise this because they
do not experience any of the ‘side’ effects they have
The small difference between antidepressants
been told to expect. Such people may do worse than
and placebo that is indicated by depression scale
they might do if they had not been enrolled in a trial
scores may not even be a genuine difference
in the first place. As such, the difference between
in actual levels of depression, however, but
antidepressants and placebo detected in clinical
may be an artefact of research designs or a
trials may be a result of ‘amplified’ placebo effects.25
consequence of the mental alterations produced by
antidepressants. Publication bias, not accounting The idea that antidepressants may be working
for withdrawal effects from previous treatment through inducing ‘amplified’ placebo effects
December 2019 39
is supported by the finding that other drugs of depressive symptoms.28 Based on these
with noticeable effects, including stimulants, studies, people who have had a single episode of
benzodiazepines, opiates, and antipsychotics depression are recommended to continue taking
have been found to have equal effects to standard antidepressants for at least six months. People who
antidepressants in randomised studies in people have had recurrent episodes are recommended to
with depression.8 take antidepressants on a longer-term basis.
In summary, antidepressants are only marginally However, the interpretation of these studies
better than placebo in randomised trials in people has been challenged particularly because the
diagnosed with depression. Some evidence people transferred onto placebo are liable to
suggests the differences are unlikely to translate experience withdrawal effects provoked by
into meaningful clinical benefit. Moreover, there stopping antidepressants (see section 4.1.5).29–31
is no current evidence that strongly supports the These effects include anxiety and mood changes
idea that antidepressants produce their effects by and may be mistaken for a relapse of the original
acting on the underlying biological mechanism of problem.32
depression.26 Although much research has been
In addition, people who experience withdrawal
conducted to look for the underlying mechanisms
effects may realise that they have been swapped
of depression, no such mechanism has been
onto the placebo and this may make them
confirmed, and there remains little evidence that
anxious and vulnerable. The next time they
serotonin or other neurochemical abnormalities
experience problems they may lapse into a
are associated with depression, or account for
state of depression because they have come to
antidepressant action. Moreover, there are other
believe that they need the drug to remain well
convincing explanations of how antidepressants
and because they realise that they have been
affect people with depression.
taken off it. This situation is likely, because the
participants of these maintenance treatment trials
4.2.5.2 Antidepressants in severe depression
are a selected group who have made a good initial
It is commonly stated that antidepressants are
response to treatment.33 They may already be
most effective in severe cases of depression.
persuaded of the benefits of drug treatment, or, at
Overall, the evidence around this is contradictory.
least, they are likely to be nervous about having
A NICE review claimed antidepressants have
it withdrawn.
their most marked benefits in people with more
severe depression, but the data actually found However, non-randomised observational studies
the greatest effects compared with placebo in provide no evidence that antidepressants improve
people whose depression was in the middle range long-term outcomes of depression. In fact, some
of severity, rather than in those with the most studies indicate that long-term antidepressant use
severe depression.21 A recent meta-analysis that is associated with increased relapse rates,34 and
specifically examined this issue found that the worse long-term outcomes,35,36 compared to people
severity of depression was not correlated with who do not use antidepressants.
drug-placebo differences.27
One such recent non-randomised study analysed
4.2.5.3 Long-term use for relapse prevention the association of antidepressant use from the age
in depression of 20 and depressive symptoms over the course
of the succeeding 30 years. Involving 159 people,
There are several studies that show that if you take
it found that those who used antidepressants
people whose depression has improved while they
were more likely to have more severe symptoms
are taking antidepressants, and you randomise
during follow-up. However, it is likely that all
some of them to have their antidepressant stopped
these studies reflect the fact that people who
and substituted with a placebo, then the people
take antidepressants generally have more severe
transferred to placebo will have more ‘relapses’

problems initially than those who decide not to including impotence, loss of libido and delayed
take them, which may account for their worse orgasm.
outcomes. Some studies have taken indicators
The effects of SSRIs and SNRIs are similar,
of initial severity into account in the statistical
although SNRIs may produce more noticeable
analysis to some degree, but it is difficult to exclude
effects. Both types of drug commonly affect gut
this problem altogether.37
activity and cause nausea, vomiting, diarrhoea,
constipation, and abdominal pain. They are also
4.2.5.4 Use in anxiety disorders
associated with sexual dysfunction, especially
A recent meta-analysis of studies of the treatment of
delayed orgasm. There are mounting anecdotal
anxiety showed that SSRI and SNRI antidepressants
reports that the sexual dysfunction associated with
were superior to placebo in reducing scores on
SSRIs can occasionally persist after the drugs are
anxiety rating scales, but again the effect was
discontinued, sometimes for months or years.43
modest. The difference in improvement between
people taking the drug and those taking placebo Both SSRIs and SNRIs can cause lethargy and SNRIs
was between two and three points on the Hamilton may cause drowsiness. The state of emotional
Anxiety Rating Scale, which has a maximum score of numbing or detachment they produce can be
56 points.38 Another meta-analysis of 12 trials of the experienced as unpleasant and debilitating44 and is
SSRI drug paroxetine found that, on average, people associated with sexual dysfunction.45 They can also
randomised to take paroxetine improved by 2.3 produce a state of anxiety and agitation, especially
points more than people randomised to placebo.39 in younger people,46,47 which can also be extremely
Studies comparing SSRI antidepressants with unpleasant and may be predictive of increased
benzodiazepines for anxiety symptoms find that suicidal impulses (see below).
benzodiazepines have larger effects.40
SSRIs and other antidepressants, particularly 4.2.7 Other adverse effects

clomipramine, one of the old tricyclic Some SSRIs, particularly paroxetine, have been
antidepressants, are commonly prescribed linked with birth defects,48 and as a class these
to people who are diagnosed with obsessive drugs can thin the blood and produce bleeding
compulsive disorder (OCD). They improve disorders.49
symptoms more than a placebo by around 3.2
points on a 40-point OCD measurement scale.41 4.2.8 SSRIs and suicide
Behaviour therapy has larger effects than Several meta-analyses of antidepressant studies in
medication, but most studies of therapy include children and adolescents show increased rates of
people who are also on prescribed drugs.42 suicidal behaviour associated with use of SSRIs.50–53
Some meta-analyses of trials in adults indicate
4.2.6 Common adverse effects small increases in suicide attempts or self-harm in
Tricyclic antidepressants can slow down the people on SSRIs compared with placebo.54,55 but
conduction of electrical impulses in the heart and others do not.56–58 A recent re-analysis of one of these
in high doses may cause dangerous irregularities of negative studies revealed a significant increase in
the heartbeat known as arrhythmias. Overdosing suicidal ideation and behaviour using a different
on these drugs is dangerous and often fatal. They statistical approach.59 However, where they have
also cause postural hypotension (a drop in blood been compared with other types of antidepressants,
pressure on standing up), which can lead to falls, SSRIs have not been found to be any worse in terms
and they increase the risk of seizures. They tend to of increasing suicidal ideation and behaviour.60,54 A
have ‘anticholinergic effects’ including dry mouth, recent meta-analysis based on data from original
constipation, difficulty passing urine and blurred trial reports (which can provide more transparent
vision. At higher doses they may cause confusion. data than official publications) found increased rates
They also cause weight gain and sexual dysfunction of suicidal thoughts and behaviour in children and
December 2019 41
young people taking antidepressants compared to diagnosed with depression. Such effects vary in
those taking placebo, but there was no difference strength and character depending on chemical class
in adults. This analysis also found an increase in and composition of the particular antidepressant. For
reports of aggressive behaviour among young example, tricyclic drugs are strongly sedating, which
people taking antidepressants compared to those might be experienced as useful for insomnia, or to
on placebo.61 This confirms evidence from case reduce anxiety and agitation. SSRIs, whilst exerting
reports of violent incidents, including legal reports weaker and more subtle effects, can induce a state
and data from drug-monitoring agencies.62 It appears of emotional numbing or restriction, which may
that these behaviours may be related to the state of reduce the intensity of people’s feelings. However,
agitation that SSRIs and related antidepressants can the fact that drug-placebo differences are so small,
occasionally produce, which, for reasons that are and easily accounted for by non-pharmacological
not understood, seem to be more common among factors, suggests that antidepressant-induced
young people.47 alterations may not be clinically useful. Moreover,
emotional restriction and other drug-induced mental
It is difficult to evaluate the conflicting evidence
alterations may complicate successful engagement in
and claims about the relationship between
psychotherapy.
antidepressants and suicide and violence because
these situations are rare. On balance, the majority
of evidence suggests that antidepressants can
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4.3 Benzodiazepines and related drugs
4.3.1 History then coma and death at very high doses. Z-drugs
also work by stimulating the GABA system.
Benzodiazepine is the chemical name for a group
of drugs discovered in the 1960s, otherwise known In most situations benzodiazepines are regarded as
as (minor) tranquilisers. The individual drugs are non-specific treatments. In other words, they are
often more familiar by their trade names. One thought to work according to a drug-centred model
of the most commonly used benzodiazepines is by producing an artificial drug-induced sedative
diazepam, whose trade name is Valium. They also state, rather than reversing an underlying disease.
include chlordiazepoxide (librium), lorazepam and Since it is well known that they induce similar
temazepam. effects in everyone, regardless of whether or not
they suffer from a psychiatric problem, it is difficult
From the 1960s onwards, benzodiazepines
to deny the impact of their drug-induced effects. An
were widely prescribed to people with sleeping
exception to this is the case of anxiety. It has been
difficulties and people with anxiety and ‘neurotic’
suggested that anxiety is caused by abnormalities of
disorders, especially women, often for long periods
GABA activity, which can be specifically reversed by
of time. In the 1980s it became apparent that many
the action of benzodiazepines on the GABA system.
people who take benzodiazepines for more than a
However, there is limited evidence of this.4
few weeks become physically dependent on them
and experience significant withdrawal symptoms
when they stop. Recommendations were then made 4.3.3 Drug effects
that they should not be prescribed routinely other Benzodiazepines and similar drugs have sedative
than for short periods. properties, similar in nature to alcohol. They cause
a sensation of relaxation, which is both mental
Starting in the late 1980s, the Z-drugs (zopiclone,
and physical, and they are recognised muscle
zolpidem and zaleplon) were introduced. These
relaxants. Like alcohol they may occasionally lead
are chemically different from benzodiazepines but
to disinhibited or aggressive behaviour, although
have similar effects and are now widely prescribed
there is little robust evidence in clinical or help-
for insomnia. The drugs pregabalin and gabapentin
seeking populations.4a The alterations they produce
also bear some similarities to benzodiazepines
are usually experienced as pleasurable, and they are
in terms of their pharmacological actions. In
used for recreational purposes, especially by those
psychiatry, they are prescribed for anxiety. They
who prefer sedative drugs or ‘downers’.
are also used for epilepsy and nerve pain. In 2013, a
UK study reported that pregabalin and gabapentin
prescribing had increased by 350% and 150%
4.3.4 Evidence of efficacy
respectively in just five years1. Withdrawal reactions Short-term studies of benzodiazepines show that they
have been described following discontinuation, reduce anxiety more than a placebo and are slightly
which are similar to benzodiazepine withdrawal more effective than other common drugs treatments
reactions.2,3 for anxiety such as SSRIs.5 However, studies generally
only last a few weeks, so it is not certain whether this
effect persists, since the body adapts to counteract
4.3.2 Theories of action
their effects. This is the mechanism of dependence.
Benzodiazepines act by enhancing the activity of
The body’s arousal mechanisms are stepped up to
the brain chemical known as gamma aminobutyric
counteract the effects of the drugs, leading to the
acid (GABA). GABA has an inhibitory effect and
need for greater doses to produce the same effects
benzodiazepines increase this. Therefore, they
and causing unpleasant withdrawal symptoms when
lower the activity of the brain, causing sedation and
they are stopped.
relaxation at lower doses, progressing to sleep and
December 2019 45
Randomised controlled trials of benzodiazepines people appear to be prescribed benzodiazepines
for insomnia show that they increase duration of over long periods. Recent research estimates
sleep by around an hour on average, but do not that the current number of people taking
improve the time it takes to get to sleep (sleep benzodiazepines long-term (beyond one year) in
latency).6 In contrast, a recent meta-analysis of England is over 266,000.10
Z-drugs found that sleep latency was reduced by
an average of 22 minutes compared to placebo, a 4.3.6 Common adverse effects
difference which the authors concluded may not be
Like all sedative drugs, benzodiazepines impair
clinically meaningful, and there was no evidence of
people’s ability to perform simple physical and
improvement of sleep duration, although there was
mental tasks like driving and mental arithmetic.
insufficient evidence on this particular outcome.7
As with alcohol, people are often unaware of their
impairment and rate themselves as functioning
4.3.5 Common uses better than they are. It may only be after they
Benzodiazepines are recommended for the short- withdraw from the drugs that they realise how
term treatment of anxiety and Z-drugs for the short- impaired they were.11 Other effects that derive from
term treatment of insomnia. Benzodiazepines the ability of benzodiazepines to suppress nervous
are also prescribed for the treatment of alcohol activity include confusion, slurring of speech and
withdrawal and are frequently prescribed to people loss of balance and usually only occur at higher
with severe psychiatric problems because of their doses, or if some other factor (like a physical illness
sedative properties. As such, they are prescribed of some sort) is present. These effects are more
extensively to psychiatric inpatients with various likely to occur in elderly people, and when they
diagnoses. do, elderly people can have falls and suffer other
accidents because of being over-sedated.
Within psychiatric hospitals, benzodiazepines
are commonly used in emergency situations to At very high doses, such as when they are taken
sedate people who are behaving in a disturbed or in an overdose, benzodiazepines can, like other
aggressive way. Studies show that benzodiazepines sedative drugs, suppress the respiratory system
are effective and comparable to other sedative and cause death.
agents (such as antipsychotics) in this situation.8
There has been some concern that benzodiazepines
However, evidence about whether they can reduce
may occasionally lead to disinhibited behaviour
disturbed behaviour over a long period is lacking.
and aggression. This mainly seems to occur when
Benzodiazepines and Z-drugs have modest effects in high doses are used in people with a prior history of
insomnia and so they might be useful, temporarily, behavioural problems and in people who are more
in someone who is having trouble sleeping. vulnerable to this, like children, the elderly and
However, this effect will wear off, and if they are people with learning disability.12
taken for more than a few weeks, withdrawing from
Pregabalin and gabapentin also suppress the
them will itself produce sleeping difficulties. It is a
activity of the central nervous system, and their use
similar situation with anxiety. Benzodiazepines can
can result in drowsiness, sedation, and reduced
have remarkable effects in reducing anxiety initially,
breathing. These risks are raised by higher doses,
but these effects are likely to decline with time.
such as might be taken in an overdose, or when
When the drugs are stopped, anxiety will be induced
they are used in combination with other drugs that
by the process of withdrawal. For this reason, it is
depress the nervous system. Like benzodiazepines,
recommended that benzodiazepines be reserved for
this can lead to respiratory failure and death in
short-term use only.9
extreme cases. They are also associated with
Despite benzodiazepines being generally weight gain, which is not generally thought to occur
recommended for short-term use only, many with benzodiazepines.

Benzodiazepines are well-recognised recreational Benzodiazepines are definitely to be avoided
drugs, often used alongside other illicit substances during the last part of pregnancy, as they can cause
like opiates. The agents with the shortest half-life neurological toxicity in the newborn infant.25
are the most susceptible to abuse, and some, like
Together with drowsiness and confusion
temazepam, have been added to the schedule
caused by their sedative properties, the most
for controlled drugs. There have also been calls
pressing concern regarding benzodiazepine use
to make pregabalin and gabapentin-controlled
is dependence. The occurrence of withdrawal
substances, due to their propensity to become
syndromes after stopping benzodiazepines and
drugs of recreational or illicit use.13 Both are
Z-drugs is well established and also reported in
reported to produce a ‘high’ in those taking them.
relation to gabapentin and pregabalin (see section
The abuse potential may be higher with pregabalin,
5 for further information).
which is absorbed faster and is more potent than
gabapentin.14,15 However, gabapentin can also
produce euphoria.16 4.3.8 Conclusion
Benzodiazepines are effective in reducing feelings
4.3.7 Long-term harm of anxiety and have a modest effect in insomnia in
the short-term. The main concern with their use is
A few studies have looked at whether long-term
the significant risk of tolerance and dependence,
use of benzodiazepines affects the structure of
and the associated difficulties that people can
the brain. Two of these studies found a reduction
experience when trying to withdraw from the drugs.
in the amount of brain matter after long-term
use of benzodiazepines, similar to findings with
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found no effects.19,20
BMJ: British Medical Journal (Online), 347.
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H., Kiefer, F. & Mann, K. (2010). Pregabalin abuse, dependence,
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Haloperidol plus promethazine for psychosis-induced 19. Busto, U.E., Bremner, K.E., Knight, K., terBrugge, K. and
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abusers. Psychological Medicine, 17(4), 869–73.

4.4 Antipsychotics
4.4.1 History in psychosis teams. After taking antipsychotic

drugs for a further one to two years after recovery
The types of drugs that are now commonly called
from the acute episode, they may be supported to
antipsychotics were previously referred to as
stop. People who have more than one episode are
neuroleptics or as major tranquillisers.
recommended to stay on these drugs long-term for
The first drugs of this sort were introduced in relapse prevention.
the 1950s and 1960s. At that time, psychiatrists
As well as being used for treating those with
viewed them following a drug-centred model as
a diagnosis of psychosis or schizophrenia,
substances that happened to have the ability to
antipsychotic drugs are also used in a range
suppress thoughts and emotions without simply
of other situations, particularly to calm and
putting people to sleep in the way the older
subdue people who are agitated or aggressive.
sedatives did. The mental restriction the drugs
Therefore, they are also prescribed to people who
produced was noted to be part of a general state
are diagnosed with mania, personality disorder,
of physical and mental inhibition that at extremes
dementia, learning difficulties, autism and anxiety.
resembled Parkinson’s disease. Early psychiatrists
They are also prescribed for depression and
regarded this state of neurological suppression as
insomnia. Some antipsychotics are considered to
useful but as potentially damaging to the brain.
be ‘mood stabilisers’ and prescribed for long-term
Over time, these drugs have come to be regarded
treatment of people with bipolar disorder (see
as treatments that target an underlying brain
section 4.5 on ‘mood stabilisers’).
abnormality, particularly through their effects on
the neurotransmitter, dopamine. Parallel to this
view, they have come to be called ‘antipsychotics’.1 4.4.3 Theories of action
Antipsychotic drugs had been in use for at least a
The first of these drugs are now sometimes referred
decade before it was discovered that some of them
to as ‘first generation’ or ‘typical’ antipsychotics.
strongly counteract the effects of the brain chemical
From the 1990s a new range of these drugs
called dopamine. This finding led to the ‘dopamine
was introduced, known as ‘atypical’ or ‘second
hypothesis’ that suggested that ‘schizophrenia’ was
generation’ antipsychotics. The second-generation
a result of abnormally increased dopamine activity.
antipsychotics were claimed to be more effective
In this view, antipsychotics are thought to reverse
and less prone to side effects than the older
the chemical imbalance causing the symptoms of
drugs, but this is now known not to be the case.
‘schizophrenia’ or psychosis.
In fact, the distinction between the two classes is
regarded now as unhelpful. Both classes contain a The dopamine hypothesis has developed over time,
diverse range of individual substances with varying and now incorporates ideas about other causal
pharmacological profiles and range of effects. factors including genetics, environmental stress
and other neurotransmitter abnormalities, but
4.4.2 Common uses of amongst this complexity, the general assumption
remains that dopamine dysfunction is part of
antipsychotics the causal pathway to psychosis. The disease-
Antipsychotic medication is a mainstay of centred view of antipsychotics is that they work by
treatment for people diagnosed with psychosis correcting, or partially correcting, this underlying
and schizophrenia. They are used to treat acute abnormality by lowering dopamine activity.
episodes of psychotic disturbance. People who
experience a first episode of psychosis in the UK Although some experts still adhere to the
are often cared for by specialist early intervention dopamine hypothesis2, the majority of evidence
December 2019 49
that has been collected over the last 50 years has may impair some aspects of cognitive performance
not confirmed any differences in indicators of in people who have recovered from their
dopamine activity between people with a diagnosis psychosis.10
of psychosis or schizophrenia and people without.3
In contrast to the disease-centred view that
The few studies that show differences include very
antipsychotics work by correcting an underlying
few people who have not already been treated with
dopamine abnormality, the drug-centred model
antipsychotics (which modify dopamine activity
suggests that the ‘antipsychotic’ effect is achieved
in themselves) and have not controlled for the
by this state of neurological restriction that
other factors that are associated with increased
antipsychotics induce. This artificial state of
dopamine activity, such as stress and arousal.3,4
suppression may reduce the intensity of ‘abnormal’
thoughts and experiences such as delusions and
4.4.4 Drug effects hallucinations and render them less distressing
Antipsychotic drugs vary in their pharmacology and intrusive. In this way, antipsychotics can be
and profile of effects, but they all produce a state of useful for the symptoms of acute psychosis or
global physical and mental inhibition or restriction. what are known as the ‘positive symptoms’ of
Many older antipsychotics act predominantly by ‘schizophrenia’. However, there is no evidence
blocking dopamine receptors, which produces a that antipsychotics are selective for ‘abnormal’
global neurological state resembling Parkinson’s thoughts or psychotic symptoms, and evidence
disease, a condition caused by degeneration of the from volunteer studies8,9 and accounts by people
dopamine producing cells. Its symptoms reflect a who have taken these drugs for a variety of
reduction of the activity of the dopamine system, problems4 suggest that they affect a wide range of
which consist of reduced movement and slowed mental processes.
mental processes. However, all antipsychotics
affect other neurotransmitter systems to some
4.4.5 Evidence of efficacy
degree, and some, such as clozapine, have
relatively weak actions on the dopamine system 4.4.5.1 Short-term use in psychosis
and a wide array of actions on other systems Although there is no evidence that antipsychotics
that are likely to be relevant to the mental and treat or target the condition known as
behavioural alterations they produce. schizophrenia or psychosis, placebo-controlled
randomised trials show that antipsychotics reduce
All antipsychotics appear to dampen down
the general disturbance in people who have an
emotional responses. Associated with this, people
acute psychotic episode or exacerbation, improve
find it difficult to motivate themselves to do
their global condition and reduce abnormal
things, or to take the initiative to act. Two Israeli
experiences like delusions and hallucinations more
doctors who took an injection of haloperidol for
than placebo.11,12 However, a significant proportion
experimental purposes described how they were
of people does not improve substantially with
unable to read, use the telephone or perform
antipsychotic treatment and have persistent
household tasks of their own will, but could do so if
symptoms despite treatment.
instructed to by somebody else.5
Evidence about whether antipsychotics are superior
Animal and volunteer studies show that individuals
to other sorts of sedative drugs is more equivocal.
taking antipsychotics perform less well on tests
Two trials suggested they were superior to
of learning, memory, attention, reaction times
barbiturates, but studies comparing antipsychotics
and other tests of cognitive abilities.6–9 Psychotic
to opium and benzodiazepines have not clearly
symptoms can also impair cognitive function, so
differentiated the different types of drugs.13–15
antipsychotics may actually improve functioning
in people who are symptomatic. However, there is The question as to whether people with psychosis
some evidence that long-term use of antipsychotics can recover without the use of antipsychotics

received interest several decades ago but has people in the placebo group in randomised trials
been neglected more recently. A study in the of long-term treatment likely reflects the effects
1970s compared people who entered the Soteria of antipsychotic discontinuation rather than the
project, a small homely unit in California designed benefits of initiating preventive treatment.
to care for people with psychotic disturbance or
Finally, most studies of long-term antipsychotic
a diagnosis of schizophrenia, whilst avoiding the
treatment have not investigated outcomes other
use of antipsychotics if possible, to similar people
than relapse, such as people’s overall ability to
treated with antipsychotics at a conventional
function, their ability to work, to have relationships
hospital. Thirty percent of people randomised to
and to enjoy their lives.
Soteria avoided the use of antipsychotics, but both
groups did equally well.16 A more recent study in
4.4.5.3 Recent evidence on long-term
Finland of people with a first psychotic episode
antipsychotic use
also found that 43% of people could be successfully
Recent naturalistic, non-randomised follow-up
managed without antipsychotics.17 So a reasonable
studies suggest that long-term antipsychotic use
proportion of people with an episode of psychosis
may be associated with poorer outcomes. For
may recover without the need for antipsychotics,
example, studies in the USA, Finland and Denmark
but more research is needed in this area.
found that people who took antipsychotics
4.4.5.2 Long-term use for relapse prevention on a continuous basis did less well in terms
of ‘symptom’ levels and general functioning,
The evidence base for the long-term prescription
than people who did not take antipsychotics or
of antipsychotics to people diagnosed with
took them only occasionally after 10–20 years
schizophrenia or other psychotic conditions
of follow-up.22–24 However, these studies were
consists of many randomised and non-randomised
not randomised and those patients able to stop
studies showing that people on placebo or no
their antipsychotic drugs may have had a milder
treatment relapse more commonly than those who
condition than those who continued. The results
take continuous antipsychotic treatment. These
are consistent, though, with the findings of a
studies have important limitations, however.18–20
long-term follow-up of participants from a Dutch
First, the studies are too short to provide useful randomised trial.25
information about the benefits and risks of long-
This study randomised people who had recovered
term antipsychotic treatment, with most lasting
from a first episode of psychosis to routine
less than six months. Second, the randomised
‘maintenance’ treatment with antipsychotics, or
controlled trials all involve people who are already
to have their antipsychotics reduced in a flexible
taking antipsychotics, often for many years before
manner and stopped if possible. After the first
the study begins. The people who are randomised
follow-up at 18 months, twice as many people had
to placebo, therefore, have their previous drug
experienced a relapse in the discontinuation group
treatment discontinued, usually abruptly over
as in the maintenance group, although relapse
a few days, and replaced by placebo. They are
was defined broadly as an increase in a single
therefore liable to the adverse effects associated
‘symptom’ of psychosis, and rates of hospitalisation
with discontinuing antipsychotics. Withdrawal
were not different. Only 20% of the discontinuation
effects include agitation and insomnia, which may
group had stopped antipsychotics at this point.
be mistaken for relapse, especially in trials that
Seven years later, 42% of the discontinuation
use broad definitions of relapse. There is some
group and 24% of the maintenance treatment had
evidence, moreover, that antipsychotic withdrawal
stopped antipsychotics or were taking only very
may precipitate a relapse of the underlying
low doses. By this point, there was no longer a
disorder that would not otherwise have occurred
difference in relapse rates, and levels of psychotic
at that point, or that withdrawal itself can produce
symptoms were similar in both groups. However,
a psychotic state.21 Therefore, the outcome of
December 2019 51
people in the discontinuation group were more 4.4.6 Evidence for use in other
than twice as likely to have recovered from a
functional point of view (40% vs 18%).
disorders
There are studies that show that some
Since this was a randomised trial, differences antipsychotics are more effective than placebo
between groups cannot be attributed to differences for people diagnosed with depression, but as
in the severity of their underlying condition. described in the section on antidepressants, almost
Therefore, the results provide some evidence that any drug with noticeable effects has been found
long-term antipsychotic use impairs some people’s to have ‘antidepressant’ effects in one study or
ability to function, which may be expected given another, strongly suggesting that the effect is in fact
their known inhibitory effects. It also suggests that an amplified placebo effect.
attempting a gradual and supported reduction of
antipsychotics may lead to people doing better in By reducing physical movement and arousal,
the long-term. antipsychotics may theoretically be useful
in people who are hyperactive, agitated or
The results of a 10-year follow-up of people aggressive. Trials have been conducted of the
who took part in a placebo-controlled trial of use of antipsychotics for the treatment of short-
quetiapine have also been reported recently.26 term aggressive behaviour, which show their
This trial was reported as showing that people effects are comparable with those of other types
who were originally randomised to placebo of sedative.29–31 Trials of longer-term treatment
had poorer outcomes than those who were for challenging behaviour in people with learning
randomised to quetiapine at 10 years. However, disability and dementia have found little or
people who were defined as showing a ‘poor’ no benefit.32,33 With regards to the diagnosis
outcome included people with a mild increase of personality disorder, only the category of
in symptoms, and also included people whose ‘borderline’ or ‘emotionally unstable’ personality
symptoms were measured only after the original disorder has been frequently studied.34 No
trial, and not at the 10-year follow-up. In fact, the evidence has been found for a positive effect of
‘symptom’ scales and measures of functioning antipsychotics on the core features of the diagnosis
indicated no difference between people who itself, but NICE guidelines suggest short-term
were originally randomised to quetiapine and use of antipsychotics can be considered for crisis
those originally randomised to placebo at the 10- symptoms, such as impulsivity and aggression.35
year follow-up, which is not surprising, since the
original trial was only a few months’ long for the Antipsychotics have been found to provide no net
majority of participants.27 benefit for the core symptoms of autism in both
children and adults.36 NICE found ‘moderate to
Long-term antipsychotic treatment may be helpful low’ quality short-term evidence for a range of
to reduce the intensity of ongoing psychotic behaviours including irritability and parent-defined
symptoms or to prevent recurrence in some people. challenging behaviours, but strong evidence of
The balance of benefits and harms still needs to be adverse effects.37 Problems with the evidence
elucidated, however, especially given the serious included inconsistent results and risks of bias, such
physical complications that antipsychotics can as unclear blinding procedures. The NICE guidance
produce. A randomised controlled trial to evaluate suggests considering antipsychotics for managing
a strategy of gradual reduction and discontinuation severely challenging behaviour in autism if other
of antipsychotics compared with maintenance interventions are not possible or effective. Another
treatment in people with recurrent psychosis or a meta-analysis judged the evidence for the use of
diagnosis of schizophrenia is currently under-way antipsychotics for irritability and aggression in
in the United Kingdom to provide more evidence in autism to be of better quality, but also noted the
this area.28 risk of adverse effects.38

There is a lack of evidence for the use of Metabolic abnormalities: Antipsychotics
antipsychotics in insomnia39, and limited evidence frequently cause people to gain weight.42 They
for anxiety. According to a recent meta-analysis cause a noticeable increase in appetite and
one antipsychotic (quetiapine) may have modest craving for carbohydrate-rich foods and decrease
benefits compared to placebo in reducing anxiety movement and energy use. Antipsychotics are
symptoms, but it also has significant adverse also linked to disruptions of the body’s normal
effects and it is not clear that the benefits can metabolic processes that can lead to diabetes
compensate for these.40 The results were also and raised cholesterol. These may, in turn, lead to
inconsistent, and all the individual trials were increased rates of cardiovascular disease (including
funded by the manufacturer. Other antipsychotics heart attacks and strokes).43
have been trialled for anxiety, with negative
Structural brain changes: Recent studies in both
results.41
animals and people have revealed that long-term
Overall, since antipsychotics are associated with antipsychotic treatment is associated with reduced
serious adverse effects (see below), the balance of brain weight and volume.44, 45
benefit to harm is not likely to be positive in less
Tardive dyskinesia: This is a neurological
serious mental health difficulties, especially with
condition involving involuntary movements,
long-term use.
usually of the face. Several studies suggest that
intellectual or cognitive deterioration also forms
4.4.7 Adverse effects part of the syndrome46,47. Recent studies find that
Antipsychotics frequently produce a variety of tardive dyskinesia affects approximately 4%–5%
bodily alterations that can be harmful, including of people per year who take antipsychotics48,49
metabolic disturbance and neurological effects. (although this may be lower in ordinary psychiatric
Less commonly, they are associated with practice in the UK, possibly due to use of lower
dangerous and sometimes life-threatening doses). It occurs more frequently in the elderly. It
complications. can be permanent, persisting after the drugs are
stopped.
Extra-pyramidal effects: This is the term used
to describe symptoms produced by the effects Neuroleptic malignant syndrome: This is an
of antipsychotics on a part of the brain involved uncommon and dangerous reaction that occurs
in bodily movement called the extra-pyramidal in around 0.5% of people newly started on
system. They include Parkinson’s disease-type antipsychotics. The exact mechanism is not known.
symptoms of muscle stiffness, tremor and slowness It consists of a sudden reaction in which people
of both movement and thought. Sometimes a have a high temperature, muscular rigidity and
‘dystonic’ reaction can occur, when the muscles there is a risk of death.
uncontrollably spasm. Most often this occurs
shortly after starting the drug, but it can occur Effects on the heart: All antipsychotics can cause a
after longer periods of treatment too. Acute defect in the ability of the heart muscle to conduct
dystonia, which most often affects the head and electrical impulses. In particular, the drugs can
neck muscles can be frightening and painful, and cause prolongation of part of the heart’s cycle of
potentially fatal, if it is severe and not treated activity and they can cause irregular heartbeats
quickly. Another ‘extra-pyramidal side effect is or arrhythmias. Rarely, these effects can lead to
akathisia, which is a state of intense restlessness, sudden death, which is more common with higher
causing people to feel compelled to move about, doses.50
together with a feeling of psychic tension or Hormonal abnormalities: Dopamine inhibits the
anxiety. Although this is classified as an extra- production of the hormone prolactin. Therefore,
pyramidal side effect, the exact mechanism behind reducing dopamine activity leads to an increase in
it is unknown. prolactin levels. This is the hormone that stimulates
December 2019 53
production of breast milk, and high levels can in the short term. The evidence on the benefits and
result in breast growth in men, lactation, infertility, harms of long-term drug treatment for people with
impotence, reduced sex drive, and the bone- a diagnosis of psychosis or schizophrenia is more
wasting condition, osteoporosis. This effect is more difficult to interpret. Over the long term, the drugs
common with some individual antipsychotics, but are probably beneficial for some, but not necessarily
sexual dysfunction is a common side effect of all, or for everyone with these conditions, and they are
most, antipsychotics. undoubtedly associated with severe adverse effects.
Increased mortality: Evidence on whether long- For an individual, the decision about whether
term use of antipsychotics increases the risk of to take antipsychotic drugs, or whether to stop
premature death is inconsistent. It is well known that taking them once they are started, depends on a
people with a diagnosis of schizophrenia or another fine balance between many considerations. For
severe mental illness die earlier than the general someone suffering unpleasant symptoms such
population, partly due to lifestyle factors such as as abusive hallucinations, they may have useful
high rates of smoking and lack of exercise. Some effects. People testify that antipsychotics help
studies suggest that antipsychotic drugs play a role, suppress distressing psychotic symptoms, but they
after taking account of these lifestyle factors.51,52 also highlight how these benefits come at a price.
However, other studies have reported reduced Many of those taking these drugs experience the
mortality among people who use antipsychotics mental slowing and emotional restriction produced
compared to those who do not.53,54 Being on more by antipsychotics as unpleasant, and their use
than one sort of antipsychotics is associated with a can lead to a variety of physical complications.
particularly high risk of early death.52 The harms related to antipsychotic drugs are
particularly likely to outweigh any benefits they
Other adverse effects: Many antipsychotics block
might produce in people with less severe mental
the activity of the transmitter acetylcholine and
health difficulties.
produce what are called ‘anticholinergic effects’.
These include symptoms such as dry mouth,
blurred vision and constipation. Many of the
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4.5 Lithium and other drugs referred to as mood stabilisers
4.5.1 History disorder includes lithium, sodium valproate other

anti-epileptics such as carbamazepine and the
Drugs labelled as ‘mood stabilisers’ are most
newer drug lamotrigine and several antipsychotics
commonly used by people diagnosed with bipolar
(e.g. olanzapine, quetiapine and ariprazole).
disorder. Bipolar disorder replaced the term manic
The antipsychotics that are officially referred
depression to describe a pattern of behaviour that
to as ‘mood stabilisers’ are the ones that have
had been recognised for a long time, consisting
been tested and marketed for this indication,
of episodes of extreme arousal, hyperactivity
but most antipsychotics are commonly used for
and elation, known as mania, often followed by
the treatment of people diagnosed with bipolar
episodes of severe depression. Although the idea
disorder or acute mania.
of a ‘mood stabiliser’ implies specific effects on the
underlying biological basis of mood variability, in
fact nothing like this has ever been demonstrated 4.5.2 Common uses
for any of the drugs referred to as mood stabilisers. The commonest use of lithium and other ‘mood
The term ‘mood stabiliser’ merely refers to drugs stabilisers’ is for the long-term treatment of people
that have been licensed for, or are commonly diagnosed with bipolar disorder. Guidelines
used in, the treatment of people diagnosed with suggest that they should be prescribed on a
bipolar disorder or manic depression. The first long-term basis to reduce the risk of relapse into
drug that was regarded as a specific treatment for a further episode of either mania or depression.
manic depression was lithium. Lithium is an alkali An episode of acute mania is usually treated with
metal, with sedating effects that are closely linked various sedative agents including drugs referred to
to neurological toxicity. The concept of a ‘mood as mood stabilisers, like sodium valproate, but also
stabiliser’ appeared in the 1990s at about the benzodiazepines and all sorts of antipsychotics.
time that an old epilepsy drug, sodium valproate,
Over the last few decades, the idea that there are
started being marketed for the treatment of
less severe forms of bipolar disorder has been
manic depression in a new preparation known
popularised and the concept of the disorder has
as Depakote.1 Other epilepsy drugs, such as
become malleable. Concepts such as ‘bipolar
carbamazepine and lamotrigine have also been
2 disorder’, which is said to consist of recurrent
marketed for this use. The implication that they
depression with mild periods of mania, and
stabilise mood has allowed these drugs to be
‘bipolar personality’ have been created, but are not
prescribed to a wide proportion of ‘psychiatric
universally accepted. It has been claimed that up to
patients’ who exhibit emotional turmoil from
20% of the population may suffer from some sort
time to time. Since the invention of the concept
of ‘bipolar spectrum’ disorder.2 Alongside these
of the mood stabiliser, such signs of emotion can
changing notions of the condition, there have been
be interpreted psychiatrically as a pathological
increasing rates of prescription of drugs referred to
or abnormal instability of mood and used as the
as ‘mood stabilisers’, particularly newer or atypical
justification for prescription of ‘mood-stabilising’
antipsychotics3, some of which have been heavily
drugs. Hence, a large proportion of people who
marketed for this indication.4
attend psychiatric services are now prescribed one
of these drugs. However, there is little evidence
that any of these drugs normalise emotional 4.5.3 Theories of action
responses or stabilise mood. Lithium is chemically similar to sodium, which is
involved in many biological processes. Researchers
Currently the group of drugs recommended for have proposed various theories of the mechanisms
long-term treatment of manic depression or bipolar for lithium’s supposed anti-bipolar action. These
December 2019 57
include correcting ‘abnormal’ sodium and calcium The effects deemed therapeutic are on a continuum
levels within cells, correcting ‘abnormal’ sodium with the manifestations of the toxic state. Thus,
dependent processes, effects on dopamine and before the signs of full-blown toxicity start, lithium
serotonin pathways, and neuroprotective effects.5 causes suppression of nervous conduction leading
However, it remains widely acknowledged that to sedation and impairment of cognitive functions.9
there is no clear evidence as to the mechanism of
These effects are clearly demonstrated in volunteer
action of lithium. This is also the case for the other
studies.8,10 After two to three weeks on lithium
drugs referred to as mood stabilisers.6
volunteers show decreased ability to learn new
Although there is no clear biochemical theory, such information, prolonged reaction times, poor
as the dopamine hypothesis of ‘schizophrenia’, memory, loss of interest and reduced spontaneous
that helps to rationalise a disease-centred view of activity. Therefore, it is not surprising that people
the action of these drugs, they appear not to be with mania and other forms of over-arousal are
regarded simply as sedatives. If this were the case, subdued when given lithium. The trouble is, the
the risk of toxic effects, especially with lithium, doses required to achieve a potentially useful
would be difficult to justify. Instead lithium and sedative effect are close to those that cause a
the other drugs are regarded as having specific, dangerous toxic state. Hence patients on lithium
although yet unidentified, actions on a presumed must have their blood lithium levels monitored on
biological basis of abnormal mood or manic a regular basis.
depression.
Other drugs now referred to as ‘mood stabilisers’
From a drug-centred perspective, all drugs all suppress nervous activity in different ways. They
currently designated as ‘mood stabilisers’ have can all cause drowsiness at normal therapeutic
sedative effects and hence they are likely to doses and, like lithium, the anticonvulsant drugs
reduce arousal and the emotions associated with cause signs of nervous toxicity such as slurred
heightened arousal like elation and irritability. The speech (dysarthria) and loss of balance (ataxia),
main research that has been conducted into their usually at higher doses.
effects on people with relevant diagnoses, and
that is used to justify the term ‘mood stabiliser’, 4.5.5 Evidence for their efficacy
concerns whether they suppress signs of mania
and prevent relapse in people diagnosed with 4.5.5.1 Treatment of acute mania
classical manic depression, now known as ‘bipolar Lithium reduces the symptoms of acute mania
1 disorder’. The only tests that have been done to better than a placebo, but there is little evidence
look at how these drugs affect the variability of that it is better than other sorts of drugs with
mood in healthy volunteers were done with lithium sedative effects. In fact, two studies of drug
and found that lithium did not reduce normal treatment for people with acute mania found that
fluctuations of mood.7,8 lithium was inferior to antipsychotics, probably
due to the limitations caused by its toxicity.11,12
4.5.4 Drug effects In contrast, a Japanese study found lithium to be
superior. However, doses of lithium were four times
Lithium is a metal that can have dangerous effects
those of the antipsychotic used and patients were
on the nervous system, the gut and the kidneys
less severely ill, and therefore probably did not
at relatively low doses. Mild symptoms of toxicity
require the same level of sedation as patients in the
include neurological symptoms such as tremor
other studies.13
and lethargy. Progressive toxicity results in
diarrhoea and vomiting, incontinence, drowsiness, Two studies have examined whether people
disorientation, abnormal jerking movements, loss with a diagnosis of mania do better with
of balance (ataxia) and slurred speech (dysarthria), lithium compared to people with a diagnosis of
finally giving rise to convulsions, coma and death. another sort of acute psychosis, such as acute

schizophrenia. Both studies compared lithium with maintenance, which were conducted in the 1970s,
an antipsychotic and found that diagnosis did not mostly involved people who were taking lithium
predict which drug treatment people responded prior to the study.
to. In other words, people with mania responded
A few further studies have been carried out since
just as well to the antipsychotic drug as they
1990. Although not reported in all studies, where
did to lithium and people diagnosed with acute
it was, a proportion of patients were reported to
schizophrenia responded just as well to lithium.14,15
have been on lithium prior to entering the study.
There has been little research into the effects One of these studies found no difference between
of benzodiazepines in mania, even though they lithium, sodium valproate and placebo.21 One
are widely used in this condition. Since they found a difference between lithium and placebo,
are sedative drugs, and mania is a condition of but it was clinically small.22 Another reported a
increased arousal, benzodiazepines would be a more substantial difference, but it appears that a
logical intervention and target for research. Some large proportion of patients may have been taking
small studies that compared a benzodiazepine lithium prior to the study (up to 69%, although
called clonazepam with lithium reported that the the published paper does not make this clear) and
clonazepam was superior, but these were never the pattern of early relapses in the lithium group
followed up.16,17 Whether this means that the results strongly suggests a discontinuation-related effect.23
did not fulfil their early promise or whether the
The most recent study is a large trial comparing
drug company that conducted them decided to aim
quetiapine, lithium and placebo.24 Patients were
the drug at a different market is uncertain.
stabilised on quetiapine prior to randomisation
Symptoms of acute mania are also improved and may have been on long-term drug treatment
by sodium valproate and the antipsychotic prior to this. Again, the pattern of relapses suggests
olanzapine, both of which have strongly sedating a discontinuation effect. Almost half the patients
actions.18 randomised to placebo (48%) experienced a
relapse of ‘any mood event’ during an average of
4.5.5.2 Long-term use four months follow-up, versus 26.4% of the lithium-
Recommendations for long-term treatment of treated patients and 23.6% of those on quetiapine
people diagnosed with ‘manic depression’ or (during an average of six months). Relapse rates
‘bipolar disorder’ are based on placebo-controlled in both groups are much higher than the natural
trials, some of which show that people taking history of manic depression recorded for patients
a mood stabiliser relapse less frequently than treated before the introduction of modern drug
people taking placebo. However, these trials are treatment in the early 20th century. Historical
mostly discontinuation studies. In other words, studies show relapse rates of around 50% over a
people who are already taking drug treatment are period of two and a half to three years in the late
randomised either to continue to take it or to have 19th and first half of the 20th century.25 Another
it substituted with a placebo. Therefore, people problem with this study is that 54 patients who
who take placebo are, in most cases, people who did not show adequate lithium blood levels were
have just had their previous prescribed drugs excluded from the population that were included
withdrawn. in the final analysis. We know that non-compliance
is associated with poorer outcomes regardless of
There is good evidence that discontinuing lithium
the effects of the treatment26, so this is also likely to
can induce a relapse in someone diagnosed with
have inflated the outcomes of the lithium group.
‘manic depression’ or ‘bipolar disorder’, especially
a relapse of mania. Several studies indicate that Another recent study found no significant
the likelihood of having a relapse after stopping difference in terms of rates of relapse between
long-term lithium is higher than it is before lithium lithium, fluoxetine and placebo for the long-term
is started.19,20 The early studies of lithium of lithium treatment of people diagnosed with ‘bipolar 2
December 2019 59
disorder’. Time to first relapse was significantly The toxic state can also sometimes occur at what
longer with fluoxetine compared to the two other would normally be regarded as safe blood levels of
treatments, but there was no difference between lithium.30 Before the full-blown toxic state develops,
lithium and placebo.27 lithium’s effects on the kidneys result in extreme
thirst and excessive urination. Its effects on the
Despite the mixed results and methodological
nervous system commonly result in a hand tremor
issues, reviews and meta-analyses continue to
as well as reduced reaction times, slow thinking and
recommend that lithium should be considered as
reduced creativity.31 Lithium also frequently causes
the ‘first line’ treatment for ‘bipolar disorder’.28
weight gain. In a small proportion of patients, long-
The evidence is just as poor for other ‘mood term lithium treatment may result in irreversible
stabilisers’, if not worse. Despite the widespread kidney damage.32 Lithium also frequently results
use of sodium valproate and similar preparations, in under-activity of the thyroid gland. Up to 20%
the only long-term study that compared it with of women on long-term treatment develop this
placebo and lithium found no difference between complication and require treatment with thyroid
any of the treatments on any of the major hormones.33 It is usually reversible on stopping
outcome measures.21 Lamotrigine, a relatively lithium. Lithium can also affect the parathyroid
new ‘mood stabiliser’, was found to be better gland, which affects calcium levels and bone health.
than placebo for preventing depressive but not
As explained above, withdrawal of lithium in
manic episodes in two trials sponsored by the
someone with a diagnosis of bipolar 1 or manic
manufacturer.22,23 However, since lamotrigine is a
depression increases the risk of a relapse, especially
drug with noticeable sedative drugs, there is likely
a relapse of mania. The mechanism for this is
to be a substantial ‘amplified placebo effect’ in
unclear, but it is as if removing the neurological
people with a diagnosis of depression. The one
suppression produced by lithium causes the nervous
placebo-controlled trial of olanzapine for the
system of a susceptible person to go into over-drive,
prevention of future episodes of manic depression
precipitating a rebound manic episode.
found a lower rate of relapse (mostly of mania)
in people treated with olanzapine compared to Sodium valproate can cause nausea, lethargy and
those randomised to placebo.29 Results indicate sedation, hair loss, weight gain and polycystic
a probable discontinuation effect, however, since ovaries, a condition associated with reduced
the majority of the relapses in the placebo group fertility. It is also known to produce a high rate of
occurred in the first three weeks of the study and foetal abnormalities if it is taken early in pregnancy
all had occurred by three months. Quetiapine and should not be prescribed to women of
performed slightly better than lithium and was childbearing age. Valproate has dangerous but rare
statistically significantly superior to placebo in the complications including liver failure, pancreatitis,
large, industry-sponsored study described above, and blood disorders.
but again a discontinuation effect is likely.24
Carbamazepine can cause a rash, nausea, sedation
and signs of neurotoxicity such as loss of balance
4.5.6 Common adverse effects (ataxia) and double vision (diplopia). Rarely it can
Lithium is highly toxic to the nervous system, the also cause serious blood disorders, such as aplastic
digestive system and the kidneys. This means anaemia and agranulocytosis, by suppressing the
that blood levels that are only slightly higher than production of blood cells in the bone marrow. Very
the levels usually associated with current doses rarely it causes a drug-induced reaction known as
can cause an acute toxic state. This can be fatal ‘hypersensitivity syndrome’, a dangerous condition
if lithium is not stopped immediately. This toxic that can lead to failure of internal organs, especially
state can occur if an overdose of lithium is taken, the liver, and has a death rate of 8%. It can also
but it also occurs if blood levels increase because cause a serious skin reaction (toxic epidermal
of dehydration or interactions with other drugs. necrolysis).

Lamotrigine also causes neurological symptoms Other people may simply prefer to live with the risk
such as loss of balance (ataxia) and double vision of recurrence and seek intervention for an ‘episode’
(diplopia). It can cause a serious hypersensitivity if and when they need it.
reaction and may impair liver function. It has also
With regards to people who do not have symptoms
been associated with blood disorders.
of ‘classical’ ‘bipolar disorder’, there is no clear
evidence to support the use of a so-called mood
4.5.7 Conclusion stabiliser. No drugs have been shown to ‘normalise’
Sedative drugs of various sorts help to reduce the or smooth out moods. All drugs described as mood
manifestations of ‘acute mania’. Despite mania being stabilisers are sedative drugs, which suppress
self-limiting and eventually subsiding naturally, mental and physical activity and may reduce
while it lasts it can be overwhelming and difficult to people’s emotional responses to their environment,
control. Therefore, the short-term use of sedative in a similar way to antipsychotics, many of which
drugs, including antipsychotics, benzodiazepines, are now regarded as mood stabilisers. For most
some drugs that are referred to as ‘mood stabilisers’, people the adverse effects of these drugs would
may be helpful while the disturbance runs its course. be likely to outweigh any benefits in terms of
Although lithium is recommended for this purpose, managing emotions that they may obtain from the
its toxicity means that other options are safer. alterations the drugs produce.
Based on current evidence, it is unclear whether
any drug reduces the risk of having a further References
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episode of ‘bipolar disorder’ because of the strong
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treatment. From a drug-centred perspective, it is Rössler, W. (2003). Toward a re-definition of subthreshold
bipolarity: epidemiology and proposed criteria for bipolar-II,
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minor bipolar disorders and hypomania. Journal of affective
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arousal. However, it is also possible that the 3. Ilyas, S. & Moncrieff J. (2012). Trends in prescriptions and costs
body’s adaptations to the long-term use of a drug of drugs for mental disorders in England, 1998–2010. British
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will counteract any suppressant effect the drug
4. Healy, D. (2006). The latest mania: Selling bipolar disorder.
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neurosciences, 35(1), 36–46.
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6. Taylor, D., Paton, C. & Kapur, S. (2015). The Maudsley
For people diagnosed with bipolar disorder, the prescribing guidelines in psychiatry. Oxford: Wiley-Blackwell.
7. Barton, Jr, C.D. Dufer, D., Monderer, R., Cohen, M.J., Fuller, H.J.,
potentially disabling and sometimes dangerous
Clark, M.R. & DePaulo, Jr, J.R. (1993). Mood variability in normal
effects of the various drugs commonly on offer subjects on lithium. Biological Psychiatry, 34(12), 878–84.
need to be weighed with a possible reduction 8. Calil, H.M., Zwicker, A.P. & Klepacz, S. (1990). The effects of
in the risk of relapse. Mania can have harmful lithium carbonate on healthy volunteers: Mood stabilization?
Biological Psychiatry 27(7), 711–22.
consequences and some people may feel that even
9. Moncrieff, J. (2008). The myth of the chemical cure. Palgrave
the hope of protection may compensate for all Macmillan; Basingstoke, UK.
the adverse effects of long-term drug treatment. 10. Judd, L.L., Hubbard, B., Janowsky, D.S., Huey, L.Y. &
Some may prefer to find other ways to try and exert Takahashi, K.I. (1977). The effect of lithium carbonate on the
cognitive functions of normal subjects. Archives Of General
some control over their experiences. For example,
Psychiatry, 34(3), 355–7.
some people manage to identify the early warning 11. Prien, R.F., Caffey, Jr, E.M. & Klett, C.J. (1972). Comparison
signs of mania and use sedative drugs and lifestyle of lithium carbonate and chlorpromazine in the treatment of
measures such as avoiding stress and taking time mania. Report of the Veterans Administration and National
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December 2019 61
12. Braden, W., Fink, E.B., Qualls, C.B., Ho, C.K. & Samuels, W.O. 23. Bowden, C.L., Calabrese, J.R., Sachs, G., Yatham, L.N., Asghar,
(1982). Lithium and chlorpromazine in psychotic inpatients. S.A., Hompland, M., ... & DeVeaugh-Geiss, J. (2003). A placebo-
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13. Takahashi, R., Sakuma, A., Itoh, K., Itoh, H. & Kurihara, M. treatment in recently manic or hypomanic patients with bipolar I
(1975). Comparison of efficacy of lithium carbonate and disorder. Archives of General Psychiatry, 60(4), 392–400.
chlorpromazine in mania. Report of collaborative study group 24. Weisler, R.H., Nolen, W.A., Neijber, A., Hellqvist, A. & Paulsson,
on treatment of mania in Japan. Archives of General Psychiatry, B. (2011). Continuation of quetiapine versus switching to
32(10), 1310–18. placebo or lithium for maintenance treatment of bipolar
14. Braden, W., Fink, E.B., Qualls, C.B., Ho, C.K. & Samuels, W.O. I disorder (Trial 144: A randomized controlled study). The
(1982), see n. 8. Journal of Clinical Psychiatry, 72(11), 1452–1464.
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The Northwick Park ‘functional’ psychosis study: Diagnosis The impact of mood stabilizers on bipolar disorder: The 1890s
and treatment response. Lancet 2(8603), 119–25. and 1990s compared. History of psychiatry, 16(4), 423–434.
16. Chouinard, G., Young, S.N. & Annable, L. (1983). Antimanic 26. Curtis, J., Larson, J.C., Delzell, E., Brookhart, M.A., Cadarette,
effect of clonazepam. Biological Psychiatry, 18(4), 451–66. S.M., Chlebowski, R. ... & LaCroix, A.Z. (2011). Placebo adherence,
17. Chouinard, G. (1988). The use of benzodiazepines in the clinical outcomes and mortality in the Women’s Health Initiative
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18. Tohen, M., Chengappa, K.R., Suppes, T., Zarate, C.A., long-term fluoxetine versus lithium monotherapy of bipolar II
Calabrese, J.R., Bowden, C.L., ... & Keeter, E.L. (2002). Efficacy disorder: A randomized, double-blind, placebo-substitution
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the treatment of mania in patients partially nonresponsive 28. Nolen, W.A. (2015). More robust evidence for the efficacy of
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psychiatry, 59(1), 62–69. lithium (again) be recommended as the single preferred first-
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Risk of recurrence following discontinuation of lithium 29. Tohen, M., Calabrese, J.R., Sachs, G.S., Banov, M.D., Detke,
treatment in bipolar disorder. Archives of General Psychiatry, H.C., Risser, R., ... & Bowden, C.L. (2006). Randomized,
48(12), 1082–1088. placebo-controlled trial of olanzapine as maintenance
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K., Mehtonen, O.P., ... & DeVeaugh-Geiss, J. (2003). discontinuation. Journal of Clinical Psychopharmacology,
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1013–1024. 33. Johnston, A.M. & Eagles, J.M. (1999). Lithium-associated
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British Journal of Psychiatry, 175, 336–9.

4.6 Stimulants
4.6.1 History effect of stimulant drugs is to increase arousal. At

high doses this results in increased activity and it
Stimulants are a group of drugs that are still
can cause obsessive-compulsive behaviours and
referred to by the type of effect they induce, rather
abnormal movements such as tics and grimaces.
than the condition for which they are prescribed.
At lower doses the main manifestation of increased
They are controlled drugs and some, such as
arousal is an increased ability to concentrate, and
amphetamines and cocaine, are commonly used
a feeling of calm. This is familiar to people who
recreationally. Stimulants are today mainly
smoke cigarettes, since nicotine is a mild stimulant
prescribed for what is referred to as attention
drug. Therefore, stimulants would be expected to
deficit hyperactivity disorder (or ADHD) – namely,
improve attention and reduce hyperactivity in the
a set of behavioural problems deemed to occur in
relatively low doses at which they are prescribed.
children and increasingly in adults. The stimulant
methylphenidate (Ritalin) is most commonly This drug-centred model of how stimulants work
prescribed, but various forms of amphetamine, suggests that the effects of stimulants in people
including dexamfetamine and lisdexamfetamine, diagnosed with ADHD are the same as those that
are also used, and a drug called atomoxetine is also are observed in people with no such diagnosis.
used, which was originally claimed to be different This is confirmed by research that showed that
from stimulants, but shows a stimulant-like profile giving methylphenidate (Ritalin) to both healthy
of effects. volunteers and people diagnosed with ADHD
led to similar increases of brain dopamine in
4.6.2 Common uses the two groups and the same improvements in
In current guidelines stimulants are recommended concentration and attention.2 These results are
as the first intervention for a diagnosis of severe consistent with the effects that are observed
ADHD in children, or if psychological therapy is in animals.3 This demonstrates that there is no
judged to have been ineffective in less severe cases. need to construct a disease-centred account for
In adults, they are the first line recommended the action of stimulants. A drug-centred model,
intervention.1 in which low-level stimulant-induced alterations
improve concentration and attention on a single
task, can account for their effects in people
4.6.3 Theories of action
diagnosed with ADHD.
Stimulants increase the availability and activity of
excitatory neurotransmitters, such as dopamine Animal studies also show that stimulants inhibit
and noradrenaline, within the brain, but they have spontaneous exploratory behaviour, reduce an
effects on a wide range of neurotransmitters and animal’s interest in its environment and reduce its
biochemical systems. social interactions with other animals. Instead, the
animal shows repetitive, over-focused, pointless
Traditionally, stimulants are said to work by correcting behaviours such as pacing, scratching, excessive
a shortage or malfunction of these neurotransmitters, grooming, gnawing and staring at small objects. They
with most research attention focusing on dopamine. also develop tics and other involuntary abnormal
However, there is no consistent evidence of a movements.4 In children too, it is recognised that
specific chemical abnormality in the brains of stimulants can suppress interest, spontaneity and
people diagnosed with ADHD, and no evidence that emotional responsiveness.5 Therefore it seems
stimulants work by reversing it. stimulants increase the ability of a person or an
There is a simple alternative explanation for how animal to focus on a single task by reducing their
stimulants work in ADHD. The main physiological interaction with the rest of the environment.
December 2019 63
Adults typically enjoy the effects of stimulant drugs, diagnosed with ADHD, found no difference in work
hence their use as recreational drugs. Children, productivity between people randomised to take
however, generally dislike the experience of being the active drug and people randomised to placebo
on stimulants.6,7 However, children may also see (the main outcome of the study), and no difference
the benefits of taking stimulants from the point of in driving behaviour either.14
view of their behaviour or school performance.8
Moreover, many of the studies in children and
When stimulants are used recreationally, people adults have been conducted by a group of
often need to increase the dose to keep getting the researchers at Harvard University who were
same desired effect. This shows that stimulants, revealed to have received millions of dollars from
like other psychoactive drugs, induce ‘tolerance’. the pharmaceutical industry in consulting fees
In other words, the body adapts to counteract and other payments.15 Studies conducted by this
their effects, so if you use them continuously, you group show consistently larger effects than other
must increase the dose to get the same effects. studies.16
Tolerance to stimulants prescribed for ADHD has
Two large randomised studies have been
been demonstrated in animals9 and documented
conducted that explored the long-term outcomes
in children10, although the fact that children are
of stimulant treatment and psychotherapy for
naturally maturing during treatment may obscure
ADHD – one in children and one in adults.
tolerance effects. If tolerance occurs, it suggests
that any beneficial effects that are experienced In the first study, children were randomly allocated
in the early days of stimulant treatment would to four different types of treatment: intensive
gradually be lost. behavioural therapy, an intensive ‘medication
management’ regime with frequent medical
4.6.4 Evidence of efficacy reviews, a combination of behavioural therapy and
Studies in children and adults find that stimulants ‘medication management,’ and routine community
reduce the symptoms of ADHD more than a care, in which children often received prescribed
placebo, as measured by various rating scales. stimulants.17
This is not surprising, given the alterations they The first set of results, based on data from the first
are known to cause in humans and animals 14 months of the study, showed that all groups
regardless of whether or not they have a diagnosis displayed a substantial decline in the severity of
of ADHD. The effects are not large, however. One their symptoms. The ‘medication management’
study of methylphenidate (Ritalin) in adults found group fared better than the group that had
differences of between four and five points on a behaviour therapy on the core symptoms of
56-point rating scale, for example11, and another inattention, as rated by parents and teachers, and
found a difference of between three and six points hyperactivity as rated by parents only. The study
on a 54-point rating scale score.12 A meta-analysis showed no differences between the groups for
of trials of methylphenidate in children found that the other factors that were evaluated, including
the drug was more effective than placebo at a level social skills, parent–child relations, academic
that was just above that judged to be a minimally achievement and aggression.
relevant difference.13
However, ratings by the only blinded rater,
In addition, few studies provide data on long- a classroom observer, showed no difference
term outcomes and controlled trials do not between the treatment groups for attention or
show evidence of beneficial effects on school hyperactivity.18 In addition, around 60% of the
achievement in children, or employment or other routine community treatment group were also
aspects of general functioning in adults. One of the prescribed stimulants and this group fared the
few trials that looked at these sorts of outcomes, same as the behavioural therapy group. Hence it
a placebo-controlled trial of atomoxetine in adults may have been something about the intensity of

the contact involved in the intensive ‘medication 4.6.5 Common adverse effects
management’ group that improved symptoms
Stimulant drugs increase the activity of the
apart from, or as well as, their prescribed drug
heart, raising the heart rate and increasing
treatment.
blood pressure.20 There is considerable debate
At the three-year follow-up, there was no as to whether these effects translate into serious
difference between the original groups in consequences such as an increased risk of heart
terms of any outcome measures.19 This study attacks, cardiac arrhythmias (irregularities of heart
is important because it is the only randomised rhythm which can lead to death) or stroke. The
study that has followed-up children with ADHD sorts of changes to heart rate and blood pressure
for more than a year. Its results are difficult to that are observed with stimulant treatment have
interpret and not decisive, but they suggest that been shown to lead to more serious cardiac
stimulants, coupled with assertive monitoring, effects in other contexts.22 Some studies of adults
may improve teacher or parent ratings of who are prescribed stimulants for ADHD show
children’s attention and activity levels in the an increased incidence of arrhythmias, transient
short to medium term, but long-term benefits are ischaemic attacks and sudden death23,24, but
not established. others have shown no detrimental cardiovascular
effects.25 A recent meta-analysis found increased
The study in adults was conducted in Germany
rates of sudden death due to a cardiac arrhythmia
and participants were randomised to one of four
with all drugs prescribed for ADHD and with
treatment conditions: to take methylphenidate
methylphenidate specifically, but no increased risk
with routine care, to take methylphenidate
of myocardial infarction, stroke or all-cause death.26
in combination with a cognitive-behavioural
Overall, the data suggest that prescribed stimulants
group psychotherapy programme or to take
cause a slight increased risk of serious cardiac
placebo in combination with routine care or
events, particularly arrhythmias and sudden death.
the group psychotherapy programme. The first
Recreational use of stimulants is well known to lead
follow-up was conducted at three months, and
to cardiac complications in some cases, but doses
subsequently at six months, a year, and two
taken are usually considerably larger than those
and a half years after the trial commenced.
that are prescribed.27
Methylphenidate performed better than
placebo at all follow-up points in this study, In some cases, stimulants induce a depressive
but differences were small. At three months picture, with lethargy, withdrawal, and loss of
the difference in symptom scores was 1.7 emotional responsiveness, sometimes referred
points on a 36 point scale, at one year it was 2.2 to as a ‘zombie’ effect.28 In others they may cause
points20 and at two and a half years’ follow-up agitation and anxiety. Insomnia is very common.
the difference was 1.4 points.21 Although these Rarely, stimulants can induce a psychotic episode.
differences were statistically significant, there
A recent study found that being prescribed
is no research that has established what sort of
stimulants for an ADHD diagnosis increased the risk
differences in symptom scales might translate
of developing Parkinson’s disease or a similar brain
into meaningful or observable improvement in
condition by more than eight times.29 The association
ADHD, as there is for the diagnosis of depression.
between taking stimulants and Parkinson’s disease
In other words, we cannot be sure of the clinical
is well established among people who take them
significance of the findings, but the differences
recreationally30, so it is plausible that prescribed use
detected appear to be modest. There was no
will have some effect too.
difference in symptom scores between those who
were randomised to the group psychotherapy An important adverse effect of stimulants in
programme and those who received routine care children is growth suppression. The three-year
at any follow-up point in this study. follow-up of the MTA study showed that children
December 2019 65
who had taken stimulants on a continuous basis and dopamine D1 receptor actions: Relevance to therapeutic
effects in Attention Deficit Hyperactivity Disorder. Behavioral
were 2.3cm smaller than a non-ADHD comparison
and Brain Functions, 1(1), 2.
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10. Ross, D.C., Fischhoff, J. & Davenport, B. (2002). Treatment
Stimulant drugs have generalised effects that may of ADHD when tolerance to methylphenidate develops.
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A randomised, placebo-controlled, 24-week, study of low-dose
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extended-release methylphenidate in adults with attention-
modest, benefits on symptom levels compared to deficit/hyperactivity disorder. European Archives of Psychiatry
placebo, but no trials have established beneficial and Clinical Neurosciences, 259(2), 120–129.
effects on other outcomes such as school or work 12. Medori, R., Ramos-Quiroga, J.A., Casas, M., Kooij, J.J., Niemela,
A., Trott, G.E., Lee, E. & Buitelaar, J.K. (2008). A randomized,
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release OROS methylphenidate in adults with attention-
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deficit/hyperactivity disorder. Biological Psychiatry, 63(10),
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associated with an increased risk of serious conditions 13. Storebo, O.J., Krogh, H.B., Ramstad, E., Moreira-Maia, C.R.,
such as heart attacks and Parkinson’s disease. The Holmskov, M., Skoog, M., Nilausen, T.D., Magnusson, F.L.,
Zwi, M., Gillies, D., Rosendal, S., Groth, C., Rasmussen, K.B.,
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hyperactivity disorder. Multimodal Treatment Study of 25. Habel, L.A., Cooper, W.O., Sox, C.M., Chan, K.A., Fireman, B.H.,
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1073–86. D.M., Andrade, S.E., Pawloski, P.A., Raebel, M.A., Smith, D.H.,
19. Jensen, P.S., Arnold, L.E., Swanson, J.M., Vitiello, B., Abikoff, Achacoso, N., Uratsu C., Go, A.S., Sidney, S., Nguyen-Huynh,
H.B., Greenhill, L.L. et al. (2007). Three-year follow-up of the M.N., Ray, W.A. & Selby, J.V. (2011). ADHD medications and risk
NIMH MTA study. Journal of the American Academy of Child and of serious cardiovascular events in young and middle-aged
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December 2019 67
4.7 Combined psychotherapeutic and
psychopharmacological intervention in depression
A combination of prescribed drugs and scale scores, but it is not clear that such an effect is
psychotherapy is often regarded as a superior clinically relevant and could provide an additional
intervention to the use of these drugs or therapy benefit to psychotherapy, or that it is a specifically
alone, particularly with depression. The current NICE pharmacological effect as opposed to an amplified
guidance1 for depression includes recommendations placebo effect.
for combined treatment, especially for more severe
NICE suggest that antidepressants can enable
symptoms and for when previous treatments or
more effective therapy through effects such as
various types have been ineffective.
improved sleep, motivation and cognitive ability.2
On the other hand, it has long been recognised that Antidepressants do produce psychological and
the effects produced by taking psychoactive drugs, behavioural changes, as described in Section
whether prescribed or illicit, may interfere with 4.2. Some antidepressants have sedative
the learning and personal development that is an effects that may improve sleep, but there is no
integral part of therapy. For example, if someone is evidence that any antidepressant increases
taking benzodiazepines that dampen anxiety, then motivation or cognitive ability more than a
they may not be able to learn other techniques placebo. From what we know of the alterations
to manage the anxiety. Any drug that dampens antidepressants produce, it is not clear that they
emotions or sensitivity may interfere with efforts would aid psychotherapy, and they may even be
to control and manage emotional reactions in non- counterproductive.
pharmacological ways.
The sedation produced by some antidepressants,
The idea that combined intervention is more for example, may be useful in terms of increasing
effective is based on several assumptions. sleep and reducing anxiety, but may hamper
Antidepressant drugs are assumed to target therapy by impairing clarity of thinking and
the biological causes of depression, whilst cognitive function during the day. The emotional
psychotherapy separately targets perpetuating restriction associated with SSRIs may, in theory,
psychological factors, with the two interventions numb intense hopelessness and feelings of
leading to a cumulative therapeutic effect.2 depression, which may help people to engage in
However, this is problematic for several reasons. therapy, but may also prevent people from learning
how to manage their emotions in other ways.
As outlined in 4.2, there is no convincing evidence for
any biological abnormalities underlying depression, Questions remain about the psychological effects
which are effectively targeted by antidepressant of taking antidepressants and how they may
drugs. In other words, current evidence does not impact on therapy. Many people understand
support the idea that antidepressants improve antidepressants to work by reversing the
or correct a specific biological component to underlying biological causes of depression,
depression (a disease-centred model), which could because, despite the lack of evidence for this
act in parallel with psychotherapy. position, this is what they have been told.
Therefore, taking antidepressants can signal the
In addition, the evidence for the actual
idea that depression is a biological condition,
effectiveness of antidepressants in depression is
over which the individual has little control. This
beset by multiple flaws (see section 4.2.5). Meta-
position is logically inconsistent with the aims of
analyses have reported that antidepressants
therapy to enable people to gain more control over
may have slightly more effect than placebo in
their feelings and behaviour and this is explored in
the short-term reduction of depression symptom
section 3.

Multiple individual studies have looked at whether blinding of assessors. In addition, only 16 studies
combined antidepressants and psychological conducted intention to treat analysis, in other words
intervention is superior to antidepressants including the outcomes of all people who entered
or therapy alone. Overall, the results are the trial. As the dropout rates varied significantly
contradictory. For example, when comparing a between combined and individual treatment groups,
psychological intervention alone to a combined this may have impacted on results.
intervention, some studies found the combined
Another 2009 meta-analysis combined 19
intervention to be more effective,3,4 others found
studies comparing combination treatment to
no difference,5–7 and others found the psychological
psychological treatment alone.19 This also found a
intervention alone more effective.8,9 Similarly, when
small difference in favour of combined treatment
comparing a combined intervention to the drugs
between the two groups in the short term, similar
alone, some studies found a combination to be
in magnitude to the other meta-analyses, which the
more effective,10–12 whilst others did not.13–15
authors admitted may be too small to be clinically
As a result of this confusing overall picture, several relevant. Some limited follow up data were
meta-analyses of randomised studies have been available, with no difference found between the
performed, with many reporting an advantage, of two groups after three to six and 12 months.
varying degrees, for the use of a combination of
The study populations also varied in this study. All
antidepressants and psychotherapy over either
looked at people with depression, with 14 studies
drugs or psychotherapy alone.16–19 However,
looking at adults in general, and five at specific
judging by two recent meta-analyses, the quality
populations (adults with HIV, multiple sclerosis,
of the individual studies included in these studies
chronic depression; older adults). The authors found
varies greatly, leading to questions about the
that the difference between combined treatment and
reliability of their results.
psychological treatment was much smaller when only
For example, one 2009 meta-analysis combined data from the general adult samples were looked at.
studies that compared antidepressants alone to a Only a minority of studies (11) reported blinding of
combination of antidepressants and psychotherapy assessors and a limited number of studies employed
for depression.18 It included 25 randomised trials an intention to treat method. As the dropout rates
and found that combination was better than were highly variable, and as high as 55% in one paper,
antidepressants alone in the short term, in term of this may have distorted results too.
changes in depression symptom scores. However,
Overall, evidence that a combination of
the effect size was small, and whilst statistically
antidepressants and psychotherapy is superior to
significant, possibly not clinically relevant. There
either intervention given alone is not conclusive.
was insufficient data to look at longer-term
The assumptions behind this research, for
outcomes. The number of studies included was
example, that antidepressants are effective,
limited, and the individual trials were also fairly
and that antidepressants and psychotherapy
small. The average number of patients per study
provide distinctive, additive mechanisms against
was 81, and 15 studies contained fewer than 50
depression have not been proven.
patients. The trials varied in their target population,
with 16 looking at adults in general with
depression, and others focusing on more specific References
1. https://pathways.nice.org.uk/pathways/depression.
groups, such as bereaved older people, and people
2. https://www.nice.org.uk/guidance/gid-cgwave0725/
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J., Bialik, R.J. ... & Griffiths, J. (1999). Treatment of primary
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Understandably, no study could blind participants Clinical symptoms and functional impairments. American
Journal of Psychiatry, 156(10), 1608–1617.
to their treatment allocation, but only 18 reported
December 2019 69
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Peen, V., Van, R. ... & Dekker, J. (2004). Psychotherapy alone psychotherapy for patients with dysthymic disorder in primary
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and cognitive/behavioral therapy in the treatment of elderly Sacks, M. (2005). A comparative trial of psychotherapy and
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4.8 Conclusion: Understanding psychiatric medication
In general, the orthodox ‘disease-centred’ view is evidence for long-term harm. People who want
that psychiatric medications reverse or partially to stop their medication, either because they are
reverse an underlying biological ‘abnormality’. The stable, or because they feel it has not helped, will
existing evidence for this has been questioned. It need information about the nature of the drug they
is suggested that, in the absence of clear evidence are on before they can decide the best method for
for targeted actions by psychiatric medications on coming off it.
specific pathologies, an alternative, ‘drug-centred’
The drug-centred model makes the service user
model is more valid and useful.
the expert in their own drug management. It is up
A drug-centred model views drugs as producing to them to decide whether they find certain effects
characteristic altered states, which vary according useful or not (unless drugs are being prescribed
to the pharmacological properties of the drug against the patient’s wishes for purposes of
concerned. These effects can alter, suppress or social control). The model highlights how taking
obscure the manifestations of mental health psychiatric drugs is always a delicate balancing act
difficulties, and may be experienced as useful for between benefits and harm. The useful effects that
some people with these problems. Within this drugs have are part and parcel of a drug-induced
model, there still remains a role for the careful and state, a state of intoxication that is not the same
judicious prescribing of certain psychiatric drugs as the ordinary state of the body and mind. Taking
in some situations involving mental distress and psychoactive drugs is likely to impair and suppress
disturbance. aspects of our mental and emotional functioning
to a greater or lesser degree. If so, the question
However, the drug-centred model does entail
is whether that impairment is preferable to the
a different relationship between person and
distress that is being experienced.
prescriber. Rather than centring the discussion
on what intervention is deemed appropriate for a Although many people are advised to take
specific diagnosis, people using services and their psychiatric drugs for long periods after their
networks can ask and debate with their doctor problems have subsided, the evidence for the
about what sort of drug-induced effects might or benefits of long-term treatment is limited and
might not be useful in their specific situation. They harmful effects accumulate with long-term use.
can explore by themselves and with others what Therefore, deciding to stop taking prescribed
the benefits of a drug-induced state would be and drugs long-term can be a logical decision in many
what negative consequences are likely to flow from situations, and it is important that professionals
that state. provide support to people to do this as safely as
possible.
People who are already taking psychiatric drugs
might want to reflect on what drug-induced effects Much of the material in this section is a condensed
they are experiencing, and how these effects and updated version of material contained in A
might be affecting their lives. They will want to Straight Talking Introduction to Psychiatric Drugs by
balance any positive effects they feel they obtain Joanna Moncrieff, published by PCCS Books, and
against the negative or unpleasant effects and the used with the publisher’s kind permission.
December 2019 71
5. What do we know about withdrawal?
Professor John Read & Dr James Davies, with Luke Montagu
& Professor Marcantonio Spada
5.1 A general introduction to dependence and withdrawal

Drugs are foreign substances from the point of view of long time for them to revert to normal. Even relatively
the body, and therefore the body tries to counteract shorter-term treatment can result in adaptations and
their effects. This is sometimes referred to as the body resulting symptoms persisting a long time.
‘adapting’ to the presence of a drug. The adaptation
For example, we know that the abnormal
can occur in a variety of ways. In the presence of a
movements of tardive dyskinesia, a potential effect
drug that reduces the activity of a neurotransmitter,
of long-term antipsychotic use, often get worse
like dopamine, noradrenalin or serotonin, the
when antipsychotics are reduced or stopped. This
body may increase the number of receptors for the
is likely to be mediated by the increased numbers
particular neurotransmitter, or existing receptors may
and activity of dopamine receptors. Sometimes
become more sensitive. Such adaptations can mean
the movements improve with time as the body
that, over time, higher and higher doses are required
readjusts to the fact the drug has been stopped.
to achieve the same drug effect, as is seen for example
However, sometimes they are permanent, implying
with benzodiazepines and alcohol. When this occurs,
that the adaptation of the body’s dopamine
the individual is said to have developed ‘tolerance’ to
system to the presence of antipsychotics can be
the effects of the drug.
irreversible. Something similar may be occurring
If the drug is stopped then the body’s adaptations after discontinuation of benzodiazepines or
are suddenly unopposed by the presence of the antidepressants, when, in some cases, withdrawal
drug, and they give rise to withdrawal symptoms. reactions last for long periods.
For example, people taking dopamine receptor-
Most psychiatric drugs affect a range of different
blocking drugs such as antipsychotics will
brain chemicals or neurotransmitters, and
manufacture more dopamine receptors in their
withdrawal effects can reflect the drug’s impact
brains, and those receptors that already exist will
on any of these chemical systems. Withdrawal
change and become more sensitive to dopamine.
reactions themselves may be mild and annoying,
This is the body’s way of trying to increase the
they may be unpleasant and sometimes they are
activity of dopamine despite the presence of a
unbearable. In addition, withdrawal from sedative
chemical that tends to reduce its activity. When the
drugs often causes agitation and insomnia, which
drug is stopped, these extra dopamine receptors
can easily be mistaken for early signs of relapse.
will still be present, and may increase the activity
When drugs have been taken for a long time,
of dopamine above normal levels until they reduce
such as several years, it is possible that the body
back down to normal numbers.
will take a considerable time to readjust and
Usually the body’s adaptations disappear gradually withdrawal reactions may go on for some time.
when the drug is no longer present, and the
Often the worst withdrawal effects are experienced
withdrawal reactions subside. However, we know
at the end of the withdrawal process, when dosage
very little about the body’s response to long-term
has been reduced to almost zero. Repeated
drug consumption and how the body reacts to the
attempts at withdrawal may result in what is
withdrawal of such consumption. It is possible that
known as the ‘kindling’ effect where neuronal
the adaptations sometimes persist or that it can take a
hypersensitivity results in the progressive

worsening of withdrawal symptoms at each body to decline by half. Drugs with a short half-life
subsequent withdrawal episode. It is reported that are eliminated rapidly, while drugs with a long half-
this can also happen when drugs are reinstated. life remain in the body for longer.
Therapists should also be aware that withdrawal
Heroin, for example, has a short half-life and causes
reactions are not limited solely to during or
more reactions after stopping than methadone,
immediately after the withdrawal process but may
which has a long half-life. This is the principle
last over a period from six to 18 months, and in
behind the practice of prescribing methadone
some cases, several years.
to people who are dependent on heroin to help
Withdrawing from psychiatric drugs has some them withdraw. The antidepressant fluoxetine is
similarities to giving up recreational drugs. For another example of a drug with a long half-life. It
example, people may become dependent on is eliminated from the body slowly over a period
psychiatric drugs in both physical and psychological of weeks. Therefore, its effects generally wear off
senses as they do with drugs of misuse. One clear more gradually following cessation than those of
difference is that recreational drugs have effects that drugs with a shorter half-life. In contrast, drugs such
are pleasurable, and so people crave the drug when as the benzodiazepine lorazepam, antidepressant
they stop taking it. In contrast, people do not usually paroxetine and antipsychotic clozapine are
crave the effects of drugs such as antipsychotics or eliminated rapidly from the body – they have short
antidepressants, since these do not cause euphoria. half-lives. That is why you must take repeated doses
People can, however, have strong beliefs about what of them every day to get an even amount of the drug
such drugs do for them and may become anxious if in the body over a daily period. These drugs cause
they withdraw from them. As anxiety can occur as more intense withdrawal reactions when stopped.
a withdrawal reaction it may not be possible to tell
When embarking upon any account of how
such feelings apart until withdrawal is complete.
therapists may best support clients either
The danger is that any anxiety may be mistaken for
withdrawing or considering withdrawing from
a relapse of the original condition – see 5.4.2 for
psychiatric drugs, we encounter a number of
further discussion of this.
immediate obstacles:
In general, if a drug is stopped suddenly, the
■■ In the first place, beyond the considerable work
withdrawal reactions will be more intense, but
undertaken on benzodiazepine withdrawal,
they may last for a shorter period (especially if
it is widely acknowledged that research into
the drug has only been taken for a short period;
antipsychotic and antidepressant withdrawal
with longer-term use the body’s response is more
is comparatively limited. One of the major
unpredictable). If a drug is gradually reduced, the
outcomes of the recent antidepressant
withdrawal reactions will usually be less intense,
withdrawal debates1 was that numerous
and may not even be noticed by some people. The
admissions made by mainstream psychiatry
way the body reacts is not entirely predictable,
showed serious gaps in our understanding of
however, and therefore withdrawal reactions can
withdrawal. It also showed that established
still be severe in cases where the drug is gradually
thinking on withdrawal (captured by NICE
reduced and when taken short-term.
guidelines) is in significant need of revision
Different drugs differ in their ability to cause (a revision which, as we mentioned in the
withdrawal reactions. ‘Short-acting’ drugs that introduction to this guidance, has now taken
act quickly and are rapidly eliminated from the place).
body cause more intense withdrawal reactions ■■ While the prescribing professions still
than ‘long-acting’ drugs that stay around in the have much work to do in deepening our
body for longer. The rate of elimination of a drug is understanding of withdrawal, research into how
measured in what is called its ‘half-life’. A half-life therapists may best support clients either in or
means the time it takes for the concentration in the considering withdrawal is even more sparse.
December 2019 73
What is therefore offered in this section is largely This section will first summarise broadly what
derived from the combined experience of those who is known about withdrawal from each class of
have worked directly with people withdrawing from psychiatric drug, paying especial attention to the
psychiatric drugs. Although more research on such incidence, severity and duration of withdrawal.
practices is still needed, experiential knowledge of Finally, some background information regarding
successful withdrawal management has become the medical management of the withdrawal
sufficiently comprehensive to merit providing a process is provided alongside the definition of key
picture of what we know, to date, works best. terms.

5.2 Evidence on the likelihood, range of possible experiences,
duration and severity of withdrawal per drug class
5.2.1 Antidepressants Shorter half-life antidepressants (such as

venlafaxine, paroxetine, duloxetine and
imipramine) are expelled from the body more
Although further and better research is
rapidly (also see section 5.1). Antidepressants
clearly needed in this area, it is safe to say,
that are eliminated more slowly (e.g. fluoxetine)
from the best available studies to date, that
allow the body time to re-adapt to being without
at least half of people who try to stop, or
the drug and hence the withdrawal reactions are
reduce, their antidepressants will experience
usually (but not always) less severe.
withdrawal effects, while about half of those
people describe the effects as ‘severe’, and the
5.2.1.2 Incidence – How many people experience
duration varies enormously.1
withdrawal reactions?
A recent systematic review of the literature on
5.2.1.1 Withdrawal reactions withdrawal from all types of antidepressants,
but predominantly covering selective serotonin
Table 1: Withdrawal effects of antidepressants reuptake inhibitors (SSRIs), revealed 17 studies that
Flu-like symptoms Headaches contained data on withdrawal incidence – namely,
on how many people taking antidepressants will
Nausea Insomnia
experience withdrawal1.
Dizziness Anxiety
Seventeen different studies were reviewed (these
‘Brain zaps’ Irritability
ranged from small, industry funded drug trials to
Emotional blunting Diarrhoea large independent online surveys of people who
Sexual dysfunction Fatigue
take antidepressants). These produced incidence
rates from five percent to 97%. Of these 17 studies,
Sweating Twitching
three were excluded on methodological grounds.*
Vivid dreams Heart palpitations The remaining 14 studies were methodologically
Muscle stiffness Sensory hypersensitivity
diverse (comprising six RCTs, five naturalistic
studies and three surveys) and produced incidence
Hallucinations Confusion
rates ranging from 27% to 86%. When grouping the
Imbalance Inability to cry three types of study together, the weighted average
Agitation
for each group was:
■■ The three surveys – 57.1% (1790/3137),

■■ The five naturalistic studies – 52.5% (127/242)
■■ The six RCTs – 50.7% (341/673)
* Two excluded studies, which reported low incidence rates (12%), were simply ‘chart reviews’ of medical notes (Coupland et al., 1996;
Himei & Okamura, 2006) which are notoriously weak owing to their reliance on practitioners being aware of, and recording, withdrawal
reactions. A further excluded study, which reported very high incidence rates (97%), comprised 693 people who were all involved in a
withdrawal programme using tapering strips (and were answering a question about their previous attempts to come off) (Groot & Van
Os, 2018). This sample was unrepresentative because people who have not experienced withdrawal reactions are unlikely to enter a
tapered withdrawal programme. (See 5.4.1 for information about tapering).
December 2019 75
As getting similar findings from different also described their antidepressants as addictive.
methodologies is typically seen to strengthen The weighted average of these three studies is
confidence in an overall, combined estimate, the 30.8%. While it is difficult to extrapolate these
most recent evidence suggests that at least half of findings to the wider population of those taking
people suffer withdrawal reactions when trying to antidepressants, it is nevertheless important to
come off antidepressants (median 55%). note in these studies that nearly a third of those
taking antidepressants, when asked, report being
5.2.1.3 Treatment duration – does the length addicted to the drugs, according to their definition
of time spent on an antidepressant affect of the term.
withdrawal?
When comparing the studies, there was no obvious 5.2.1.5 Severity of withdrawal based on surveys
relationship between incidence of withdrawal Unfortunately, questions as to the severity of
reactions and duration of treatment, but, as noted withdrawal have not been sufficiently addressed in
above, the information on treatment duration randomised trials. Therefore, the preponderance
was incomplete. There were some useful data, of data we have on withdrawal severity is derived
however, within some of the studies. Two studies from direct-to-consumer surveys.1 As it is difficult
found no significant difference in the treatment to extrapolate from surveys to the general
duration of those who did and did not experience antidepressant population (e.g. people who
withdrawal reactions,2,3 demonstrating that experience withdrawal may be more likely to respond
withdrawal reactions do not only occur in people to surveys) population level estimates are hard to
who had been on the drugs for long periods of make. Nonetheless, the survey data are important
time. Both an international online survey4 and as they indicate that for a proportion of those taking
an even larger NZ survey5,6 found that those who antidepressants withdrawal can be severe.
had been on the drugs for more than three years
For example, in a recent New Zealand survey, 46%
were significantly more likely to report withdrawal
of the 750 who experienced withdrawal effects
effects, but these findings could partly be explained
reported those effects to be ‘severe’ rather than ‘mild’
by a larger number of withdrawal attempts. Most
or ‘moderate’,5,6 which was very similar to the 43%
participants in all four of these studies had been on
finding in the international sample.4 Furthermore, a
antidepressants for months or years, so the studies
recent Dutch study found that of 671 people who had
were not able to assess whether there is a plateau,
experienced some degree of withdrawal effects, 51%
within the first few weeks of treatment, beyond
reported the most extreme of six levels of withdrawal.
which the probability of withdrawal reactions does
Additionally, a recent international survey of 605
not increase for most people.
people, all self-identifying on antidepressant
withdrawal websites as experiencing withdrawal,
5.2.1.4 Self-reported addiction
asked participants to rate on a scale of 0–10 how
Another approach to the question of the incidence
severely withdrawal had impacted upon their life. The
of withdrawal reactions is to ask how many people
average rating was 8.4 with 41% indicating the highest
report becoming ‘addicted’ to or dependent on
level of severity on the scale.7
antidepressants. Traditional studies ignore this
somewhat taboo topic. We do have important The percentages selecting the most extreme level
data, however, on how many recipients experience of severity on offer in each of these four studies
antidepressants as ‘addictive’. ranged from 41% to 51%, with a weighted average
of 45.3%. So regardless of the scale used, nearly
Three studies have provided percentages, which
half of all people surveyed in these studies who
range from 27% to 37%. Of 192 people taking
experienced withdrawal effects ticked the most
antidepressants in the Netherlands, 30% described
extreme level of severity on the scale they were
their drugs as addictive. The two large online
presented with.
surveys found that 27% of 1,5215 and 37% of 9434

5.2.1.6 Difficulty, and duration, of withdrawal or a longer persistence of disturbances occurred
In a recent UK survey, 245 responded to the as well’ and recommended that ‘Clinicians need to
question ‘How easy did you find it to come off your add SNRIs to the list of drugs potentially inducing
medication?’ withdrawal symptoms upon discontinuation’.9
■■ 20% ticked ‘very easy’; Even longer durations have been reported by
■■ 51% ticked ‘fairly easy’; and two real life samples of people experiencing
difficulties with withdrawal. For instance, a recent
■■ 29% ticked ‘not easy at all’.8
international survey of people self-identifying as
Of the 247 who responded to ‘How long did it take experiencing withdrawal found that when 605
you to come off your medication?’ people who had experienced withdrawal were
asked ‘How long have you experienced withdrawal
■■ the majority (68%) did so within three months;
symptoms?’ 87% responded at least two months,
■■ but 21% took between three to six months; 59% at least one year, and 16% more than three
■■ 6% took between six and 12 months; and years.7 Additionally, a recent content analysis of a
■■ 5% took more than a year.8 population likely to have experienced withdrawal
difficulties assessed the content of 137 online posts
5.2.1.7 Duration of withdrawal reactions about AD withdrawal in the real world. The mean
A recent systematic review of antidepressant duration of withdrawal reactions was 90.5 weeks
withdrawal identified 10 relevant studies that for the 97 taking SSRIs and 50.8 weeks for the 40
had gathered data on the duration of withdrawal taking SNRIs. Although neither of the above two
reactions.1 While this review could not provide study samples are representative of all those taking
firm conclusions about the average duration of antidepressants, they nevertheless indicate that it
withdrawal reactions (because of the variety of is not as rare as sometimes thought for withdrawal
methodologies and ways duration was reported), reactions to last more than a year.1
it did conclude that there is far more variability in
duration than previously believed.E Nine of the 10 5.2.1.8 Qualitative studies on antidepressant
studies found that a significant number of people withdrawal
experience withdrawal reactions beyond a week, Qualitative studies are consistent with and serve
while seven of the 10 studies showed that it is not to bring to life the findings of the recent review
uncommon for people to experience withdrawal for of quantitative research.1 Illustrative examples
several months. of personal testimony regarding the severity and
duration of withdrawal effects follow:
This review’s findings were consistent with other
reviews. For instance, a 2015 review of quantitative “I am currently trying to wean myself off of
studies and case reports noted that in only four out Venlafaxine, which honestly is the most awful thing
of 18 case reports (22%) did withdrawal reactions I have ever done. I have horrible dizzy spells and
spontaneously remit within two weeks, and in nausea whenever I lower my dose.
two cases withdrawal effects were ongoing a year
“It took me almost two years to get off Paroxetine
after discontinuation. It concluded that withdrawal
and the side effects were horrendous. I even had
reactions ‘typically last a few weeks’ but noted that
to quit my job because I felt sick all the time. Even
‘many variations are possible, including…longer
now that I am off of it, I still feel electric shocks in
persistence of disturbances’.9 A more recent review,
my brain.”10
of research just on withdrawal from serotonin-
norepinephrine reuptake inhibitors (SNRIs), “It took me two months of hell to come off the
concluded that ‘Symptoms typically ensued within antidepressants. Was massively harder than I
a few days from discontinuation and lasted a few expected.
weeks, also with gradual tapering. Late onset and/
“I forgot to take my Citalopram for two days and
December 2019 77
woke up one morning with severe dizziness. It was 8. Read, J., Gee, A., Diggle, J. & Butler, H. (2018). Staying on and
coming off: The experiences of 752 antidepressant users.
so extreme that I fell over when I tried to get out of
Addictive Behaviors. doi.org/10.1016/j.addbeh.2018.08.021.
bed, and I threw up.”6 9. Fava, G., Gatti, A., Belaise, C., Guidi, J. & Offidani, E. (2015).
Withdrawal symptoms after selective serotonin reuptake
“The withdrawal effects if I forget to take my pill inhibitors discontinuation: A systematic review. Psychotherapy
are severe shakes, suicidal thoughts, a feeling of and Psychosomatics, 84, 72–81.
too much caffeine in my brain, electric shocks, 10. Pestello, F. & Davis-Berman, J. (2008). Taking anti-depressant
medication: A qualitative examination of internet postings.
hallucinations, insane mood swings. … kinda stuck
Journal of Mental Health, 17, 349–360.
on them now coz I’m too scared to come off it.”11 11. Gibson, K., Cartwright, C. & Read, J. (2016). ‘In my life
antidepressants have been….’: A qualitative analysis of users’
“While there is no doubt I am better on this diverse experiences of antidepressants. BMC Psychiatry, 16,
medication, the adverse effects have been 135.
devastating – when I have tried to withdraw – 12. Cartwright, C., Gibson, K., Read, J., Cowan, O. & Dehar, T.
(2016). Long-term antidepressant use: Patient perspectives
with ‘head zaps’, agitation, insomnia and mood
of benefits and adverse effects. Patient preference and
changes. This means that I do not have the adherence, 10, 1401–1407. doi:10.2147/PPA.S110632.
option of managing the depression any other
way because I have a problem coming off this 5.2.2 Benzodiazepines and Z-drugs
medication. The incidence of withdrawal range in different
studies from 20% to 100%. Rather than report all
The difficulty of getting off has been a tough road
the studies that draw these estimates, it can safely
and taken me years of trying and is something
be concluded that these drugs are highly addictive
that doctors could be more knowledgeable of and
and that dependence and withdrawal reactions
supportive with.”12
are common. For this reason, the British National
Formulary (2012)1 recommends that uninterrupted
References usage, for both benzodiazepines and Z-drugs, does
1. Davies, J. & Read, J. (2018). A systematic review into the
not exceed four weeks, because the drugs so quickly
effects: Are guidelines evidence based? Addictive Behaviors. pii: lead to tolerance and to physical and potentially
S0306-4603(18)30834-7. doi: 10.1016/j.addbeh.2018.08.027. psychological dependence. However, it is now clear
[Epub ahead of print] that there are substantial numbers of people taking
2. Himei, A. & Okamura, T. (2006). Discontinuation syndrome
them for longer than two years (see 4.3.5).
associated with paroxetine in depressed patients: A
retrospective analysis of factors involved in the occurrence of
Benzodiazepines are a drug-class that includes
the syndrome. CNS Drugs 20, 665-672.
3. Yasui-Furukori, N., Hashimoto, K., Tsuchimine, S., Tomita, sedatives and anxiolytics:
T., Sugawara, N., Ishioka, M. & Nakamura, K. (2016).
Characteristics of escitalopram discontinuation syndrome: A
■■ Sedatives (otherwise known as hypnotics or
preliminary study. Clinical Neuropharmacology, 39, 125–127. sleeping pills), such as flurazepam, temazepam,
4. Read, J. & Williams, J. (2018). Adverse effects of antidepressants nitrazepam and loprazolam, tend to be short
reported by 1,431 people from 38 Countries: Emotional
acting.
blunting, suicidality, and withdrawal effects. Current Drug
Safety, 13. doi: 10.2174/15748863136661806050095. ■■ Anxiolytics (also known as tranquillisers or anti-
5. Read, J., Cartwright, C. & Gibson, K. (2014). Adverse anxiety drugs), such as diazepam, alprazolam,
emotional and interpersonal effects reported by 1,829
chlordiazepoxide, oxazepam and lorazepam, are
New Zealanders while taking antidepressants. Psychiatry
Research, 216, 67–73. longer-acting.
6. Read, J., Cartwright, C. & Gibson, K. (2018). How many of
1,829 antidepressant users report withdrawal symptoms or
‘Z-drugs’ are non-benzodiazepine sedatives/
addiction? International Journal of Mental Health Nursing. hypnotics. The Z-drugs available in the UK are
doi.org/10.1111/inm.12488. zaleplon, zolpidem, and zopiclone.
7. Davies, J. & Pauli, G. (2018). A survey of antidepressant
withdrawal reactions and their management in primary care. Both benzodiazepines and Z-drugs boost the effect
Report from the All Party Parliamentary Group for Prescribed
of a substance in the brain called Gabba Amino
Drug Dependence (2018).
Butyric Acid (GABA), which is thought to have a

calming effect. Because the Z-drugs are short- Table 2.1: Other withdrawal effects of
acting, it was hoped they may avoid or minimise benzodiazepines and Z-drugs
dependence and withdrawal. However, there seems Flu-like symptoms Sore tongue and metallic taste
to be no robust evidence that they are significantly
Blurred vision Tinnitus (ringing in the ears)
less addictive, or less often lead to withdrawal
reactions, than short-acting benzodiazepines. Nightmares Tingling in the hands and feet
Lethargy Hallucinations and delusions

5.2.2.1 Withdrawal reactions
Someone who uses benzodiazepines for more than Sudden cessation of benzodiazepines and Z-drugs
a few (two to four) weeks is likely to experience increases the probability of these withdrawal
withdrawal reactions when they stop them. The reactions and may also cause grand mal seizures,
reactions include anxiety, agitation, insomnia hallucinations, and suicidality.1-7
and muscle stiffness. Since benzodiazepines
suppress nervous activity, stopping them increases 5.2.2.2 Severity of withdrawal
the activity of the nervous system. Withdrawal The severity of these reactions increases with:
can therefore induce unusual and usually
■■ longer usage
unpleasant sensory experiences such as tingling
and numbness, electric shock-like feelings and ■■ higher dosage
occasionally delusions and hallucinations. ■■ the use of multiple benzodiazepines
■■ oral rather than injected use
Withdrawal reactions usually start between six and
48 hours of stopping, or after reducing the dose of ■■ shorter half-life benzodiazepines (such as
a benzodiazepine, but can start later for longer- lorazepam or temazepam) because these are
acting drugs, such as anxiolytics. expelled from the body more rapidly. Drugs that
are eliminated more slowly allow the body time
The most common withdrawal effects of these to re-adapt to being without the drug and hence
drugs include: the withdrawal reactions are usually (but not
always) less severe
Table 2: Most common withdrawal effects of
benzodiazepines and Z- drugs ■■ an abrupt cessation, and so it is recommended
that benzodiazepines are withdrawn slowly.
Sweating Irritability
Nausea Agitation 5.2.2.3 Incidence – How many people experience

Dizziness Muscle stiffness withdrawal reactions?
Although initially marketed as a non-addictive
Headaches Twitching
alternative to barbiturates, benzodiazepines have
Insomnia Heart palpitations long been recognised as highly addictive. Estimates
Anxiety Sensory hypersensitivity of how many people experience withdrawal effects
are determined by how long they have been on
But many other reactions may be experienced, the drugs, how quickly they withdrew from them,
including: and the definition or measure used to assess
the withdrawal effects. Approximately 40% of
Table 2.1: Other withdrawal effects of
benzodiazepines and Z-drugs people will become addicted within six weeks of
taking them.8 Some research finds that everyone
Panic attacks Restlessness
who has been on benzodiazepines for at least six
Weight loss Abdominal cramps months and then tries to stop the drugs quickly will
experience some withdrawal reactions, and for 40%
Depression Poor memory and concentration
the reactions will be moderate or severe.3
Agoraphobia Burning sensations in the skin
December 2019 79
5.2.2.4 Duration Drugs that were developed in the 1950s to treat
Estimates of how long withdrawal reactions last people diagnosed with schizophrenia were
vary greatly, and are largely determined by duration initially described as ‘major tranquillisers’,
of treatment, dosage and drug type. Almost all acknowledging their powerful sedating effects.
people stopping or reducing benzodiazepines will They have since become known as ‘antipsychotics’
experience an ‘acute’ phase of withdrawal, which or ‘neuroleptics’. They are now often used on
typically lasts for two weeks to two months. A other groups besides those diagnosed with
minority will experience protracted (or ‘post-acute’) schizophrenia, including prisoners; children with
withdrawal phases, for a year or more,9,1,10,11 with learning and other difficulties, and people in care
anecdotal reports of five to 10 years. homes for the elderly. The first antipsychotics
included chlorpromazine, haloperidol, pimozide
References and trifluoperazine. These ‘first generation’
1. British National Formulary (2012). BNF 63. London: antipsychotics had a disturbing adverse effects’
Pharmaceutical Press. profile (including tardive dyskinesia – a usually
2. Dodds, T. (2017). Prescribed benzodiazepines and suicide risk: irreversible movement disorder). A second
A review of the literature. Primary Care Companion for CNS
generation of antipsychotics, sometimes referred
Disorders 19. doi:10.4088/PCC.16r02037.
3. Hood, S., Norman, A., Hince, D., Melichar, J. & Hulse, G. (2014). to as ‘atypical’ were developed, in the 1990s.2
Benzodiazepine dependence and its treatment with low dose These include: amisulpride, aripiprazole, clozapine,
flumazenil. British Journal of Clinical Pharmacology 77, 285–94. olanzapine, quetiapine and risperidone.
4. Lader, M. (2012). Benzodiazepine harm: How can it be
reduced? British Journal of Clinical Psychopharmacology, 77, We were introduced to the concept of withdrawal
295–301.
effects after stopping antipsychotics in section 4.4.5,
5. Mind (2018). Sleeping pills and minor tranquillisers. https://
www.mind.org.uk/information-support/drugs-and-treatments/
in relation to understanding efficacy studies. As is the
sleeping-pills-and-minor-tranquillisers/withdrawal-effects-of- case for other central nervous system drugs, such as
benzodiazepines/#.W0SbC4cVCpo. (Accessed July 2018.) benzodiazepines and alcohol, the brain can develop
6. Moncrieff, J. (2009). A straight talking introduction to
a tolerance to antipsychotics.3 Antipsychotics,
psychiatric drugs. Ross: PCCS Books.
7. Petursson, H. (1994). The benzodiazepine withdrawal
however, are clearly not addictive, if one’s definition
syndrome. Addiction 89, 1455–9. of addiction involves a craving for the drugs. In fact,
8. Royal College of Psychiatry (2018). Benzodiazepines. https:// because of the unpleasant adverse effects many
www.rcpsych.ac.uk/healthadvice/treatmentsandwellbeing/
people try hard to stop taking antipsychotics soon
benzodiazepines.aspx. (Accessed July 2018.)
9. Authier, N., Balayssac, D., Sautereau, M., Zangarelli, A., Courty,
after commencing them,4,5 or have to be forced to take
P., Somogyi, A. … & Eschalier, A. (2009). Benzodiazepine them against their will via the Mental Health Act, often
dependence: Focus on withdrawal syndrome. Annales with involuntary, long-acting injections.6 About half of
Pharmaceutiques Francaises, 67, 408–13.
people prescribed antipsychotics for ‘schizophrenia’
10. Murphy, S. & Tyrer, P. (1991). A double-blind comparison of
the effects of gradual withdrawal of lorazepam, diazepam and
are ‘noncompliant’.5 In one large sample, 74% tried at
bromazepam in benzodiazepine dependence. British Journal least once to discontinue the antipsychotics within 18
of Psychiatry, 158, 511–6. months of starting treatment.7
11. Soyka, M. (2017). Treatment of benzodiazepine dependence.
New England Journal of Medicine, 376, 1147–1157. The adverse effects that lead to people trying to
come off these drugs include8-11:
5.2.3 Antipsychotics
Table 3: The adverse effects that lead to people
trying to come off these drugs
The most recent survey found that of 105
Sedation Cardiovascular effects (arrhythmia &
people who tried to come off antipsychotics, sudden cardiac death)
65 (62%) experienced unwanted withdrawal
Dizziness Akathisia (extreme restlessness)
effects ‘across the full-range of physical,
Sexual Metabolic effects (obesity, glucose
emotional, cognitive, and functional domains’1
dysfunction intolerance, high cholesterol and diabetes)

In an international survey of 832 people taking 5.2.3.2 Antipsychotic induced psychosis and
antipsychotics, twice as many (395) cited tardive dyskinesia
‘unpleasant side effects’ than ‘felt better and didn’t As described in section 4.4.3, antipsychotics
need it’ (195) as their main reason for wanting to blockade, to a varying degree, the dopamine
stop their antipsychotics.12 system and other neurotransmitter systems
(along with many other effects on the brain and
Despite not being addictive in the strict sense of that
body).13 This led to the notion that ‘schizophrenia’
word, there are two types of withdrawal syndrome
is ‘caused’ by an overactive dopamine system, a
that can make it very difficult to reduce, or come off,
hypothesis that was never proved and that is now
these drugs. The first type has much in common with
largely abandoned. The brain tries to compensate
the withdrawal effects of the other central nervous
for the blockade.
system drugs discussed in this guidance, such as
benzodiazepines. The second type is somewhat As early as 1974 Dr Solomon Snyder, Professor of
more specific to psychosis and/or antipsychotics. Psychiatry and Pharmacology at John Hopkins
University warned that:
5.2.3.1 Classic withdrawal reactions
A recent review3 found that antipsychotics share a Something within the neurons recognises this
range of ‘classic symptoms of withdrawal’ with all sudden absence of neurotransmitter molecules
central nervous system drugs. These reactions, which at their appropriate receptor site and one way
usually emerge within four days of stopping, include: or another transmits a message back to the
dopamine neurons saying something like the
Table 4: Classic withdrawal reactions associated
with antipsychotic drugs following: ‘We don’t have enough dopamine.
Please send us some more!’ Whereupon the
Nausea Irritability
dopamine neuron in question proceeds to fire
Tremor Aggression at a more rapid rate.14
Anxiety Depression It has since been established that the brain’s
Agitation Sleep disturbances attempted compensation also includes an increase
in the number, and sensitivity, of dopamine
Headache Decreased concentration
receptor cells,3 a process that is not unique to
The reviewers suggest that these reactions usually antipsychotics. When an antipsychotic, and the
last ‘up to six weeks’ and ‘may last more than six dopamine blockade, are removed, or reduced, the
weeks and become a post-withdrawal disorder’ brain is effectively overwhelmed with dopamine,
but the review provides no data to support these partly because of the abnormal drug-induced
suggestions. sensitivity and number of dopamine receptor
cells. This process is likely to apply to the other
There are, in fact, relatively few studies of the neurochemical systems that antipsychotics
frequency or duration of classic withdrawal influence. These effects may result in a withdrawal
reactions following discontinuation of psychosis, which is often mistaken for a return of
antipsychotics. The largest direct-to-user, the ‘schizophrenia’ that the drugs were intended
international survey, of 832 people prescribed/ to treat. This in turn often leads to a reinstatement
taking antipsychotic medication, found that 65% of the drugs that have, paradoxically, caused the
reported withdrawal effects when trying to stop neurotransmitter abnormalities.15,2,14
or reduce, and that half of those people (51%)
described those withdrawal effects as ‘severe’.12 The first cases of dopamine ‘Supersensitivity
Reported withdrawal was strongly correlated with Psychosis’ [SP] were reported 40 years ago.16 A 2006
duration of treatment (p < .001). reviewer of the available evidence concluded:
December 2019 81
There is evidence to suggest that the process be reclassified as ‘Persistent Postwithdrawal
of discontinuation of some antipsychotic Supersensitivity Psychosis’,3 but this area is hard
drugs may precipitate the new onset or to research and there are a range of opinions
relapse of psychotic symptoms. Whereas on the topic. If PPSP does exist it is one of two
psychotic deterioration following withdrawal long-lasting Postwithdrawal Disorders caused by
of antipsychotic drugs has traditionally been antipsychotics. The other is the movement disorder
taken as evidence of the chronicity of the Tardive Dyskinesia that is discussed later.
underlying condition, this evidence suggests
that some recurrent episodes of psychosis may 5.2.3.5 How many people experience Rebound
be iatrogenic [caused by medical treatment]. Psychosis and PPSP and for how long?
Clinicians may therefore want to re-evaluate Few studies have addressed the incidence or
the benefits of long-term treatment in some duration of withdrawal induced psychosis. The
patients.15 [Definition added] 2006 review mentioned earlier had reported
mostly only case studies, including nine people
There have been two recent, comprehensive
with no previous history of psychosis, whose new
reviews of the research literature on what
psychosis (typically hallucinations or delusions)
now tends to be called ‘antipsychotic-induced
usually responded to reintroduction of the
Dopamine Supersensitivity Psychosis’ or
antipsychotic.15 It was possible, however, to
‘Supersensitivity Psychosis’ [SP] for short.3,17 One
estimate that 20–25% of people withdrawing from
of the reviewers has designed criteria for two
a specific antipsychotic, clozapine, experienced
SP-based withdrawal syndromes, differentiated
Supersensitivity Psychosis (SP) or, as the reviewer
primarily by duration.
prefers to call it ‘Rapid Onset Psychosis’.
5.2.3.3 Rebound psychosis An early study estimated that between 22% and 43%
One set of criteria for ‘Rebound Psychosis’, or of 224 outpatients diagnosed with schizophrenia
‘Withdrawal Psychosis’, are new psychosis reactions had SP. Two recent studies of atypical antipsychotics
occurring, or old psychotic reactions recurring at have reported SP incidence rates of 65%18 and
above pre-treatment levels, after antipsychotic 72%.19 All three studies, however, included cases
discontinuation, reduction, switching or in between that occurred due to tolerance (see section 5.1)
dose intervals, usually (but not always) after while the person was still taking the antipsychotics.
about three months continuous exposure to the In the latter study, 42% of the cases were identified
drug (the time necessary for increased dopamine as ‘Rebound Psychosis’, which means that overall
receptor density to occur), and causing distress or 30% of the sample, not all of whom had tried to stop
impairment in functioning.3 These reactions usually their antipsychotics, had experienced withdrawal-
appear within roughly four days of stopping oral induced psychosis. Another study found SP in 26%
antipsychotics but can take several weeks to emerge of people while changing from one antipsychotic
after cessation of long-acting injections. Rebound to another.20 This is, however, a very difficult issue
psychosis seems to be rather rare and the evidence to research because of the fluctuating nature of the
most clearly supports it in relation to withdrawal underlying psychosis.
from clozapine. British psychiatrist Joanna Moncrieff
In a recent international survey of people taking
prefers the term ‘Rapid Onset Psychosis’ because it
antipsychotics, ‘new or increased psychosis’ was the
is neutral about the underlying mechanisms that,
second most frequently reported ‘other side effect’
she suggests, are unclear.15
(after ‘akathisia/restlessness’). Thirteen reported
new reactions and six reported the exacerbation
5.2.3.4 Persistent Postwithdrawal
of previous reactions. It was not known, however,
Supersensitivity Psychosis (PPSP)
how many of the instances of new or exacerbated
Some researchers think that if Rebound
psychosis reactions followed withdrawal.12
Psychosis lasts longer than six weeks it should

There is some evidence that antipsychotics with In another study, 55% of 105 people who attempted
shorter half-lives (e.g. clozapine, metroclopromide, discontinuation of APs described successfully
sulpiride and amisulpiride) are more likely to stopping all APs for varying lengths of time, half
provoke SP.15,3 reported no current use, and half described having
some form of professional, family, friend, and/
5.2.3.6 Tardive Dyskinesia or service user or peer support for their attempt.
Tardive Dyskinesia (TD), also mentioned briefly Having support was associated with less relapse.1
in section 4.4.7, is a disabling, often irreversible, Furthermore, withdrawing gradually across more
antipsychotic-induced neurological disorder involving than one month was positively associated with
uncontrollable movements of the face, tongue, successful withdrawal.24 There will, of course, be
arms and legs. It is also associated with cognitive large variability in how long people need to take to
impairment.21 It is likely, but not proven, to be the result withdraw.
of the over activity of the dopamine system caused
by changes such as increased receptor numbers and References
sensitivity caused by antipsychotics. Some researchers 1. Larsen-Barr, M., Seymour, F., Read, J. & Gibson, K. (2018a).
consider TD to be either a component or predictor Attempting to discontinue antipsychotic medication: Withdrawal
methods, relapse and success. Psychiatry Research, 270, 365–374
of SP.3,18,19 The average prevalence of TD in people
2. Hutton, P., Weinamann, S., Bola, J. & Read, J. (2013).
taking antipsychotics is about 30%,22,23,2 rising to Antipsychotic drugs. In J. Read & J. Dillon (eds.). Models of
57% after 15 years of treatment with first generation madness: Psychological, social and biological approaches to
antipsychotics.22 The prevalence was thought to be psychosis (2nd edition). London: Routledge, pp.105–24.
3. Chouinard, G., Samaha, A., Chouinard, V., Peretti, C., Kanahara,
lower for second generation, ‘atypical’, antipsychotics,
N., Takase, M. & Iyo, M. (2017). Antipsychotic-induced
but the difference has found to be slight or non- dopamine supersensitivity psychosis: Pharmacology, Criteria,
existent,22,2 or the consequence of second generation and therapy. Psychotherapy and Psychosomatics, 86, 189–219.
antipsychotics being prescribed at lower dosages. 4. Cooper, D., Moisan, J., Gaudet, M., Abdous, B. & Gregoire,
J. (2005). Ambulatory use of Olanzapine and Risperidone:
It is listed here as a withdrawal effect because the
A population-based study on persistence and the use of
reactions of TD are often masked by the withdrawal concomitant therapy in the treatment of schizophrenia. The
of antipsychotics. When the drugs are stopped, it is Canadian Journal of Psychiatry, 50, 901–908.
thought that dopamine activity increases due to the 5. Perkins, D. (2002). Predictors of noncompliance in patients with
schizophrenia. Journal of Clinical Psychiatry, 63, 1121–1128.
increased sensitivity of the dopamine system produced
6. West, J., Marcus, S., Wilk, J., Countis, L., Regier, D. & Olfson, M.
by long-term antipsychotic treatment. Increased (2008). Use of depot antipsychotic medications for medication
dopamine activity can produce abnormal movements. nonadherence in schizophrenia. Schizophrenia Bulletin, 34,
Thus, the overt physical reactions (but not necessarily 995–1001.
7. Lieberman, J., Stroup, T., McEvoy, J., Swartz, M., Rosenheck, R.,
the cognitive reactions) of TD are often either seen for
Perkins, D. ... & Severe, J. (2005). Effectiveness of antipsychotic
the first time, or are exacerbated, after discontinuation, drugs in patients with chronic schizophrenia. New England
reduction or switching of antipsychotics.22,2 People Journal of Medicine, 353, 1209–1223.
over 50 are three to five times more likely than younger 8. Ho, B., Andreasen, N., Ziebell, S., Pierson, R. & Magnotta, V.
(2011). Long-term antipsychotic treatment and brain volumes.
people to develop TD.22
Archives of General Psychiatry, 68, 128–137.
9. Longden, E. & Read, J. (2016). Assessing and reporting the
5.2.3.7 Withdrawing slowly, with support adverse effects of antipsychotic medication: A systematic review
A recent study exploring the personal accounts of clinical studies, and prospective, retrospective, and cross-
sectional research. Clinical Neuropharmacology, 39, 29–39.
of individuals discontinuing antipsychotic drugs
10. Weinmann, S., Read, J. & Aderhold, V. (2009). The influence
identified that ‘weaving a safety net to safeguard of antipsychotics on mortality in schizophrenia: A systematic
well-being’ was a pivotal process in drug reduction. review. Schizophrenia Research, 113, 1–11.
This involved taking precautionary steps prior to 11. Weinmann, S. & Aderhold, V. (2010). Antipsychotic medication,
mortality and neurodegeneration. Psychosis, 2, 50–69.
reducing drugs taken to establish interpersonal
12. Read, J. & Williams, J. (2019). Positive and negative effects of
alliances with family, friends, support groups and antipsychotic medication: An international online survey of
mental health professionals that can be activated 832 recipients. Current Drug Safety, 14. doi: 10.2174/157488631
should problems arise.23 4666190301152734.
December 2019 83
13. Moncrieff, J. (2009). A straight talking introduction to Lithium is a toxic alkali metal, similar to sodium
psychiatric drugs. Ross: PCCS Books.
and potassium. It is prescribed primarily for people
14. Snyder, S. (1974). Madness and the Brain. New York: McGraw-Hill.
15. Moncrieff, J. (2006). Does antipsychotic withdrawal provoke who experience relatively extreme emotional highs
psychosis? Review of the literature on rapid onset psychosis and lows, who often receive the diagnostic label
(supersensitivity psychosis) and withdrawal-related relapse. ‘Manic Depression’ or, more recently, ‘Bipolar
Acta Psychiatrica Scandinavica, 114, 3–13.
Disorder’. The dose considered to be therapeutic
16. Chouinard, G., Jones, B. D. & Annable, L. (1978). Neuroleptic-
induced supersensitivity psychosis. The American journal of is so close to the dose that causes a hazardous
psychiatry. toxic state (which can be fatal if the Lithium is not
17. Yin, J., Barr, A., Ramos-Miguel, A. & Procyshyn, R. (2017). stopped immediately) that levels of lithium in the
Antipsychotic induced dopamine supersensitivity psychosis:
blood have to be carefully monitored.2
A comprehensive review. Current Neuropharmacology, 15,
174–183.
The mental health charity Mind advises that:
18. Kimura, H., Kanahara, N., Komatsu, N., Ishige, M., Muneoka, K.,
Yoshimura, M. ... & Hashimoto (2014). A prospective comparative
There do not appear to be physical
study of risperidone long-acting injectable treatment-resistant
schizophrenia with dopamine supersensitivity psychosis. withdrawal symptoms with lithium.
Schizophrenia Research, 155, 52–58. However, if you come off lithium too quickly
19. Suzuki, T., Kanahara, N., Yamanaka, H., Takase, M., Kimura, you are very likely to have a rebound manic
H., Watanabe, H. & Iyo, M. (2015). Dopamine supersensitivity
or psychotic episode and become quite ill, so
psychosis as a pivotal factor in treatment-resistant
schizophrenia. Psychiatry Research, 227, 278–282. you need to be cautious, reduce gradually –
20. Takase, M., Kanahara, N., Oda, Y., Kimura, H., Watanabe, H., over at least one month, and much longer if
& Iyo, M. (2015). Dopamine supersensitivity psychosis and you have been taking it for years. If relapse
dopamine partial agonist: A retrospective survey of failure
occurs, it happens in the first few months
of switching to aripiprazole in schizophrenia. Journal of
Psychopharmacology, 29(4), 383–389. after withdrawal and then tails off.5
21. Waddington, J., Youssef, H. & Kinsella, A. (1990). Cognitive (Mind, 2018).
dysfunction in schizophrenia followed up over 5 years, and
its longitudinal relationship to the emergence of tardive Some studies have reported increased suicidality
dyskinesia. Psychological Medicine, 20, 835–842. following withdrawal from Lithium, especially if
22. D’Abreu, A., Akbar, U. & Friedman, J. (2018). Tardive dyskinesia:
abrupt.6,7
Epidemiology. Journal of Neurological Science, 389, 17–20.
23. Le Geyt, G., Awenat, Y., Tai, S. & Haddock, G. (2017). Personal
Other drugs, sometimes described as ‘mood
accounts for discontinuing neuroleptic medication for
psychosis. Qualitative Health Research, 27(4), 559–572. https://
stabilisers’, include the three anticonvulsants
doi.org/10.1177/1049732316634047. carbamazepine (Tegretol), lamotrigine (Lamictal)
24. Larsen-Barr, M., Seymour, F., Read, J. & Gibson, K. (2018b). and valproate (Depakote, Epilim). Little research
Attempting to stop antipsychotic medication: Success,
has been conducted into the withdrawal
supports and efforts to cope. Social Psychiatry and Psychiatric
Epidemiology, 53, 745–56.
reactions for people taking these drugs who do
not have seizure disorders. A case series of six
5.2.4 Lithium and other ‘mood people coming off lamotrigine found distressing
stabilisers’ psychiatric reactions, especially anxiety and
irritability.8 A study of 90 people who withdrew
The relatively small amount of research from carbamazepine found that 26 (29%)
conducted suggests that reducing, or reported withdrawal reactions within four days
withdrawing from, Lithium does not seem to of withdrawal. Reactions, which alleviated
cause the physical reactions caused by coming within one week, included insomnia, dysphoria,
off other psychiatric drugs. Several studies, hallucination, hand fremitus (vibratory sensation),
however, show that stopping Lithium can cause and headaches.9
a relapse of mania, and that the probability of
For the withdrawal effects of asenapine (Sycrest),
having such a relapse when withdrawing after
an antipsychotic which is sometimes used as a
long-term use is higher than before Lithium was
mood stabiliser, see the section on antipsychotics.
started.1–4

References The depression can be intense, and it may be
1. Balon, R., Yeragani, V., Pohl, R. & Gerson, S. (1988). Lithium accompanied by suicidal thoughts. The symptoms
discontinuation: Withdrawal or relapse? Comprehensive can persist for between a few days and several
Psychiatry, 29, 330–334. weeks or even months.1
2. Moncrieff, J. (2009). The myth of the chemical cure: A critique of
psychiatric drug treatment. New York: Palgrave Macmillan. Withdrawal from prescribed stimulants is less
3. Post, R. (2007). Kindling and sensitization as models for affective
commonly described. Studies that have explored
episode recurrence, cyclicity, and tolerance phenomena.
Neuroscience & Biobehavioral Reviews, 31, 858–873. the consequences of withdrawal have focused only
4. Suppes, T., Bladessarini, R., Faedda, G. & Tohen, M. (1991). Risk on whether or not it is associated with a relapse of
of recurrence following discontinuation of lithium treatment in the symptoms of ADHD, without considering the
bipolar disorder. Archives of General Psychiatry, 48, 1082–1088.
possible physiological and psychological effects
5. Mind (2018). Lithium and other Mood Stabilisers. https://www.
mind.org.uk/information-support/drugs-and-treatments/ of the withdrawal itself.2,3 However, it has long
lithium-and-other-mood-stabilisers/coming-off-mood- been recognised that use of prescribed stimulants
stabilisers/#.W0R0UYcVCpo. (Accessed July 2018.) by people with ADHD is associated with the
6. Baldessarini, R., Tondo, L. & Hennen, J. (1999). Effects of
phenomenon known as ‘rebound’.
lithium treatment and its discontinuation on suicidal behavior
in bipolar manic-depressive disorders. Journal of Clinical
This occurs when the effects of a dose of a
Psychiatry, 60 (Supplement 2), 77–84.
7. Tondo, L., Baldessarini, R. J., Hennen, J., Floris, G., Silvetti,
stimulant wear off, usually towards the evening,
F. & Tohen, M. (1998). Lithium treatment and risk of suicidal and consists of a worsening of the symptoms of
behavior in bipolar disorder patients. The Journal of Clinical ADHD beyond their original level before treatment
Psychiatry, 59(8), 405–414.
was started. Children, in which ‘rebound’ has
8. Frey, L., Strom, L., Shrestha, A. & Spitz, M. (2009). End-of-dose
emergent psychopathology in ambulatory patients with
mainly been noted, become highly excitable and
epilepsy on stable-dose lamotrigine monotherapy: A case distractible. Since low- dose stimulants reduce
series of six patients. Epilepsy & Behavior, 15, 521–523. activity and increase focused attention, these
9. Chen, M., Zhang, W., Guo, Z., Zhang, W., Chai, Y. & Li, Y. (2014).
rebound effects are a predictable response to the
Withdrawal reaction of carbamazepine after neurovascular
decompression for trigeminal neuralgia: A preliminary study.
wearing off of the direct effects of the drug.
Journal of Neurological Science, 338, 43–45.
Rebound is also characterised by the onset of some
5.2.5 Stimulants prescribed for ADHD new symptoms including tearfulness, irritability
and emotional lability, which are not usually part
The effects of withdrawing from stimulant drugs
of ADHD.4–6 These rebound effects suggest that
like cocaine and amphetamines that are taken for
stimulants restrict or dampen emotional responses
recreational purposes are well-documented. Even
at the doses used in clinical practice. It has also
after taking stimulants for a day or two, people taking
been shown to manifest in the worsening of driving
them typically experience a period characterised by
performance in adults who had taken a dose of a
reduced energy, depression, irritability, hunger and
stimulant several hours earlier compared to those
excessive sleeping, which can last for a couple of days.
who took a placebo.7
When someone has taken stimulants continuously
for a long period, they may initially have insomnia, The existence of rebound suggests the presence of
and feel anxious, sad and agitated, and they can the drug has modified the brain in some way, which
experience chills and intense cravings for the drug. in itself consists of a form of withdrawal syndrome.
The rebound phenomenon also illustrates how
After this, the person withdrawing will likely begin
quickly the body adapts to the presence of a drug
feeling both mental and physical exhaustion, start to
and how rapidly withdrawal symptoms can occur
sleep excessively, although they may still experience
after the effects of a drug have worn off.
periods of insomnia, and become more depressed.
They may continue to feel anxious and irritable A few case reports document a withdrawal
and stop feeling pleasure, they may become less syndrome following the complete discontinuation of
sensitive to stimuli such as touch and sound, be prescribed stimulants in children which, as in adults,
socially withdrawn and have vivid dreams. includes depression and malaise. New episodes of
December 2019 85
migraine and psychosis have also been reported.8-10 5.2.6 Polypharmacy
However, there is no research that could confirm
Polypharmacy, the prescribing of more than one
how common or severe this withdrawal syndrome is,
drug at the same time, has increasingly become the
and how long it might last when it occurs.
norm in psychiatry.1 By the 1990s 80% of people
As with research on the long-term effects of other receiving psychiatric intervention were on more than
psychiatric drugs, the probable existence of a one drug.2 A particularly common combination is
withdrawal syndrome following discontinuation of antidepressants and benzodiazepines.3 A 2009 study
stimulant treatment is likely to confound attempts found that up to one third of psychiatric outpatients
to assess relapse or recurrence of ADHD symptoms were on three or more psychiatric drugs.4
after medication is stopped.
Despite its commonality, little research has
explored the role that this multiple prescribing
References: has on the frequency, severity or duration
1. Center for Substance Abuse Treatment (1999). Chapter 5: Medical
of withdrawal effects, or has studied how
aspects of stimulant use disorders. In Treatment for stimulant
use disorders. Rockville, MD: Substance Abuse and Mental Health polypharmacy affects the process of coming off the
Services Administration. Available at: https://www.ncbi.nlm.nih. various combinations of drugs.
gov/books/NBK64323/. (Accessed 26 April 2019.)
2. Buitelaar, J., Asherson, P., Soutullo, C., Colla, M., Adams, In the large New Zealand online survey5 people
D.H., Tanaka, Y. et al. (2015). Differences in maintenance who were taking, or had taken, more than one
of response upon discontinuation across medication
antidepressant reported a higher incidence of
treatments in attention-deficit/hyperactivity disorder. Eur
Neuropsychopharmacol. 25(10), 1611–21.
withdrawal effects (68.3%) than those who had
3. Coghill, D.R., Banaschewski, T., Lecendreux, M., Johnson, taken just one antidepressant (e.g. Fluoxetine –
M., Zuddas, A., Anderson, C.S. et al. (2014). Maintenance 35.5%), with the exception of Paroxetine (75.9%)
of efficacy of lisdexamfetamine dimesylate in children and
and Venlafaxine (70.4%).
adolescents with attention-deficit/hyperactivity disorder:
Randomized-withdrawal study design. Journal of the American
In the large international online survey6 55.4%
Academy of Child and Adolescent Psychiatry, 53(6), 647–57 e1.
4. Carlson, G.A. & Kelly, K.L. (2003). Stimulant rebound: How
of those who had taken only antidepressants
common is it and what does it mean? Journal of Child and reported withdrawal effects, compared to 65.9%
Adolescent Psychopharmacology, 13(2), 137–42. of those who had taken both antidepressants and
5. Sarampote, C.S., Efron, L.A., Robb, A.S., Pearl, P.L. & Stein,
antipsychotics. The figures for reported addiction
M.A. (2002). Can stimulant rebound mimic pediatric
bipolar disorder? Journal of Child and Adolescent
were 36.8% and 47.7% respectively.
6. Lopez, F.A., Childress, A., Adeyi, B., Dirks, B., Babcock, T.,
Scheckner, B. et al. (2017). ADHD symptom rebound and
References
1. Preskorn, S. & Flockhart, D. (2006). Guide to psychiatric drug
emotional lability with lisdexamfetamine dimesylate in children
interactions. Primary psychiatry, 13, 35–64.
aged 6 to 12 years. Journal of Attention Disorders, 21(1), 52–61.
2. Rittmannsberger, H. (2002). The use of drug monotherapy
7. Cox, D.J., Moore, M., Burket, R., Merkel, R.L., Mikami, A.Y.
in psychiatric inpatient treatment. Progress in Neuro-
& Kovatchev, B. (2008). Rebound effects with long-acting
Psychopharmacology & Biological Psychiatry 26, 547–551.
amphetamine or methylphenidate stimulant medication
3. Read, J., Gee, A., Diggle, J. & Butler, H. (2017). The
preparations among adolescent male drivers with attention-
interpersonal adverse effects reported by 1,008 users
deficit/hyperactivity disorder. Journal of Child and Adolescent
of antidepressants; and the incremental impact of
polypharmacy. Psychiatry Research, 256, 423–427.
8. Krakowski, A. & Ickowicz, A. (2018). Stimulant withdrawal
4. Mojtabai, R. & Olfson, M. (2010). National trends in
in a child with autism spectrum disorder and ADHD: A case
psychotropic medication polypharmacy in office-based
report. Journal of the Canadian Academy of Child & Adolescent
psychiatry. Archives Of General Psychiatry, 67, 26–36.
Psychiatry, 27(2), 148–51.
5. Read, J., Cartwright, C. & Gibson, K. (2018). ‘How many of 1829
9. Brown, R.T., Borden, K.A., Spunt, A.L. & Medenis, R. (1985).
antidepressant users report withdrawal effects or addiction?’,
Depression following pemoline withdrawal in a hyperactive
International Journal of Mental Health Nursing, 27(6), pp.1805–1815.
child. Clinical Pediatrics, Philadelphia, 24(3),174.
6. Read, J. & Williams, J. (2018). Adverse effects of
10. Rosenfeld, A.A. (1978). Depression and psychotic regression
antidepressants reported by a large international cohort:
following prolonged mehtylphenidate use and withdrawal:
Emotional blunting, suicidality, and withdrawal effects.
Case report. American Journal of Psychiatry, 136, 226–7.
Current Drug Safety, 13(3), 176–86.

5.3 Overall impacts of withdrawal on individuals
In addition to understanding the objective effects undermined their ability to support and take
of withdrawal, it is also necessary to understand sufficient care of others, including their children.
the subjective impact that withdrawal can They also reported that their ability to engage
have on the lives of individuals. It is important socially was significantly impaired, leading to
to be particularly mindful of how debilitating increased isolation.
– physically, psychologically and relationally –
A lack of understanding by family members about
withdrawal, in some cases, can be.
withdrawal reactions can also place further strain
A recent survey of 319 people using services in on relationships. When withdrawal is perceived as
England, all self-identifying as experiencing varying an ‘over-reaction’ this can lead to a breakdown of
degrees of antidepressant withdrawal, showed that mutual trust and understanding. Alternatively, a
half reported being incapacitated in some way by decrease in self-care can also lead to heightened
the experience, with their capacity to perform basic dependency on others, again compounding
daily tasks being impaired.1 A full (27), reporting relational strain.
more extreme withdrawal reactions, indicated
At its most extreme, then, withdrawal can lead to
that the experience had ‘ruined their lives’ or had
family break-ups, job losses and unemployment,
led them to ‘lose everything’. Many individuals
reliance on state benefits, bankruptcy and even
also reported that their reactions had a significant
suicide.2 While this study cannot be said to
impact on their ability to work. Decision-making,
represent all those taking antidepressants, or
memory, concentration and communication skills
even all those who experience withdrawal, it
were also affected, to varying degrees, leading
nevertheless indicates that for some, withdrawal
some participants to take time off or struggle
can be a highly destructive experience, adversely
through in a ‘brain-fog’ or a ‘zombie-like’ state.1
impacting families and beyond.
As a result, many participants experienced some
level of financial loss, while many experienced a
significant lowering of their confidence and self- References
1. Davies, J., Pauli, R. & Montagu, L. (2018). Antidepressant
esteem.
withdrawal: A survey of patients’ experience (an APPG for PDD
Report).
Withdrawal can have far-reaching consequences,
2. Council for Evidence-Based Psychiatry (2014). Unrecognised
extending beyond those personally impacted to facts about modern psychiatric practice. Available online:
affect families, friends and associates. In the same http://cepuk.org/wp-content/uploads/2016/05/Unrecognised-
survey, some individuals reported that withdrawal Facts-about-Modern-Psychiatric-Practice.pdf.
December 2019 87
5.4 The withdrawal process and terminology
Before outlining some key strategies therapists Recent research in the Lancet Psychiatry also
can use to support clients through withdrawal in supports the vital need for long tapering for some
section 6, it will be useful to first provide some people.3
background information regarding the medical
■■ Given the need to taper slowly, two years to
management of the withdrawal process.
complete withdrawal is not exceptional.4
Tapering strips can help facilitate a successful
5.4.1 Some background on tapering
■■
withdrawal. These strips comprise a roll of

Tapering is defined here as the slow reduction over
small pouches that each contain a daily dose of
time of a prescribed drug. It should be managed
antidepressant. Each strip contains 28 pouches,
by a knowledgeable prescriber. There are various
with the dose in each pouch getting successively
successful recommended protocols for tapering.
lower over a 28-day period. In a recent study
All agree that people should never stop taking
of 895 individuals wishing to discontinue their
psychiatric drugs abruptly or use a rushed tapering
antidepressants, 71% were able to withdraw
schedule.
successfully with the use of one to three strips.5
Schedules should be flexible and the reduction rate These are not currently available on the NHS
based on the individual’s withdrawal reactions, but can be ordered by a prescriber from the
intensity of reactions, their ability to cope and Netherlands. See the resources section for links
whether there is sufficient support available.1 A for further information.
knowledgeable prescriber will be mindful of such ■■ Some prescribed psychiatric drugs are available
factors when supporting a person through tapering. in liquid form, which can make reducing dosage
People’s experience can vary significantly, with some easier.
experiencing no withdrawal reactions whilst others ■■ It is helpful to also be aware that some
can experience severe and protracted withdrawal. psychiatric drugs, such as antidepressants,
may interact with other prescribed medical
Whilst it is beyond the remit of the psychological
drugs. It would clearly be part of the role of
therapist to give specific tapering advice, there
the prescriber to decide if any readjustment is
are some helpful rules of thumb and practical
needed if a client decides to withdraw.6
considerations with which it is useful to become
familiar, especially with respect to those who do
5.4.2 Clarifying the language of
experience severe and protracted withdrawal:
withdrawal
■■ Schedules: there are multiple online resources In order to support clients who have decided to
that anyone can consult for information withdraw from psychiatric drugs, it is important to
on tapering. One such resource distils become familiar with the language used to describe
wide experiential knowledge shared by withdrawal. Some of the key terms are:
individuals with lived experience of tapering
and withdrawal into clear information about ‘Withdrawal’, ‘withdrawal reaction’ or ‘symptom’ or
tapering schedules. For example, it states that: ‘discontinuation syndrome’
‘...most people most of the time have the All these terms refer to the various adverse
least-disruptive, least-disabling, and most reactions that result from reducing or discontinuing
successful outcomes by reducing their a drug. While the first three terms are non-
psychiatric drugs at a rate between 5–10% contentious, ‘discontinuation syndrome’ is
per month, recalculated each month based on controversial. Its current meaning was first defined
the most recent, previous month’s dose.’2 at the ‘Discontinuation Consensus Panel’ funded

by Eli Lilly in 19967 and has been criticised for ‘Inter-dose withdrawal’
obscuring and minimising withdrawal (perhaps Clients who take their antidepressants or other drugs
for commercial reasons). 8 It is advised that it be only sporadically, can experience what is known as
replaced with one of the less problematic terms ‘inter-dose withdrawal’. This refers to withdrawal
such as ‘withdrawal reaction’ or ‘withdrawal reactions that are caused by the drug’s effects wearing
symptom’ or just simply ‘withdrawal’. off before the next scheduled dose is taken. Inter-dose
withdrawal is more likely to be encountered with
‘Relapse’ benzodiazepines or drugs with a short half-life (see 5.1).
This term refers to the gradual return of the original
issue, at the same intensity, for which the drug was In some cases, withdrawal reactions resulting
initially taken.9,6 from tolerance or inter-dose withdrawal can be
as disabling as those experienced during and
‘Rebound’ after tapering, and so should not be overlooked
as reasons why a client may start displaying
This refers to one’s pre-drug problems returning
debilitating reactions.1
with greater intensity after the drug is withdrawn
and is directly linked to withdrawal from the drug.10
5.4.3 How withdrawal can be
‘Recurrence’ misinterpreted or misdiagnosed
This term is used to denote a new episode of distress When these different types of experience are
(as opposed to the return of the original ‘episode’). either overlooked or confused, withdrawal can be
This new ‘episode’, following withdrawal, may be misunderstood or misdiagnosed, with detrimental
induced by the withdrawal itself.10 effects for the client.
‘Persistent postwithdrawal disorder’ In 2007, and with respect to antidepressants,

This refers to the return of the original symptoms Haddad and Anderson11 provided an instructive
at greater intensity and/or additional symptoms list of the various ways in which withdrawal can be
related to a supposed new emerging ‘disorder’, misdiagnosed:
which have persisted for at least six weeks after i. as relapse (i.e. the original problem returning)
drug withdrawal.6,10 This term is controversial, with drugs being reinstated as a consequence.
however, given that it can be used to ascribe For example, as antidepressants are now widely
wrongly the responsibility for an adverse prescribed for anxiety-related problems, and
withdrawal reaction to an unspecified, unidentified as increased anxiety is a common withdrawal
‘disorder’ within the individual – thus medicalising reaction, ignorance of withdrawal reactions
a drug-induced reaction. could have led, in the past, to relapse being
overestimated when antidepressants were
‘Tolerance withdrawal’
withdrawn.12 This could still be leading, in the
Withdrawal reactions can be experienced at any present, to genuine withdrawal being misread
stage during the prescription course and not as relapse with drugs being reinstated.13
just during tapering or after discontinuation. For
ii. as failure to respond to treatment (e.g.
instance, withdrawal reactions can be experienced
patients not taking prescribed drugs as directed,
when there is a marked decrease in the drug’s
leading to withdrawal reactions which are then
effect (which may lead to higher drug doses
mistaken for the condition worsening, leading
being prescribed to maintain a said effect). This
to dose increase or drug switching).
experience is termed ‘tolerance withdrawal’ – an
experience that, if not properly acknowledged, is iii. as a new mental health ‘condition’ such as
susceptible to being either denied or misdiagnosed ‘bipolar I or II’ (e.g. with ‘manic’ of ‘hypomanic’
(e.g. as failure to respond to treatment). withdrawal reactions being misdiagnosed as the
early onset of ‘bipolar’).
December 2019 89
iv. as side effects of a new drug e.g. withdrawal ■■ Fuller lists of commonly experienced withdrawal
reactions can also be experienced when reactions can be found online, a good example
‘switching’ between antidepressants. If this is not being that given by the Withdrawal Project2 (see
correctly recognised, such reactions are liable to resources section).
being misdiagnosed as side effects of the new
drug to which the person has now switched.11 Guidance on how a psychological therapist
v. as new physiological conditions such as might ethically consider using this information
‘functional/somatic system disorders’ or to assist both prescriber and client can be
‘medically unexplained symptoms’.14 found in section 3. As mentioned previously,
tapering should ideally be performed under
While we do not currently possess any clear
the supervision of a knowledgeable medical
evidence as to how common the misdiagnosis of
professional although the current reality is
withdrawal by doctors may be, we do know from
sometimes the right support is not offered
anecdotal reports and qualitative survey data that it
leaving people to withdraw on their own or
may be more common than traditionally supposed.
with the support of online information and
For this reason, some general rules of thumb have communities.19
been devised to help safeguard against, or identify,
such misdiagnosis:
References
■■ When did the experience arise? One prevailing 1. Ashton, C.H. (2007). Benzodiazepines: How they work and how
view has been that it is possible to distinguish to withdraw. Newcastle upon Tyne: School of Neurosciences.
2. The Withdrawal Project (2018). TWP’s companion guide to
antidepressant withdrawal from relapse as the
psychiatric drug withdrawal part 2: Taper. Retrieved October 1,
former usually commences within a few days 2018, from https://withdrawal.theinnercompass.org/taper
of stopping the drugs and resolves quickly 3. Horowitz, M.A. & Taylor, D. (2019). Tapering of SSRI treatment
if the drug is reinstated, whereas relapse is to mitigate withdrawal symptoms. Lancet Psychiatry. Mar 5.
doi: 10.1016/S2215-0366(19)30032-X
uncommon in the first weeks after stopping
4. Hammersley, D.E. (1995). Counselling people on prescribed
treatment.12,15 While this view on timing makes drugs. London: Sage.
intuitive sense, it has limitations as many 5. Groot, P.C. & van Os, J. (2018). Antidepressant tapering strips
withdrawal variations are possible, including to help people come off medication more safely. Psychosis,
1–4. doi: 10.1080/17522439.2018.1469163
late onset of withdrawal and/or longer
6. Fava, G.A. & Belaise, C. (2018). Discontinuing antidepressant
persistence of disturbances.16 Also, the evidence drugs: Lesson from a failed trial and extensive clinical
is unclear as to whether relapse is uncommon in experience. Psychotherapy and Psychosomatics, 87, 257–267.
the first weeks after stopping treatment. 7. Schatzberg, A., Haddad, P., Kaplan, E., Lejoyeux, M.,
Rosenbaum, J., Young, A. & Zajecka, J. (1997). Possible
■■ Are emotional and physical reactions occurring mechanisms of the serotonin reuptake inhibitor discontinuation
at the same time? e.g. if unattributed feelings syndrome. Discontinuation Consensus Panel. The Journal of
of anxiety or depression are present alongside Clinical Psychiatry, 58, 23–27. [PubMed] [Google Scholar]
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difference between dependence and withdrawal reactions?
of their being related to withdrawal.17,15 A comparison of benzodiazepines and selective serotonin
■■ Is there any evidence of other medical re-uptake inhibitors. Addiction (Abingdon, England), 107 (5),
problems? If physical reactions cannot be 900–908.
9. Cohen, D. (2007). Helping individuals withdraw from
attributed to other identifiable medical
psychiatric drugs. Journal of College Student Psychotherapy,
problems they may well indicate withdrawal.18 21(3–4), 199–224. doi: 10.1300/J035v21n03_09
■■ How does the experience ‘feel’? many people 10. Chouinard, G. & Chouinard, V.A. (2015). New classification
of selective serotonin reuptake inhibitor withdrawal.
say that withdrawal related reactions feel
Psychotherapy and Psychosomatics, 84(2), 63–71.
qualitatively different to the client’s original doi: 10.1159/000371865
presenting issue, with some describing 11. Haddad P. & Anderson I. (2007). Recognising and managing
withdrawal reactions as having a ‘chemical’ feel.18 antidepressant discontinuation symptoms. APT 13, 447–457.
[Google Scholar]

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and Therapeutics Bulletin, 37, 49–52.
13. Davies, J. & Read, J. (2018). A systematic review into the
effects: Are guidelines evidence based? Addictive Behaviors. pii:
S0306-4603(18)30834-7. doi: 10.1016/j.addbeh.2018.08.027.
[Epub ahead of print].
14. Guy, A., Brown, M. & Lewis, S. (2018). The patient voice: An
analysis of personal accounts of prescribed drug dependence
and withdrawal submitted to petitions in Scotland and Wales.
London, UK: All-Party Parliamentary Group for Prescribed Drug
Dependence.
15. Breggin, P.R. (2013). Psychiatric drug withdrawal: A guide for
prescribers, therapists, patients, and their families. New York,
NY: Springer Publishing Company, LLC.
16. Fava, G.A., Gatti, A., Belaise, C., Guidi, J. & Offidani, E. (2015).
Withdrawal symptoms after selective serotonin reuptake
inhibitor discontinuation: A systematic review. Psychotherapy
and Psychosomatics, 84(2), 72–81. doi:10.1159/000370338
17. Rosenbaum J., Fava M., Hoog S., Ascroft R. & Krebs W. (1998).
Selective serotonin reuptake inhibitor discontinuation
syndrome: A randomized clinical trial. Biological Psychiatry, 44,
77–87. [PubMed] [Google Scholar].
18. Frederick, B. (2017). Recovery and renewal: Your essential guide
to overcoming dependency and withdrawal from sleeping pills,
other “benzo” tranquillisers and antidepressants (4th edn.).
Cardiff: Minelli Publishing.
19. Guy, A. & Davis, J. (2018). An analysis of four current UK service
models for prescribed medication withdrawal support (an APPG
for PDD publication). Available online: http://prescribeddrug.
org/wp-content/uploads/2018/11/APPG-Service-Model-
Report.pdf
December 2019 91
6. The role of the therapist in assisting
withdrawal from psychiatric drugs –
what do we know about what is helpful?
Dr Anne Guy, with Dr James Davies, Daniel C. Kolubinski,
Luke Montagu & Baylissa Frederick
Currently in the UK there are no national dedicated decisions will depend on their theoretical
services working with dependency and withdrawal modality, practice setting and the individual
issues. The services that do exist cover less than needs of the client. The client’s agency, as
three percent of the national population (see 3.2 always, should be supported and respected
for further information about these). However, at all times. Clients should be encouraged to
psychological therapists are already working with a discuss withdrawal from prescribed psychiatric
proportion of those who are likely to be dependent drugs with a knowledgeable prescriber who
on such drugs and who have no access to other can give medical advice, oversee and manage
services. For example, a 2018 survey of BPS, BACP any withdrawal process appropriately. While
and UKCP members asked what percentage of their this guidance advocates the importance
clients were taking prescribed psychiatric drugs – it of informed client choice based on full
showed that: information about potential benefits and risks,
it does not advocate therapists telling their
■■ 27% said between 25-50%
clients to take, not take, stay on or withdraw
■■ 23% said between 50-75% from psychiatric drugs. These matters should
■■ 31% said more than 75%.1 be left to the prescriber and client to decide.
Given that all therapists are likely to have already

Therapists are often in the advantageous position
found themselves in the position of working with
of having a pre-existing therapeutic relationship
a client in withdrawal, therapists may provide
with an individual. Based on this relationship it is
vital support by acquiring some basic additional
possible that therapists can respond to prescribed
knowledge. They do not need to be ‘specialists’ in
drug issues, including withdrawal, in an integrated
order to be helpful. Education and awareness of the
process.2 There are two distinct aspects to the role
issues raised in this guidance will allow therapists
that psychological therapists can play:
to consider whether, and how, to begin integrating
issues of prescribed drug dependence within their The first is that of helping the client understand
practice. and manage any causes and effects of emotional
distress that led them to be prescribed psychiatric
This guidance aims to empower and support
drugs in the first place.* The second is to support
conversations often already taking place
the client during drug withdrawal if this becomes
between therapists and their clients. Therapists
necessary, when, dependent upon the clients’
will need to decide for themselves whether, and
experience, the first role might need to be largely
to what extent, they wish to use this guidance
placed on hold.
in the context of their therapeutic work. These
* It is important to note, however, that some people are prescribed such drugs for physical conditions.

6.1 The combined wisdom approach
Although there is a lack of formal research into the 6.1.1 Stage 1: Before withdrawal is
effectiveness of therapeutic strategies aimed at
supporting withdrawal, the theoretical, experiential
started – preparation
and anecdotal evidence from those working in Preparation is essential to any successful withdrawal,
this field nonetheless offers useful suggestions. and therapists may need to consider with the client
What follows in this section is a summary of the whether they are ready to take their first reduction.
combined wisdom from these sources.2–8 Understanding the withdrawal process, alongside
adopting a stance of non-judgmental acceptance,
There are five relevant factors that have been found may assist the therapist in engaging the client in a
to be helpful in supporting people to successfully discussion about the advantages and disadvantages
withdraw: of withdrawal. It also opens up a space where the
client’s motivations and goals can be discussed.
■■ access to accurate information about
withdrawal and an opportunity to discuss Before withdrawal begins, 10 areas to consider
it and find answers to any questions before reviewing with the client are:
withdrawal starts
1. exploring whether a client feels physically and
■■ the involvement of a knowledgeable
emotionally ready to begin the withdrawal process;
prescriber to devise, help monitor and manage,
a tapering programme that is tolerable and 2. exploring who is going to provide medical
agreeable to the client support, and their relationship with their GP or
other prescriber;
■■ access to client-centred, non-authoritarian
support that empowers client choice and 3. signposting and discussing relevant information
enables understanding of withdrawal on withdrawal (e.g. the desirability of slow
experiences tapering: see 5.4.1 and online resources at the
end of this section);
■■ access to information about and help in
engaging with useful coping strategies and/or 4. discussing the possibility and general nature of
supportive lifestyle changes withdrawal effects so clients know what to look for;
■■ awareness of the need to suspend customary 5. clarifying the high-level definitions of relapse,
assumptions about the source of distress rebound, recurrence and withdrawal and
and associated interventions (i.e. emotional how they might be mistaken (see 5.4.2 for the
processing or analysis) for the duration of difference between these terms);
withdrawal. This obliges both client and 6. addressing any potential fears about the
therapist to judge carefully when to resume withdrawal process, including understanding
conventional therapeutic work, ideally after any what happened during previous attempts or
adverse withdrawal effects have abated. concerns about living without psychiatric drugs;
7. identifying possible ways the attempt might be
inadvertently sabotaged, either by the client or
Stages of support
others;
The combined wisdom approach comprises three
stages. First, the therapist helps the client prepare 8. identifying potential support networks. Are
for the onset of withdrawal. Second, the therapist friends, family or others prepared to assist if
offers support during withdrawal. And finally, withdrawal becomes either severe or protracted?
the therapist helps the client to adjust to a new 9. discussing the idea of the client using a diary
‘normal’ once withdrawal has ended. Each of these or log to keep track of drug reductions and
stages will now be considered in turn. experiences (see the resources in Appendix A for
examples of these);
December 2019 93
10. discussing the availability of extra sessions or with your way of working, facilitate open
other contact if needed in between scheduled communication between the individual, family
meetings, being clear about the limits of what members, the prescriber and other health
can be provided.2 professionals.
It may be useful here again to clearly distinguish Frederick7 states that as clients may experience
between medical advice and medical information. intense anxiety and fluctuating levels of physical
Whilst it is clear that psychological therapists are and mental pain during withdrawal, they should
neither trained to issue medical diagnoses nor to be encouraged to make sense of their experiences,
prescribe medical or pharmacological treatment, as well as to accept them as normal to the
they may frequently be asked by clients for medical process. Reactions can also come and go, and this
information. Discussing facts, scientific evidence or is sometimes referred to as ‘waves’ and ‘windows’,
information where appropriate with clients differs where the ‘waves’ of reaction slowly decrease in
substantially from offering a diagnosis, prescribing intensity and are interspersed with ‘windows’ of
drugs or advising withdrawal. It is important to be no or reduced reactions. Some clients may only
clear about this distinction with clients (see 3.2.5 experience ‘waves’ within ‘waves’.
for further discussion on this).
It is also important to help manage expectations
while advocating the use of self-care tools and
6.1.2 Stage 2: During withdrawal – techniques (see below). It is helpful for therapists
support to also be aware that ‘emotional anaesthesia’ – the
Therapists are likely to have more regular contact inability to feel pleasure or pain – is a common
with a client than a prescriber – they are therefore withdrawal effect. If the client therefore feels
in a strong position to offer the client ongoing distant from their emotions, any therapeutic work
support for the withdrawal process.3,8 During may need to take account of this, focusing on
withdrawal itself, practitioners have identified a helping with withdrawal experiences rather than
number of useful ways of supporting clients: attempting to process deeper emotional material.
Equally, as clients reduce their drugs, feelings can
■■ Helping clients to identify withdrawal reaction come back in sudden and very powerful ways;
and offering reassurance that they will pass.6,7 feelings that the client may be learning to cope
It is important to assume that any reactions with for the first time without drugs.2
that emerge during the transition are due to
withdrawal unless proven otherwise.3,7 6.1.2.1 Coping tools for use during withdrawal
■■ Encouraging the client to proceed at whatever The experience of those working with withdrawal
pace is right for them, while continuing to draw supports the use of a range of coping tools. As
on relevant information to support the client’s withdrawal can sometimes be severe, it might
decision making. be challenging for a client to learn new coping
■■ Suspending any attempt to understand deeper strategies during the withdrawal itself. For this reason,
psychological material during periods when therapists might consider supporting their clients in
withdrawal reactions are strong, shifting instead selecting coping strategies that are both realistic and
to providing support. appropriate to clients’ needs and current capacities.7,8
■■ Helping clients to identify supportive practices, Such client strategies may include:
which enable them to manage and tolerate
a. Acceptance/non-resistance: maintaining a non-
withdrawal experiences while they last. These
resisting attitude is one of the most important
may include coping strategies – see the list of
requirements for managing withdrawal. It
‘coping mechanisms’ below.
involves clients staying with painful experiences
■■ Continuing to provide a warm and attentive as they become aware of them without
therapeutic relationship, and, if consistent struggling or attempting to stop them.

b. Mindfulness*: this encompasses a variety of with mindfulness, this includes the idea of
practices that help clients get in closer touch moving past self-criticism into self-kindness.
with the present moment including their m. Sleep: it is important that clients take
thoughts, feelings and physical sensations, reasonable steps to maximise the probability of
importantly without judgment or resistance. achieving satisfactory levels of sleep and rest.
c. Positive self-support and self-talk*: this n. Keeping a diary*: this can be used to track
is a technique often used in CBT to help the changes in experiences such as sleep and mood
client influence their mood by developing self- as reductions in dosages are made. It could also
awareness of how they think about themselves, include goal setting for the next day if found to
their present and future and where thought be helpful.
patterns start to become unhelpfully negative.
o. Visualisation*: this involves clients focusing on
d. Breathing exercises*: such as diaphragmatic an image of what they want and visualising it as
breathing can be generally helpful to clients if it were already there.
when anxious or panicked.
p. De-catastrophising*: clients learning to
e. Emotional freedom technique (EFT)*: this recognise when they are thinking about worst
is an acupressure technique often described case scenarios, while also working to bring
as ‘psychological acupuncture’ and involves attention back to what is actually happening.
tapping particular meridian points on the face,
body and hands. Once a client has made a number of small reductions
successfully and has learned what works for them
f. Exercise: (if tolerated and appropriate to the
in coping with any reactions that arise, some clients
client’s level of fitness and capacity – it can
might choose to withdraw from counselling until
trigger a ‘wave’ of reactions in some).
they are completely off the drugs and can resume or
g. F
aith: where there is an existing faith or practice
review therapeutic work again if needed.2
this can prove helpful for some people – for
example, some report using prayer as a way of
achieving a more tranquil and hopeful state.
6.1.3 Stage 3: After withdrawal is
h. Grounding†: this is a term used to describe a complete
strong feeling of connection between mind and At the end of withdrawal, therapists may find it useful
body, including a sense of being fully present. to review the client’s experience and to determine
There are various exercises that can promote that with them what further therapeutic needs they have.
sense including some mindfulness exercises. It may be helpful to remember the following points:
i. Healthy distractions ■■ If the client has experienced any cognitive problems
j. Hobbies: coping with an intense withdrawal can as a part of their withdrawal experience it may take
leave some clients with a sense that all normal a while for confidence in decision making to rebuild
life has been lost, in some cases, irrevocably. (including the ability to say ‘no’ to others).
For many clients it is helpful, when possible, ■■ Ensure the clients’ aims and assessment of progress
to resume elements of a more balanced life, are realistic given their experience of withdrawal.
appropriate to their capacity and circumstances.
■■ If the clients’ withdrawal was experienced as
k. Meditation*: for those with less intense traumatic this might need to be considered in
withdrawal reactions formal methods of any further therapeutic work.9
meditation can be helpful to experience
■■ Post-withdrawal reactions can occur for some
periods of respite.
time after stopping prescribed psychiatric drugs.
l. Self-compassion work*: sometimes linked
* Some introductory sources of information for these can be found in the resources section in appendix A. Interested clients or therapists
will be able to find further information on any of the above tools for themselves and the list is by no means exhaustive – it is intended
to give an idea of the range of activities that might be of use.
December 2019 95
6.2 Psychiatrist led multidisciplinary models
There are examples in the theoretical and research ■■ Adults who are dependent on others such as
literature of psychiatrist/ prescriber-led models their parents or state authorities
to support withdrawal that may be of interest for ■■ Adults who are seriously disabled, emotionally
further reading if a therapist has an opportunity or cognitively
to suggest this in a multidisciplinary team setting. ■■ Adults receiving routine psychiatric drugs
They are most notably:
including the elderly
■■ Any individual whose judgment or ability to take
6.2.1 Breggin’s ‘person-centred care of themselves is seriously impaired.3
collaborative approach’ to
psychiatric care 6.2.2 Fava and Belaise’s (2018)
This model was developed by the US psychiatrist three-module approach6
Peter Breggin. It is a model for prescribers working This model for psychotherapeutic management of
with patients in psychiatric outpatient settings antidepressant withdrawal was developed in Italy
in the US, and is based on the core principles by the psychiatrists, Gatti Fava and Guidi Belaise.
of working within an empathic relationship, It also advocates collaborative team working (e.g.
communicating information openly and honestly comprising a psychiatrist trained in psychotherapy,
and fostering empowerment and respect for the a physician and clinical psychologists) to support
client’s viewpoint, wishes and needs.3 the client’s withdrawal from, in this case,
antidepressants. They used CBT as their core
Whilst it can be used in any circumstance in which
therapeutic modality and, as with the common
a person might need more support than can be
wisdom model already described, focused on
provided in a one-to-one relationship (with a
different tasks in preparation for, during and after
prescriber or therapist), it is suggested that this
withdrawal.
approach might be of particular use when working
with ‘vulnerable’ clients, such as:

6.3 How are UK therapists already working with withdrawal?
Some UK psychological therapists are already –– Prescribed Medication Support Service (PMSS)
directly involved in supporting people in covering six counties in North Wales,
withdrawal from prescribed psychiatric drugs and the
either through working in one of the very few –– Bridge ‘Addiction to Medicines’ Programme
dedicated services (which together cover just based in Bradford.
three percent of the population8) or as individual
therapists working independently. The PMSS
■■ works alongside local GPs and pharmacists

6.3.1 In dedicated services to identify patients taking painkillers or
Those working in dedicated services receive benzodiazepines who are in need of a drug
additional training about withdrawal from review for a variety of reasons e.g. prescribing
prescribed psychiatric drugs, including: is beyond current guidelines, newly pregnant
women. Patients can self-refer but not many
■■ How to help people prepare to withdraw
do.
■■ How to engage and achieve the support of the ■■ Patients are invited in for a holistic assessment
persons’ prescriber
of their needs with one of a small number of
■■ How to support people during withdrawal Prescribed Medication Therapists (a nurse/
including offering relevant information, counsellor hybrid role).
signposting helpful coping strategies and ■■ a plan is developed, usually including a
supporting gradual tapering (although
personalised drug reducing regime, which is
plans should always be overseen by a
then signed off by the GP.
prescriber)
■■ other appropriate support is drawn from a range
■■ How to judge what kinds of therapeutic
of services, including a traditional primary care
intervention are helpful at each stage of
counselling service.
withdrawal.
First, it is helpful to recognise that under the The above model has been recommended, by the
umbrella of those dependent on prescribed Welsh Government Petitions Committee,10 as one
psychiatric drugs there are different groups of possible model upon which to base the national
patients. Broadly speaking there are those: distribution of similar services.
a. who are currently unaware they might be The Bridge in Bradford operates on a similar basis,
dependent and therefore need to be contacted and again focuses on painkillers, benzodiazepines
proactively, and and Z-drugs.8
b. those that know they are dependent and need People who are taking antidepressants and
support to withdraw through reactive services antipsychotics, and who are prescribed beyond
they can self-refer to. guidelines, are not currently proactively contacted
by either of these services.
The four existing dedicated services in the UK
tend to be primarily aligned with one of these two b. Reactive services
groups: The other two dedicated services offer support
a. Proactive services to people within their vicinity who contact them
directly for help. They are:
The two small multidisciplinary services which
currently cater for patients in the first group are –– the Bristol and District Tranquiliser Project (BTP)
the: and
December 2019 97
–– REST (Mind in Camden), recently taken over by a only two services work directly with doctors. The
large substance misuse service provider.* reactive services offer training to local GP surgeries
on a request basis, but the people using the service
Both these services are staffed by a small number
remain responsible for establishing contact with
of counsellors trained in supporting withdrawal.
their prescriber. This mirrors the situation generally
Given that many people who contact these
for psychological therapists who either work in
services report having had poor experiences
a multi-disciplinary team, or independently of
with their doctors, meetings are offered in non-
doctors, either in an agency or alone.
medical settings. However, it remains important
that prescribers are involved in the withdrawal
process. Those using services take responsibility
6.3.2 In independent practice
for contacting their GP and getting their support A few therapists working independently with
for an agreed tapering plan. If the person is a local prescribed drug dependency and withdrawal
resident, the service might offer group or one-to- have acquired substantial experience through
one counselling, with peer-to-peer support offered working with this specific client group. They have
outside of meetings. considerable knowledge of the available literature,
to which they may even have contributed via
The above dedicated prescribed drug dependence practice-based research. This knowledge is
services rely on psychological therapists who have reflected in the ‘combined wisdom’ approach
some additional knowledge of withdrawal, but outlined in 6.1.
* It is important to note that whilst there is excellent work being done in substance misuse teams who are often working with people
dependent on a mixture of prescribed and non-prescribed drugs, the majority of people who are only dependent on prescribed drugs
understandably do not identify themselves as ‘substance misusers’ – they have taken drugs as prescribed by their doctors and so
attending a service focused on substance misuse is regarded by them as inappropriate.

6.4 Conclusion
Throughout this section it has been emphasised that decisions will depend on their theoretical
it is not the role of the therapist to decide when drugs modality, practice setting and the individual
should be withdrawn, how this may be best achieved needs of the client. The client’s agency, as
or what tapering protocols should be deployed. always, should be supported and respected
However, this does not mean that therapists cannot at all times. Clients should be encouraged to
have a critical role to play in supporting the client discuss withdrawal from prescribed psychiatric
during withdrawal. By using this guidance, therapists drugs with a knowledgeable prescriber who
will be better informed about some of the possible can give medical advice, oversee and manage
variables impacting a client’s potential withdrawal any withdrawal process appropriately. While
experience. They may also be in a better position this guidance advocates the importance
to communicate with other practitioners where of informed client choice based on full
appropriate (if the client does not wish to do so information about potential benefits and risks,
themselves), and to suggest that the client consults it does not advocate therapists telling their
their prescriber in cases where adverse drug reactions clients to take, not take, stay on or withdraw
arise before, during or after withdrawal. from psychiatric drugs. These matters should
be left to the prescriber and client to decide.
Finally, if the therapist holds any particular concerns
regarding how the prescriber may be understanding
and managing an individual’s withdrawal, it may be References
advisable (again, if the client does not wish to do so 1. BPS (2019). The Psychologist, March 2019. Leicester: The
themselves and with their consent) to communicate British Psychological Society.
2. Hammersley, D.E. (1995). Counselling people on prescribed
these formally to the prescriber. The ethical
drugs. London: Sage.
therapist, while practising within their own sphere 3. Breggin, P.R. (2013). Psychiatric drug withdrawal: A guide for
of professional competence, will always be thinking prescribers, therapists, patients, and their families. New York,
about the importance of the relationship their client NY: Springer Publishing Company, LLC.
4. Cohen, D. (2007). Helping individuals withdraw from
has with their prescriber, assessing any ways in which
psychiatric drugs. Journal of College Student Psychotherapy,
that relationship can be supported in service of the 21(3–4), 199–224. doi: 10.1300/J035v21n03_09
client’s needs and wants. This has been covered in 5. Guy, A. & Davis, J. (2018). An analysis of four current UK service
more detail together with ethical considerations, such models for prescribed medication withdrawal support (an APPG
for PDD publication). Available online: http://prescribeddrug.
as the importance of ‘informed choice’, in 3.2.5.
org/wp-content/uploads/2018/11/APPG-Service-Model-
This section reflects the current state of knowledge Report.pdf
6. Fava, G.A. & Belaise, C. (2018). Discontinuing antidepressant
on what is helpful for psychological therapists to
drugs: Lesson from a failed trial and extensive clinical
consider when working with clients withdrawing experience. Psychotherapy and Psychosomatics, 87, 257–267.
from, or preparing to withdraw from, psychiatric 7. Frederick, B. (2017). Recovery and renewal: Your essential guide
drugs. As withdrawal becomes better recognised to overcoming dependency and withdrawal from sleeping pills,
other ‘benzo’ tranquillisers and antidepressants (4th edn.).
throughout the mental health professions, it is
Cardiff: Minelli Publishing.
hoped that appropriate and directed research will 8. Houghton, P. (2016). Joining the debate around psychiatric
further add to this knowledge. medication. Clinical Psychology Forum, 286, 10–14.
9. Whitfield, C. (2010). Psychiatric drugs as agents of trauma. The
This guidance aims to empower and support International Journal of Risk & Safety in Medicine, 22(4) 195–207.
10. National Assembly for Wales (2019). Prescription drug
conversations often already taking place
depenence and withdrawal: Recognition and support.
between therapists and their clients. Therapists Report and Welsh Government Response: Available online:
will need to decide for themselves whether, and http://www.senedd.assembly.wales/ieIssueDetails.
to what extent, they wish to use this guidance aspx?IId=19952&Opt=3 [Viewed 19th June 2019]
in the context of their therapeutic work. These
December 2019 99
7. Patient voices – examples from real life
Dr Anne Guy (Ed.)
The stories that follow have been offered by attempt at withdrawing sent me into a state of
volunteers with the intention of helping therapists shock, in effect, to the point where I developed a
understand some possible experiences some movement disorder and symptoms of trauma. When
people may have when taking or withdrawing I finally completely stopped the drug, it took four
from psychiatric drugs. These experiences are years for the majority of the symptoms to subside.
not presented as being representative, they are
rather offered as examples that may illuminate Peter’s story
some of the complexities involved. The people
I had a decade of mixing and matching anti-
here are described as ‘patients’ as their stories are
psychotic, antidepressant and mood stabilising
primarily about the impact of the drugs they were
medications from my late teens to late twenties.
prescribed. Suggestions for further reading are
During my early twenties the consultant
provided at the end of the section.
psychiatrist I saw regularly had prescribed Largactil
[editor’s note: an antipsychotic], he then withdrew
Sarah’s story it in favour of another medication when I said it
I took an SSRI antidepressant for 17 years. The wasn’t effective.
reasons I ended up staying on the drug for that long
Firstly, I would say that the advice around
are threefold:
withdrawing was sparse and effects that I might
a. I was lied to and told I had a chemical imbalance encounter never discussed. What ensued was a
in my brain, so, until I investigated and couple of weeks that I can only describe as ‘scary’
challenged this ‘diagnosis’, I believed I needed that saw me become extremely paranoid, have
the drug. visual hallucinations and physical sensations.
b. Whenever I tried to stop taking it and went into
My paranoia was based around the fact I was
withdrawal, I was told that the drug was not
relaying information back to my consultant and on
addictive so my symptoms were an indication of
one occasion to an on-call duty psychiatrist that my
the extent of my illness.
wife had called because she was so worried. The
c. The only place to get advice on tapering was information I relayed was dismissed as me ‘lying’
from the internet. This was sporadic and ‘exaggerating’ and ‘making it up’.
inaccurate and so my tapering efforts constantly
failed. I was explaining that in my peripheral vision I could
see a dark figure and it seemed to be following
The withdrawal symptoms I experienced were,
me everywhere I was going, during this time I was
in the early days: nausea, vertigo, IBS, weight
experiencing repeated and extreme panic attacks.
loss, muscle tension, brain zaps, palpitations and
I was also getting repeated sensations in my brain,
insomnia. Each time I tried to come off the drug by
from temple to temple that I can only describe as
tapering more and more slowly, those withdrawal
electric shocks, these were extremely frightening,
effects got stronger as key bodily systems were
and I was convinced I was going to die.
affected by the absence of the drug.
My trust in the doctor and his profession was shaken
As time went on my nervous system became more
at a time that I was very unwell, this eventually led to
and more hyper vigilant as I felt unsafe, finding
me taking a non-medication approach to my mental
danger everywhere. I developed a number of phobic
health, something that has proved successful as I
reactions to external and internal stimuli – e.g. a
look back on a decade of wellness but something my
hot flush would be followed by a wave of fear. Each
consultant did not support.

Molly’s story week, then a quarter every other day for a week
and stop. I did this regime however when I stopped
I was under the care of a psychiatrist in the
my nervous system went into chaos.
community mental health team. I was taking a
combination of Mirtazapine [editor’s note: an I felt extremely anxious, depressed, angry and
antidepressant] and Trazodone [editor’s note: irrational and couldn’t eat or sleep. I went back to
an antidepressant which is also a sedative] with my GP and asked whether this was a reaction to
Zopiclone [editor’s note: a ‘Z’-drug, similar to a stopping the medicine, but he said not on the low
benzodiazepine, induces sleep] when I became dose you were on! He suggested that I was having a
tired of the side effects while the psychiatrist was relapse into an anxious state as I have had a history
on holiday and chose to stop taking the first two. of anxiety due to PTSD although never to this
extent before!
Within a couple of days, I had started to become
increasingly ‘up’ and became hypomanic nudging He gave me 14 days prescription of 3.75mg
into mania with symptoms of psychosis two Zopiclone sleeping tablet without warning about
days later. I became convinced my psychiatrist how addictive they were if used for more than a few
and the mental health team were conspiring to nights at a time! After two weeks I hadn’t improved
have me sectioned and managed to persuade and was given another 14 days prescription of
my psychiatrist to discharge me although I was Zopiclone. By week four I had reached tolerance
exhibiting pressured speech. and needed to double the dose to sleep. The
following day I had a bad reaction to the drug and
My therapist, who was separate from the mental
my body became numb all over and I was having
health team but was funded by the CCG, was
continuous, uncontrollable body jerking and finally
someone I confided in and who tried to get support
I collapsed, and the paramedics were called.
from my psychiatrist by calling him directly. When
we discussed it afterwards, he said he found the It was only then that I googled Zopiclone and read
lack of support difficult to handle as he watched the many articles warning about the high risk
me spiraling out of control. of dependency and the department of health’s
warning to all GPs that Zopiclone and other
In the end I ran away to Paris and ‘snapped out’
Benzos should not be taken for more than two
of the episode after putting my safety at risk
weeks! To cut a long story short, I received no
several times. The therapist had to manage the
help or sympathy from my GP and had to plan
repercussions in terms of the impact on my mental
my own escape from the hell I found myself in.
health but also rebuilding my trust in medication,
The only help I could find was the Bristol drug
which I was cautious about taking with a fear of
project helpline and the one in Camden. I used
withdrawal if I ever had to stop.
the Ashton manual and tried reducing 10% of
Zopiclone but the withdrawal symptoms were so
Angela’s story bad that I couldn’t get out of bed. The helplines
In 2015 I was advised by my GP to try 10mg and the Ashton manual recommended swapping to
of Nortriptyline [editor’s note: a tricyclic Valium, which has a longer half-life, compared with
antidepressant] to see if it helped reduce the Zopiclone’s very short half-life and would be easier
frequency of my migraines. It didn’t help so after to wean off. I made the swap and started weaning
three months I wanted to wean off and asked off at 10% every two weeks but still had horrendous
my GP for it in liquid form so that I could do it withdrawal symptoms, I became housebound
gradually. and couldn’t work or drive for five months due to
shaking most of the time. It was the worst time of
My GP refused saying the liquid was only licensed
my life and has taken me a couple of years to get
for elderly patients and suggested I cut the 10mg
my life back on track.
tablet in half for a week, then into quarters for a
December 2019 101

Majid’s story group therapy to be positive and I had no insight into
my illness – 10 years made it a normality).
I have been a service user and carer for over 15
years. Initially my diagnoses was depression and My psychologist argued my case, but the
anxiety and I was treated with venlafaxine [editor’s psychiatrist was saying that I was not taking my
note: an SNRI antidepressant]. medication! (Not true and this was the first time
he saw me but looked at history notes) that is why
Over the years my illness was then changed to
I was behaving manic. After another appointment
personality disorder with severe depression. Over
with the psychiatrist and psychologist he changed
10 years I have never seen the same consultant
my tablets to mirtazapine. I had no tapering of the
twice, therefore, no one knew how I was doing.
other drug just a straight swap and had to endure
The side effects made me deteriorate with little
sweating sleeplessness, panic attacks, anxiety
sleep. I would be mentally exhausted and sleep
attacks, paranoia and I could not trust anyone in
on benches in the park or on settees when visiting
my family.
family. I was soon banned going to houses due
to me not looking after myself and sleeping I was later told the side effects of venlafaxine had
everywhere. made me manic. I am now on a different medication
but still have issues with people and have flashbacks
The medications made me put on weight and I
of how I was. I am more relaxed with this medication
was outgrowing my clothes. I can remember that I
but would like to come off them so I can concentrate
found walking up three steps a struggle and would
and do more things, because the medications make
be out of breath. I would often feel dizzy and faint,
me tired and forgetful. Since I am calm, the family is
(and thought this was normal). Yet I was told by the
calm and not alert.
team to carry on taking the medicines.
Medicines are dangerous if not checked upon and
I took venlafaxine for 10 years and tried to come
can make you do stupid things which you have no
off them twice but was advised to stay on them
control over. Venlafaxine was making me suicidal.
by a locum psychiatrist and a support worker. The
Thank Allah I am off them and in more control of
medicine in the long-run made me more alert and
my life. Due to this I have lost my benefits and had
I would often be awake till 5am in the morning,
housing eviction letters because I was not filling in
which ruined my relationship with my family.
the forms on time (poor concentration/sleep).
When I eventually saw a psychologist, she told me
I am now diagnosed with general anxiety and
that I needed ‘tweaking up’ and would attend my
depression. Not personality disorder or Bipolar
psychiatric appointment. The problem was identified
which they were thinking of labelling me. It’s
that I would say I am fine (because we were told in
amazing what medicines can do to you.

Suggestions for further reading
i. I nternational survey into withdrawal from

psychiatric drugs1
In Sep 2017 the All-Party Parliamentary Group

for Prescribed Drug Dependence, in conjunction
with researchers at the University of Roehampton,
undertook one of the largest direct-to-consumer
international surveys of its kind into withdrawal
from psychiatric drugs (antidepressants,
antipsychotics and benzodiazepines). There were
approximately 1,700 respondents, 319 of whom
were taking antidepressants living in the UK.
This report summarises both the quantitative
and qualitative data on those in the UK taking
antidepressants (319) who reported their
withdrawal experience.
ii. Petition submissions – Scotland & Wales

One hundred and fifty-eight personal accounts of
people impacted by prescribed drug dependence
and withdrawal (specifically for antidepressants
and benzodiazepines) were submitted in response
to two petitions lodged with parliamentary
Petitions Committees in Scotland2 and Wales3 in
2017. These submissions have also been analysed
and summarised in a report.4
References
1. Davies, J., Pauli, R. & Montagu, L. (2018). Antidepressant
withdrawal: A survey of patients’ experience (an APPG for PDD
Report).
2. Scottish Petition PE01651 http://www.parliament.scot/
GettingInvolved/Petitions/PE01651.
3. Welsh Petition reference P-05-784 http://www.senedd.
assembly.wales/ieIssueDetails.aspx?IId=19952&Opt=3.
4. Guy, A., Brown, M. & Lewis, S. (2018). The patient voice: An
analysis of personal accounts of prescribed drug dependence
and withdrawal submitted to petitions in Scotland and Wales
(an APPG for PDD Report).
December 2019 103

Appendix A – Resources
Withdrawal Support Sites Lehmann, P. (Ed), (2004). Coming off psychiatric
drugs: Successful withdrawal from neuroleptics,
The Ashton Manual
antidepressants, lithium, carbamazepine and
Research information and protocol for the
tranquilizers. Berlin: Peter Lehmann Publishing.
treatment of withdrawal
benzo.org.uk/manual/ Mad in America
Learning about psychiatric withdrawal
Battle Against Tranquilisers
madinamerica.com/2017/11/learning-psychiatric-
Support for withdrawal from benzodiazepines,
drug-withdrawal/
tranquillisers and sleeping pills, and drugs with
similar effects Mind
www.bataid.org Coming off of psychiatric drugs
mind.org.uk/media/4727659/coming-off-
Benzo Buddies
psychiatric-drugs-2016-pdf.pdf
Online support for benzodiazepine withdrawal
benzobuddies.org NHS
Information on coming off of antidepressants
Benzo.org
nhs.uk/conditions/antidepressants/dosage/
Articles, information, expert medical documents,
news stories and personal accounts on Nice Guidelines
benzodiazepine withdrawal British National Formulary – Guidance, advice and
benzo.org.uk information for health, public health and social
care professionals.
Bloom in Wellness
cks.nice.org.uk/benzodiazepine-and-z-drug-
Free info or membership at nominal monthly fee for
withdrawalbnf.nice.org.uk/treatment-summary/
benzodiazepine and anti-depressant withdrawal
antidepressant-drugs.html
baylissa.com
Recovery Road
British Psychological Society
Antidepressant and benzodiazepine withdrawal
Understanding psychosis and schizophrenia
support
https://www.bps.org.uk/what-psychology/
http://www.recovery-road.org
understanding-psychosis-and-schizophrenia
Royal College of Psychiatrists
Coming Off Psych Drugs: A Meeting of Minds
Information on antidepressants
A film by Daniel Mackler
rcpsych.ac.uk/healthinformation/
bit.ly/1UcVqNh
treatmentsandwellbeing/antidepressants.aspx
The Council for Evidence Based Psychiatry
RxISK.org
Providing evidence of the potentially harmful
This is owned and operated by Data Based
effects of psychiatric drugs to the people and
Medicine Americas Ltd. (DBM), based in Toronto,
institutions in the UK that can make a difference
Canada. It is run by a group of high-profile medical
cepuk.org
experts with international reputations in early
Icarus Project and Freedom Centre drug-side-effect detection and risk mitigation,
Harm reduction guide to coming off psychiatric pharmacovigilance, and patient-centered care.
drugs
Guide on stopping antidepressants: https://rxisk.
willhall.net/files/
org/guide-stopping-antidepressants/
ComingOffPsychDrugsHarmReductGuide2Edonline.
https://rxisk.org
pdf

Surviving Antidepressants Coping tools for use during
Online forum providing peer support for tapering
and withdrawal syndrome
withdrawal – introductory links
survivingantidepressants.org/ The Withdrawal Project
Coping Mechanisms a-z, available online:
The Withdrawal Project https://withdrawal.theinnercompass.org/page/
Support for tapering off psychiatric medication coping-techniques-z
withdrawal.theinnercompass.org
Mindfulness
Tapering strips Baer, R. A. (Ed)(2014). Mindfulness based treatment
For general information about tapering strips and approaches.
how then can be legally ordered from the UK see: https://www.sciencedirect.com/
http://www.taperingstrip.org book/9780124160316/mindfulness-based-
treatment-approaches#book-description
A petition to make such strips available in the UK
http://www.change.org/p/provide-tapering-strips- Anthony, Wen & Howard, Matthew & Garland,
to-help-people-withdraw-from-antidepressant- Eric & McGovern, Tricia & Lazar, Michael. (2017).
and-antipsychotic-drugs Mindfulness treatment for substance misuse: A
systematic review and meta-analysis. Journal
of Substance Abuse Treatment, 75. 10.1016/j.
Dedicated services currently
jsat.2017.01.008.
offering support in the UK
Bristol & District Tranquiliser Project Mind (2013). Mindfulness exercises and tips.
Support for withdrawal from tranquilisers and Available online: https://www.mind.org.uk/
antidepressants information-support/drugs-and-treatments/
btpinfo.org.uk mindfulness/mindfulness-exercises-tips/
The Bridge Project, Bradford: New Directions NHS (2018). Guide to mindfulness. Available online:
‘Addiction to Medicines’ service (painkillers, https://www.nhs.uk/conditions/stress-anxiety-
benzodiazepines and Z-drugs) depression/mindfulness/
https://thebridgeproject.org.uk
Positive self-support and self-talk
The Prescribed Medication Support Service Battles, M. (2019). Self talk determines your success.
(PMSS) – North Wales Available online:
https://www.nhsdirect.wales.nhs.uk/localservices/ https://www.lifehack.org/504756/self-talk-
ViewLocalService.aspx?id=2556&s=Health determines-your-success-15-tips
Sound Mind (2017). Positive self talk. Available

Shared Decision Making
online:
NHS (2012). Liberating the NHS: No decision about
https://www.sound-mind.org/positive-self-talk.
me, without me – Government Response. Available
html
online: https://assets.publishing.service.gov.uk/
government/uploads/system/uploads/attachment_ Scott, E. (2019). Reduce stress and improve your life
data/file/216980/Liberating-the-NHS-No-decision- with positive self talk. Available online:
about-me-without-me-Government-response.pdf https://www.verywellmind.com/how-to-use-
positive-self-talk-for-stress-relief-3144816
December 2019 105

Breathing exercises Headspace.com, What is Meditation? Available
Breathing techniques online:
https://withdrawal.theinnercompass.org/coping/ https://www.headspace.com/meditation-101/
breathing what-is-meditation
Boyes, A. (2016). Breathing techniques for anxiety. Self-compassion work

Psychology Today. Available online: Good Therapy, Self-compassion, Available online:
https://www.psychologytoday.com/us/blog/in- https://www.goodtherapy.org/learn-about-
practice/201607/breathing-techniques-anxiety therapy/issues/self-compassion
Human Givens Institute (2012). 7–11 breathing: Neff, K. & Germer, C. (2018). The mindful self-
How does deep breathing make you feel more compassion workbook. Guilford Press, New York.
relaxed? Available online: https://www.hgi.org.uk/
resources/delve-our-extensive-library/resources- Keeping a diary
and-techniques/7-11-breathing-how-does-deep
Mind (2013). ‘Self-care for anxiety’ encourages
keeping a diary. Available online:
Emotional freedom technique (EFT) aka
https://www.mind.org.uk/information-support/
“tapping”
types-of-mental-health-problems/anxiety-and-
It’s suggested that this is ideally learned from an panic-attacks/self-care-for-anxiety/
EFT practitioner, although there are some You Tube
videos from its founder, Gary Craig, which describe Scott, E. (2019). A ‘how to’ guide on keeping a diary.
its use e.g. EFT Intro Available online:
https://www.youtube.com/watch?v=5r4kVp1yf5E https://www.verywellmind.com/journaling-a-great-
tool-for-coping-with-anxiety-3144672
Grounding
Bipolar UK, Mood Diary (a template for tracking
Get self help (2018). Grounding techniques for
medications and feelings). Available online:
coping with flashbacks and distress. Available
https://www.bipolaruk.org/FAQs/mood-diary
online: https://www.getselfhelp.co.uk/flashbacks.
htm
Visualisation
Taibbi, R. (2019). Upset? 10 grounding techniques Okhai, F. (2003). The power of deep relaxation and
first-aid for when you feel stressed, angry, guided imagery. Human Givens Institute, Available
overwhelmed. Psychology Today. Available online: online:
https://www.psychologytoday.com/gb/blog/fixing- https://www.hgi.org.uk/resources/delve-our-
families/201905/upset-10-grounding-techniques extensive-library/case-histories/power-deep-
relaxation-and-guided-imagery
Meditation
Villines, Z. (2017). What is the best type of De-catastrophising
meditation? Medical News Today Beck, A.T. (1985). Anxiety disorders & phobias. NY:
Available online: Harper & Row
https://www.medicalnewstoday.com/
Blair, L. (2017). De-catastrophising. Available online:
articles/320392.php
https://www.theguardian.com/lifeandstyle/2017/
Inner Compass, Guided Meditation Resources, dec/29/stop-catastrophising-expert-guide-
Available online: https://withdrawal. psychologist
theinnercompass.org/coping/guided-meditation

Drug classes and their uses – summary table
Drug class Subtypes Examples Common uses
Antidepressants ■■ SSRIs ■■ Sertraline Depression, anxiety disorders,

■■ Fluoxetine obsessive compulsive disorder,
post-traumatic stress disorder,
■■ Citalopram
bulimia nervosa
■■ Paroxetine
■■ SNRIs ■■ Venlafaxine Depression, anxiety disorders

■■ Duloxetine
■■ Other ■■ Mirtazapine Depression
■■ Tricyclic antidepressants ■■ Amitriptyline Depression, chronic pain

■■ Lofepramine (amitriptyline)
Antipsychotics ■■ First generation ■■ Chlorpromazine Psychotic disorders, acute

antipsychotics ■■ Haloperidol mania, sedation
■■ Zuclopenthixol
■■ Second generation ■■ Olanzapine,

antipsychotics ■■ Risperidone
■■ Aripiprazole
■■ Quetiapine
Benzodiazepines and ■■ Benzodiazepines ■■ Diazepam Anxiety, sedation, alcohol

related drugs ■■ Lorazepam withdrawal
■■ Chlordiazepoxide
■■ Z-drugs ■■ Zopiclone Insomnia

■■ Zolpidem
■■ Zaleplon
■■ Pregabalin and Anxiety, chronic pain

gabapentin
Mood stabilisers ■■ Lithium Bipolar affective disorder
■■ Drugs used in epilepsy ■■ Sodium valproate Bipolar affective disorder,

■■ Carbamazapine epilepsy
■■ Lamotrigine
■■ Some antipsychotics ■■ Olanzapine Bipolar affective disorder
Stimulants ■■ methylphenidate (Ritalin) Attention deficit hyperactivity

disorder
■■ atomoxetine
■■ amphetamine
Dr Joanna Moncrieff, Dr Tom Stockmann, May 2019
December 2019 107

Distributed under licence CC-BY-NC-ND 4.0 by:
APPG for Prescribed Drug Dependence
http://prescribeddrug.org/
This is not an official publication of the House of Commons or the House
of Lords. It has not been approved by either House or its committees.
All-Party Parliamentary Groups are informal groups of Members of both
Houses with a common interest in particular issues. The views expressed
in this report are those of the editors and writing team.
REP132/12.19 for Prescribed

Drug Dependence

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for Prescribed

Section 4: Professor Joanna Moncrieff & Section 7: Dr Anne Guy (Ed.)

2 Guidance for Psychological Therapists

Core steering group

Dr James Davies Dr Che Rosebert

Luke Montagu Professor Peter Kinderman

Fiona Ballantine Dykes Dr Lewis Blair

Dr Naomi Moller Dr Esther Cohen-Tovee

Suzie O’Neill Dr Yetunde Ade-Serrano

Professor Sarah Niblock Rachel Dufton

Jo Watson Stephanie Taylor-King

4 Guidance for Psychological Therapists

Dr James Davies (CEP)

Lead authors (section/s)

Professor Rosemary Rizq Dr Anne Guy

Dr James Davies Dr Tom Stockmann

Luke Montagu (CEP) Marion Brown

6 Guidance for Psychological Therapists

8 Guidance for Psychological Therapists

1.2 Who is this guidance for?

1.3 The medical model and the emerging crisis

10 Guidance for Psychological Therapists

1.6 How to use the guidance

12 Guidance for Psychological Therapists

2.1 The place of prescribed drugs in Mental Health Services

2.2 How do psychiatric drugs work?

14 Guidance for Psychological Therapists

16 Guidance for Psychological Therapists

3.1 The biomedical paradigm and its relationship to

18 Guidance for Psychological Therapists

20 Guidance for Psychological Therapists

Evidence box B: Summary of psychiatric drug effects by class.

Benzodiazepines and Z-drugs ■■ Sedative ■■ Sweating, nausea, dizziness,

Antidepressants ■■ Sedative ■■ Anxiety

Stimulants ■■ Insomnia ■■ Rebound effects, including

Mood stabilisers ■■ Sedative ■■ No physical withdrawal effects

Anti-psychotics ■■ Sedative ■■ Nausea, headache, tremor

22 Guidance for Psychological Therapists

24 Guidance for Psychological Therapists

26 Guidance for Psychological Therapists

28 Guidance for Psychological Therapists

Box C: Evidence summary – useful information for therapists to know

The ‘combined wisdom’ approach

30 Guidance for Psychological Therapists

The ‘combined wisdom’ approach

Stage 3: After withdrawal is complete

Working in multidisciplinary teams

assumed by clients and their prescribers to signal b) Implications for therapy

32 Guidance for Psychological Therapists

34 Guidance for Psychological Therapists

4.1 Interpreting the evidence on psychiatric drugs

36 Guidance for Psychological Therapists

4.2.1 History term physical health condition, or has ongoing

The small difference between antidepressants

38 Guidance for Psychological Therapists

40 Guidance for Psychological Therapists

SSRIs and other antidepressants, particularly 4.2.7 Other adverse effects

42 Guidance for Psychological Therapists

44 Guidance for Psychological Therapists