Sarah’s Health Notes: What everyone should know about antidepressants according to the UK regulatory body

The UK Government drug regulatory body, the MHRA, has just issued new warnings about possible side effects of antidepressants. Sarah explains these in Health Notes this week but also warns that anyone wanting to come off their drugs should consult their doctor to do it more safely.

First: A VERY IMPORTANT WARNING

If you are taking an antidepressant and want to stop, always consult your doctor. Antidepressants are what’s called ‘dependence-forming drugs’, which means that the body and brain gets used to the drug and needs more and larger doses in order to function.

Depending on the length of time you’ve been taking the drug and the type of antidepressant, you may need to come off very slowly in order to avoid distressing side effects of withdrawal, which may last for a considerable length of time.

The most comprehensive resource for health professionals is The Maudsley Deprescribing Guidelines by Professor David Taylor and Dr. Mark Horowitz (a pharmacist and psychiatrist respectively). As well as evidence-based guidance on safely reducing or stopping antidepressants, it also covers other dependence-forming drugs – benzodiazepines, gabapentinoids and z-drugs (sleeping pills).

Your doctor may have a copy; NHS Wales makes it freely and digitally accessible to all NHS clinicians, doctors, nurses, pharmacists and trainees there.

In the New Year, there will be detailed online resources giving doctors information about safer prescribing of antidepressants as well as safer deprescribing. Meanwhile, NICE guidelines on treating depression are here: https://www.nice.org.uk/guidance/ng222

Second: new safety measures from the UK Government Medicines and Healthcare products Regulatory Agency (MHRA)

Over the last year, the MHRA has held meetings involving patients and their families about how doctors prescribing antidepressants are informing their patients about the risks of suicidal thoughts and behaviours, and also of persistent sexual dysfunction. It’s the principle of ‘informed consent’ ie giving the patient clear information they have a right to know about a medication.

The MHRA now advises that when healthcare professionals start patients on an antidepressant, change the dose, or conduct a medication review, they should discuss the evidence that some antidepressants (usually an SSRI or SNRI) may cause suicidal thoughts and behaviours. The patient should be told to seek urgent medical attention if this happens.

The other risk is sexual dysfunction (often called PSSD for Post SSRI Sexual Dysfunction), where the symptoms may start during the time the patient takes the drug and persist after stopping it. According to the MHRA, PSSD is linked to these drugs: citalopram, escitalopram, duloxetine, fluvoxamine, fluoxetine, paroxetine, sertraline, venlafaxine, amitriptyline, nortriptyline.

You can find out the details here.

These risks are not new but the MHRA has now taken firmer steps to warn patients following various reviews including the 2019 PHE Prescribed Medicines Evidence Review, advice from the Commission on Human Medicines, and Coroners Prevention of Future Deaths Reports where the suicide has been linked to antidepressants.

One high profile case was that of Tom Kingston, who was married to Lady Gabriella Windsor, a second cousin of the King. He took his own life in February 2024.

The Coroner reported these Matters of Concern, which went to the MHRA and other healthcare bodies:

Whether there is adequate communication of the risks of suicide associated with the selective serotonin reuptake inhibitor (SSRI) medications, and
Whether the current guidance to persist with SSRI medication or switch to an alternative SSRI medication is appropriate when no benefit has been achieved and/ or especially when any adverse side effects are being experienced.

Tom’s parents were at the MHRA meetings and have emphasised how important it is that patients should be warned of the potential risks of antidepressants. They have spoken at events including Stolen Lives London Talks in July, organised by the UK charity Antidepressants Risks.

Third: how can patients get clear information so they can exercise ‘informed consent’

I’ve written about this before but the most practical thing anyone can do when a doctor suggests taking a drug is to use the acronym B-R-A-N.

Patients can ask the doctor to explain:

the possible Benefits of the drug and the number needed to treat (NNT) – that’s how many people will need to take the drug for one to benefit. For mild depression, medical guidelines show that antidepressants help very little and are not recommended as first line treatment because side effects probably outweigh any small benefit;
the Risks: patients have a right to know these, as the MHRA has now acknowledged;
the Alternatives: non-medical ways of helping people feel better, such as being referred to a Social Prescribing Link Worker (usually via a GP) who has time to explore underlying factors from loneliness to debt, bereavement to inappropriate housing, which may be causing sad feelings and low mood; physical activity – dancing, jogging, yoga etc - has been shown in big reviews to be more effective than medication and CBT, as I explained here;
what happens if we do Nothing: sometimes it’s a case where doing Nothing is better than doing Something or Anything. It’s sometimes called ‘watchful waiting’: being aware of the concerns and monitoring the situation but putting one foot in front of another and living as normally as possible.