Antidepressant Prescribing in Australian Primary Care: Time to Reevaluate

In Reply We welcome the correspondence [1, 2] about our article [3] and agree that it raises important questions about the high and rising rates of antidepressant prescribing in Australian primary care and the difficulty that some people have stopping antidepressants. While we applaud the Royal Australian and New Zealand College of Psychiatrists (RANZCP) for providing guidance on stopping antidepressants, the guideline authors acknowledge that their guidance for dose reduction (halve the dose then reduce more slowly ‘according to how the tablet can be divided’ [4]) is ‘not feasible with medications that are encapsulated (e.g., venlafaxine and duloxetine)’. Yet the RANZCP provides no alternative guidance. Thus, unfortunately, the RANZCP guidance is not helpful for people at highest risk for withdrawal symptoms, that is those on higher-risk encapsulated antidepressants and those who need to reduce their dose beyond ‘how the tablet can be divided’ to safely stop antidepressants. It is important to discuss the risk of withdrawal symptoms when starting antidepressants. It is also important to discuss this risk when continuing antidepressants. Withdrawal symptoms can be severe and prolonged, are not necessarily easily distinguishable from symptoms of relapse and can occur weeks or even months after antidepressants are stopped for reasons we do not yet understand [5]. We agree with Malhi and colleagues that ‘discontinuing antidepressants is as important as initiating them’, but argue that we need to get better at supporting people to make an informed choice and to safely and successfully stop antidepressants. This is all the more pressing as market research predicts that the antidepressant market size will double over the next 10 years fuelled in part by government initiatives to destigmatise mental illness and enhance access [6]. We agree that general practitioners also care for people who are very distressed or unwell, and that it can be difficult to access non-pharmacological therapy and support. But many of the 3.9 million Australians taking antidepressants are not in the severe category [7], and in any case, the evidence does not suggest that antidepressants are substantially more effective in people with severe depression [8]. Stopping antidepressants has implementation challenges for general practice; millions may be eligible to stop, but general practice is already stretched. While the fast pace and multiple competing demands in general practice add to the challenges [9], other countries have succeeded in stabilising antidepressant prescribing rates [10]. Katharine A. Wallis: writing – original draft. Joanna Moncrieff: writing – review and editing. The authors have nothing to report. The authors received funding from the Medical Research Future Fund for the trial. The funding played no role in this manuscript. Joanna Moncrieff receives some payment from book sales. The authors have nothing to report.