Antidepressants are not ‘dependence-forming’ drugs, although they can cause withdrawal symptoms, a final NICE guideline has said.
A draft version of the guidelines published in October referred to these as ‘medicines associated with dependence or withdrawal symptoms’.
But the new NICE guideline, published yesterday, referred to the same set of drugs as ‘a dependence-forming medicine or antidepressant’.
It said: ‘Medicines associated with dependence include benzodiazepines, Z‑drugs (such as zopiclone and zolpidem), opioids, gabapentin and pregabalin.
‘Antidepressants, although historically not classified as dependence-forming medicines, can nevertheless cause withdrawal symptoms when they are stopped.’
The new guideline published today also underlined the 'important role' of pharmacists in prescribing, continuity of care and different health professionals successfully working together.
It also rubberstamped the draft’s recommendations that clinicians should provide regular reviews for patients on antidepressants and drugs for chronic pain that may cause dependency or withdrawal.
And it confirmed that secondary care clinicians who ‘recommend a dependence-forming medicine or antidepressant to be started or continued in primary care’ should explain to the patient that their primary care team will prescribe and review this.
However, it added: ‘If the primary care team declines to prescribe the medicine, or wishes to delay it, the secondary and primary care teams will discuss the medicine and involve the person in these discussions, explaining the reasons for any delay.’
The guideline also reiterated that clinicians deciding about prescribing ‘dependence-forming’ medicines or antidepressants should determine whether there are any factors that could increase a patient’s risk of developing problems associated with dependency.
However, it added that healthcare professionals should ‘not withhold the medicine solely on the basis of one of these factors’.
And it said that the prescription could be delayed if clinicians need ‘additional time’ to ‘consider options and consult with colleagues’.
The NICE guideline said: ‘Acknowledge that these decisions are also difficult for the prescriber particularly when supporting a person who is distressed, and in the presence of risk factors for developing problems associated with dependence, and that additional time may be required to consider options and consult with colleagues.
‘Consider delaying prescribing if the person needs more time to think about their options or the prescriber needs to consult with other members of the healthcare team. If prescribing is delayed, ensure that a follow-up appointment is arranged.’
It also recommended that healthcare professionals ‘take steps to reduce the risk of developing problems associated with dependence, for example starting at a low dose, and consider avoiding modified-release opioids’.
‘Once an effective dose has been established, avoid automatically increasing the dose if the response is not sustained’, it added.
And it recommended a tailored approach to agreeing any dose reduction schedule with patients, including ensuring the planned rate of reduction is ‘acceptable’ to them.
It said clinicians should consider giving patients ‘additional control’ over the pace of reduction, for example by ‘issuing their usual daily dose in a form that allows them to reduce the amount in small decrements at a pace of their choosing, rather than issuing successive prescriptions for reduced daily doses’.
It added: ‘Explain that although withdrawal symptoms are to be expected, the reduction schedule can be modified to allow intolerable withdrawal symptoms to improve before making the next reduction.’
The new guidance does not cover the prescription of gabapentinoids for epilepsy, opioids for acute pain, cancer pain or at the end of life, or management of illicit drug dependence.
It follows new draft guidance on stopping antidepressants – published in November – that said GPs could be supporting patients for months if they experience severe side effects which could include suicidal thoughts and panic attacks.
This was NICE’s third attempt at drafting a guideline on that topic, with expected final publication next month.
NICE had previously revised its depression guidelines in 2019 to warn of ‘severe’ and lengthy antidepressant withdrawal symptoms, having originally said such symptoms were ‘mild’.
It follows a 2019 report from Public Health England that warned that one in four patients had been given a prescription for a potentially addictive medicine, including antidepressants.