More than a quarter of a million people in the UK are likely to be taking highly dependency-forming hypnotic medication far beyond the recommended time scales. As there is evidence that long-term use of BZDs causes adverse physiological and neurological effects, and protracted withdrawal (with associated complications), this represents a serious public health problem.

Reboxetine for acute treatment of major depression: systematic review and meta-analysis of published and unpublished placebo and selective serotonin reuptake inhibitor controlled trials. BMJ 2010; 341: c4737. Cipriani and colleagues 1 confirm previous findings of a small effect of antidepressants over placebo for depression; however, there are some limitations to their assessment of risk of bias and the classification of included trials. Their method of classification was not in accordance with the Cochrane Handbook, 2 as stated by the authors. 1 According to their assessments of risk of bias and the categories proposed by Cochrane (table), only one (<1%) of 522 included trials fulfilled the criteria for low risk of bias, 383 (73%) had unclear risk of bias, and 138 (26%) had high risk of bias. Several important issues were not considered. First, well known sideeffects of antidepressants mean that adequate blinding in placebocontrolled trials is unlikely. 3 Second, the assessment of selective outcome reporting bias did not consider the three secondary outcomes 4 (eg, dropouts due to adverse events, which were not reported in 91 [17%] of 522 trials). 1 Third, assessment of attrition bias was done on the basis of arbitrary drop out thresholds and did not consider reasons for dropout; 4 all drugs had increased dropout rates due to adverse events compared with placebo. 1 Fourth, the authors rated the studies according to sponsorship but used these ratings in a covariate analysis only, even though vested interests have been shown to intro duce bias and significantly affect trial results. 5 Finally, the authors failed to provide their certainty of evi dence (in accordance with the GRADE framework) for the placebo comparisons. Given the issues we have outlined, certainty in the estimated effects should be rated as very low and be interpreted with caution. We declare no competing interests.

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Davies and colleagues highlight the issue of inappropriate long-term benzodiazepine and Z-drug (BZD) prescribing 1 but their conclusions and recommendations are flawed.First, they suggest that prescribing should be reduced by ensuring adherence to existing guidelines for prescribing and withdrawal, or developing new guidelines where needed.Guidelines have failed to reduce benzodiazepine and Z-drug prescribing: clinicians do not adhere to recommendations to use hypnotics and anxiolytics short term and only after trying psychological therapies. 2 The reasons for this are multifaceted and complex. Second, they advocate more research into the harms associated with long-term BZD use. Many studies have investigated harms from long-term benzodiazepine use, including risks of cognitive impairment, falls, hip fractures, and road traffic collisions. Finally, the authors recommend mandatory national drug withdrawal services and a helpline and website for prescribed drug dependence. These recommendations are arguably the most concerning because they lack evidence to support them. There is already evidence for benzodiazepine withdrawal, ideally combining discontinuation with psychological therapy for the underlying disorder. 3 Setting up new services without considering the likely workforce and resource needs, effectiveness, costs, or unintended consequences ignores the evidence that points to multifaceted rather than simplistic solutions to address the complex problem of BZD prescribing.

Background: There is a growing number of service users looking to discontinue use of psychiatric medicines. Tapering is the recommended approach for reducing and/or discontinuing the use of psychiatric medicines. This involves gradually reducing the dose over time to minimise the potential for withdrawal symptoms. However, many uncertainties exist regarding the process of reducing and stopping psychiatric medicines. This study will use a James Lind Alliance Priority Setting Partnership to determine the Top 10 unanswered questions and uncertainties about reducing and stopping psychiatric medicines. Methods: The Priority Setting Partnership will be conducted using the James Lind Alliance methodology. It will involve seven stages: (i) creating an international Steering Group of representatives from key stakeholder groups that will include people with lived experience of taking and/or stopping psychiatric medicines, family members, carers/supporters and healthcare professionals, and identifying potential partners to support key activities (e.g. dissemination); (ii) gathering uncertainties about reducing and stopping psychiatric medicines from key stakeholders using an online survey; (iii) data processing and summarising the survey responses; (iv) checking the summary questions against existing evidence and verifying uncertainties; (v) shortlisting the questions using a second online survey; (vi) determining the Top 10 research questions through an online prioritisation workshop; (vii) disseminating results. Conclusions: This study will use a Priority Setting Partnership to generate a Top 10 list of research questions and uncertainties about reducing and stopping psychiatric medicines. This list will help to guide future research and deliver responsive and strategic allocation of research resources, with a view to ultimately improving the future health and well-being of individuals who are taking psychiatric medicines.