Double counting, double standards

In their discussion of our paper (Henssler et al., 2024), Moncrieff and co-authors came to a different incidence of antidepressant discontinuation symptoms (Moncrieff et al., 2025).In getting there, they excluded data from 97% of patients in our meta-analysis and entirely disregarded placebo results.We are grateful to Psychological Medicine for allowing us to explain why we cannot share Moncrieff et al.'s confidence, neither in their process nor in their results.While others (e.g.(Kalfas et al., 2025) and we use the descriptive term antidepressant discontinuation symptoms (ADSs), antidepressant withdrawal symptoms (WSs) are also defensible.What is more important than terminology is to take seriously the problems patients can experience following antidepressant discontinuation (AD)the reason for our metaanalysis.One of its main findings is that one-third of patients experience ADS (31% [95% CI: 27%-35%]).Another concerns the substantial incidence of ADS after discontinuing placebo (17%), suggesting that some symptoms may be false positive.We agree that subtracting 17% from 31% and arriving at 14% across different studies yields a methodologically debatable approximation, which is why we also presented the within-study difference in randomized controlled trials (RCTs) only.The antidepressant placebo difference was even smaller: 8%.We note that the authors refrained from mentioning that this calculation was included in our paper.In questioning the inclusion of studies ascertaining ADS without specific instruments, such as the Discontinuation Signs and Symptoms Scale (DESS), Moncrieff et al. ignore the fact that instruments may overestimate ADS: For example, in the Stein ( 2008) study, 44% of patients reported symptoms on the DESSafter placebo discontinuation.This is a strong argument to not only rely on DESS in assessing ADS. Double standards?We cannot help wondering whether Moncrieff et al. applied double standards: When questioning antidepressant efficacy, they advocate for rigorous methods and emphasize small antidepressantplacebo differences in RCTs (e.g.Kamp et al., 2024), yet, when addressing ADS, they rely on studies that fall short of these methodological criteria, for example, surveys with low response rates (e.g.18%) (Horowitz et al., 2025) or case reports (Haddad 2001 in (Moncrieff et al., 2025).However, in evaluating all acute effects of antidepressants, accounting for placebo effects is a standard requirement, especially since placebo and nocebo effects are particularly pronounced in depressive and anxiety disorders (Bschor, Nagel, Unger, Schwarzer, & Baethge, 2024; Bschor, Unger, Nagel, Schwarzer, & Baethge, 2025).Moncrieff et al. themselves point to the ambiguity of symptoms and that 'withdrawal symptoms can be overlooked or misclassified'a powerful reason for comparisons against placebo withdrawal.In a similar example of double standards, the last author, Dr. Horowitz, while criticizing our inclusion of studies not using ADS instruments, selected several studies not using an instrument in his co-authored meta-analysis on WS (Zhang et al., 2024).This systematic review also included some studies (e.g.Sir et al., 2005), based on what the authors now call an unreliable denominatordescribing that, unfortunately, some papers do not report on drop-outs.Not least, in this meta-analysis, two samples with ADS incidences above 50% overlapped (Read and Williams 2018 and Read 2020), and therefore, individuals have been double-counted. Three meta-analysesThis meta-analysis (Zhang et al., 2024) is also noteworthy because 1) Moncrieff and co-authors suggest that it resulted in a considerably higher incidence than our investigation and 2) because it selected at least four online surveys, a design carrying high risks of selection, response, and nonresponse bias.Although stated differently in the registration, Zhang et al. apparently did