I saw a patient recently, a 35 year-old woman who needed a refill of her Zoloft. She been started on it four years prior, after the birth of her first child when she had been overwhelmed with a fussy infant at home. She told me that she hadn’t wanted to start on medicine, but her obstetrician insisted on it. “Post-partum depression is a disease,” she said, “and you need this medicine.” Up to this point in her life, she had never battled with any mental health problems, and even then she was not suicidal or in acute distress, rather just sad and lonely and overwhelmed by this major life transition.
Trusting her doctor, she started Zoloft and noticed that she seemed to feel a little better. A year and a half later, she wanted to come off the medicine in order to get pregnant again, and so she just stopped taking it. She experienced a terrifying rush of physical and mental withdrawal symptoms within three days of stopping it. She believed this to be a recurrence of the illness, which confirmed her need for the medicine, so she resumed it.
She continued taking it, became pregnant, and took it throughout pregnancy, because her obsetrician was too concerned about her mental status deteriorating off of medications, and reassured her that it was safe in pregnancy. When her baby was born with a heart defect, she was told this was not due to the Zoloft. However, she has since seen advertisements for class-action lawsuits against Zoloft for causing precisely that. This has led to an intense source of guilt for her, and confusion about what was told to her by her obstetrician, whom she trusts.
She is done having children now, and so when she came to see me, she was not thinking of stopping the medicine. Her family practice doctors had assumed the supervision of her medicine, and she needed a refill. She wondered if she needed a higher dose because it wasn’t working well any more. The stressors of having two children, one with a serious heart issue, were large, as well as serious financial and marriage pressures. However, she was already on the highest dose of Zoloft. She then wondered if she should switch medications.
She was a new patient to me, and at this point, I told her my concerns about the lack of long-term effectiveness of SSRIs generally, and the potential for harm and increasing depressive symptoms. I told her that there were a number of common and devastating side effects, including weight gain (she had gained 50 pounds), sexual dysfunction (she reported an absent libido which was hurting her marriage), and stomach problems (she had been diagnosed with irritable bowel syndrome within the year). We discussed that if the medicine wasn’t working well anymore, and if these common side effects were occuring, then perhaps we should consider coming off the drugs slowly, under supervision, and bolstered by a program of integrative lifestyle interventions. She was caught off guard, but expressed interest in exploring this plan.
Then she said something that has become distressingly common for me to hear: “How come no other doctors ever told me about the side effects, or that I could come off of it?”
Indeed. Why is it so easy for doctors to push patients onto the medication highway, and so difficult to help them exit it? Why aren’t we more aware of how some of our patients are being negatively affected by these ineffective drugs?
Although I have strong personal feelings about the quagmire that has been created by our drug-intensive mental health paradigm, I am generally cautious in how I approach unsuspecting patients with this paradigm shift. Patients and providers are all engulfed in the system together, and it’s tough to see beyond it. If it’s possible to gently rock somebody’s boat, that’s what I’m trying to do, but not in a way that will increase a patient’s distress. Some people send clear signals that they aren’t ready to engage in such a paradigm shift, and for them I make a few alternative recommendations, perhaps refill their medicine for a month, and then recommend that they follow up with another doctor who better fits their value system.
But is what I’m doing so radical? It’s not like I’m sharing new information. I’m merely communicating out loud the side effects that appear on the drug inserts, as well as the evidence compiled in Anatomy of an Epidemic that points to the next ineffectiveness and harm of long-term drug use.
In the visit with this woman on Zoloft, she and I counted that there had been at least five different prescribers who had refilled or increased her medicine over the previously four years. According to her, none of them had ever hinted that stopping the drug might be possible, or even desirable.
In fairness, many patients feel they are doing well on the medications, and report few or no side effects. But many patients do poorly on them, and yet are never advised to stop them or to explore alternatives. Why?
Primary care physicians prescribe greater than 75% of all antidepressants in America. Below, I’m posting a partial list of potential barriers that would prevent us (and patients) from recogniznig side effects or recommending withdrawal from harmful and ineffective psychiatric drugs.
Barriers to primary care physicians advocating safe withdrawal from psychiatric drugs.
Providers:
- May be unaware of side effects.
- May assume somebody else in the system will address withdrawal from drugs.
- May have inherent bias about the effectiveness of their treatments.
- May receive biased information exclusively from drug reps.
- May not be informed about effective alternatives.
- May not be informed about appropriate withdrawal techniques.
- May underestimate the level of harm inflicted on their patients.
- May underestimate the resolve and the resilience of their patients.
- May be wary of backlash from psychiatrists, employers, and the mental health community.
- May be wary of malpractice suits should a patient’s condition worsen.
- May be too embedded in the medical model to see beyond it
Barriers to patients withdrawing safely from psychiatric drugs.
Patients:
- May be unprepared or unwilling to make a change.
- May not be in a life position to make a change.
- May be physiologically dependent on drugs.
- May be psychologically dependent on diagnoses.
- May have had prior bad experiences withdrawing.
- May lack financial, social and intellectual resources.
- May have been convinced by other doctors, counselors and family members that they need to remain on the drugs for life, and that to come off of them is irresponsible.
These lists are incomplete, but they are daunting and reflective of the mess we find ourselves in. How are we ever going to see our way out?
To me, it starts with honest information., and this is something always in my control.
- What are the medications actually doing?
- What are their known side effects?
- What is their long-term effectiveness?
- What are effective alternatives?
We won’t change the system overnight. But each provider can ask and answer these questions with our patients, who come to us one by one in the exam room, and we can give them true informed consent, always remembering our oath to Do No Harm.
Or as the Dalai Lama said: “Our prime purpose in life is to help others. And if you can’t help them, at least don’t hurt them.”
Those are words that all primary care physicians would do well to remember the next time you are sitting down with a patient who is simply asking for a refill of her Zoloft. Maybe she’s doing fine. But maybe she’s not. Better spend some time finding out why.
Best regards,
Mark
