Part of what has scared me straight about ever starting a patient on an antidepressant (or antipsychotic or mood stabilizer) again is bearing witness to the incredible havoc that medication discontinuation can wreak. This can range from transient headache, gastrointestinal distress, and irritability to violence, suicide, physiologic disability, and diffusion of identity. Patients, even in my practice, where I support and advocate for cautious withdrawal, feel understandably afraid of life without medication, and their fears are often realized.
As readers of MadinAmerica know, the wake of medication taper is an iatrogenic illness – it is medication-induced physiologic destabilization. I have made diagnostic efforts to quantify this withdrawal/relapse phenomenon by looking at adrenal cortisol patterns, inflammatory markers, and amino acid perturbance without clarification. I do know that most of my patients present to me on SSRIs and their cortisol rhythms are grossly suppressed. A paper entitled, Do Antidepressants Regulate How Cortisol Effects the Brain? addresses this, stating:
“Studies in depressed patients, animals and cellular models have demonstrated that antidepressants increase glucocorticoid receptor (GR) and mineralocorticoid receptor (MR) expression and function; this, in turn, is associated with enhanced negative feedback by endogenous glucocorticoids, and thus with reduced resting and stimulated hypothalamic–pituitary–adrenal (HPA) axis activity.”
I work to restore resiliency prior to taper by unearthing physiologic imbalances, autoimmune phenomenon, and perceived stress before medication decreases as a means of mitigating the taper’s effects – helping the body to become more adaptive to the absence of medication because it has more available resources in wellness. However; there is no antidote, no magic bullet, when patients are in the throws of taper. This is why the informed consent process becomes paramount. Patients need to know, before filling that first prescription, that their episode is likely to resolve on its own within 3 months (no treatment), that there are effective alternatives, and that there are significant potential short and long term risks.
To further quantify this, Professor Dee Mangin, will be evaluating patterns of relapse/discontinuation in 330 patients prescribed and weaned off of antidepressants. I, for one, cannot wait for the pearls of truth to emerge, but I remain concerned that it may take a lot more to change practice, particularly given analyses, which suggest a 17 year lag in clinical translation of medical data. In the meantime, we are learning from patients reports about their experiences and cautionary tales.
If we leave the monoamine hypothesis behind and we recognize the dangers of perturbing a system with a pharmaceutical product, then we can only look at what the symptoms are trying to tell us. Many wonderful clinicians listen to these symptoms and help to translate their message through energy medicine, acupuncture, chiropractic, and homeopathy. I see mental illness and I think of a gene/environment mismatch – I look to sources of inflammation and hormonal disruption, such as diet, stress, sedentary lifestyle, and toxic exposures, and I get to the root.
I am half way through the first e-course of its kind, and it has been incredibly well-received. There are so many people out there, disenfranchised by psychiatry, skeptical of its promises, and who want a better way, a more thoughtful assessment of them as whole persons. We seem to be onto something here, so let’s keep the dialogue flowing, keep our eyes wide open, and reform what psychiatry means, one patient at a time.
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Of further interest: short interview with Dee Mangin at the Dartmouth conference on over diagnosis: