In this podcast, we hear from the renowned clinician and researcher Dr. Giovanni Fava. Dr. Fava is a psychiatrist and professor of clinical psychology at the University of Bologna in Italy. He is also a clinical professor of psychiatry at the University of Buffalo School of Medicine and Biomedical Sciences. Since 1992, he has been the editor-in-chief of the peer-reviewed medical journal Psychotherapy and Psychosomatics.

Dr. Fava has authored more than 500 scientific papers and is known for researching the adverse effects of antidepressant drugs. In a 1994 editorial, he argued that many of his fellow psychiatrists were too hesitant to question whether a given psychiatric treatment was more harmful than it was helpful.

He recently released his latest book entitled “Discontinuing Antidepressant Medications” published by Oxford University Press. The book is designed to be a guide for clinicians who want to help patients withdraw from antidepressants.

In this interview, we discuss the new book, approaches to antidepressant cessation and explore some of the concepts including novel psychotherapeutic approaches to withdrawal.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Fava, pictured here on the right, in discussion with psychopharmacologist Guy Chouinard.
James Moore: Dr. Fava, thank you so much for joining me on the podcast today. To begin with, can I ask you to tell us a little bit about your background and how it was that you became interested in issues around the difficulties that some people have when they want to stop antidepressant drugs?

Giovanni Fava: Yes, unlike most of the researchers today, I actually evaluate and personally treat quite a number of patients and I’ve always been doing that. I think this is very important to get a good understanding of what’s going on.

In the early 90s, in my practice, I started seeing patients having problems discontinuing antidepressant drugs. I had very extensive experience in discontinuing antidepressants with some studies we did but these were tricyclics, the first generation of antidepressants. So, I was having these problems and I saw that the literature was not really addressing these issues.

Back in ’94, I had written an editorial in the journal I had, Psychotherapy and Psychosomatics, raising some questions about tolerance issues in antidepressant drugs. I must say that the freedom I enjoy as an editor was very valuable because it sparked quite a debate in terms of antidepressants. So, the journal became a forum for hosting papers dealing with withdrawal syndromes after antidepressants or during tapering. I kept on seeing and assessing patients and I noticed at a certain point, about a decade ago, that withdrawal issues were going to pass unnoticed and there were fewer and fewer papers.

So, we decided to do two systematic reviews on SSRI and SNRI antidepressants. These were the first reviews and researcher Michael Hengartner commented that these came after nearly 200 systematic reviews on the benefits of antidepressant drugs.  So, two against 200, that is the ratio we are addressing. It has had a profound impact because from that time on, the term withdrawal has become more and more accepted and used in the literature.

So, my knowledge comes from being a researcher and being a clinician.

Moore: Thank you. Before we come on to talk about the book, I think you are perhaps unique in having a grounding in psychopharmacology but also having an understanding of how psychotherapy might sit alongside.  That struck me as quite important in this work.

Fava: Yes, there are very few people around who have a research background and clinical background in both areas. That was quite common in the old days, but nowadays, I’d say very few people.

Moore: The new book is entitled Discontinuing Antidepressant Medications and it’s published by Oxford University Press.  I’m so glad to see this book is due to be released because as you said yourself, there is a dearth of good quality material on withdrawal.
In the book, as you mentioned, you identified in the 1990s that the pharmaceutical industry planned to extend the use of SSRI and SNRI drugs beyond depression and they took steps to popularize the term “discontinuation” as opposed to withdrawal.  Yet, here we are, three decades later, we still have the chemical imbalance being talked of. We still have doctors reducing drug dosages by, say, 50% every two weeks and saying that SSRIs are not drugs of dependence.  I just wonder what your thoughts were on how this kind of mythology about antidepressants has persisted for so long?

Fava: No, it’s not surprising. In the 90s, the pharmaceutical companies were planning to extend the use of antidepressants to anxiety disorders, which in most cases, is an unfortunate practice, as I write in the book.  For doing this, they had to sweep away any reference to dependence, tolerance problems and the basic assumption was the fact that you shouldn’t be too abrupt, too quick in discontinuing antidepressants, but if you go slowly, no problem is going to arise.

Of course, any practicing clinician knew that this was not true that you could have patients with a minimal decrease in dosage presenting with symptoms. The problem, you see, and you captured a very complicated issue at the beginning of the interview, is that not all patients develop withdrawal symptoms. This creates some misunderstanding and this is a very sad story in academic psychiatry and psychopharmacology. Most of the researchers follow the switch into discontinuation syndrome and as I said before, until 2015, when Guy Chouinard, one of the most important psychopharmacologists today and our group came out to recommend that discontinuation problems are no longer acceptable in terms of terminology. We should speak of antidepressant withdrawal as we speak of withdrawal with benzodiazepines, with antipsychotics, and with any other psychotropic drugs.

So, let’s say that this is going on in terms of research and the journals but meanwhile, the spectacular achievements of propaganda stayed. No one has been knocking on the door of the primary care physicians to say, “Look, our view of this issue has changed,” and most of the clinicians are simply unaware of what has been going on in recent years.  This is why I wrote this book, we tried to write something which may give the clinician and patients some perspective, even though it’s a very technical book, as you might have seen.

Moore: The book clearly delineates, I think, the clinician or patient-centered view of how difficult withdrawal might be compared to perhaps the more sanitized version that you read in academic journals, which typically says ‘it’s two weeks, it’s mild, it’s transient’, and ‘if it persists longer than that, it’s almost certainly relapse, not withdrawal’.  So, I think the book does a fantastic job of splitting apart the mythology and looking at the reality.

Fava: Thank for you raising this. Not only are these discontinuation syndromes and this means that you are going too fast, and you have to slow down, but if there is withdrawal, you should think of relapse and continue the medication again. From a commercial viewpoint, this is perfect. This means that you can have these people taking antidepressant drugs forever.

Moore: Absolutely.  It’s a market which populates itself almost, doesn’t it?

Fava: Yes.

Moore: In the book, you talk about the behavioral toxicity of psychotropic drugs and I wonder if you could help me understand this concept?

Fava: This is a very important concept. We owe this concept to two psychopharmacologists in the Boston area, Alberto DiMascio and Dick Shader. These were living psychopharmacologists who were publishing their papers in the most important journals, and they elaborated this concept which they were able to publish only in a journal called Connecticut Medicine.

If you have people who are regularly publishing the New England Journal of Medicine and then you find this paper in Connecticut Medicine, a journal which is very hard to find, that means that the paper might be seen to try to undermine the pharmaceutical industry.

I’m simply renewing and applying their concept to the field of antidepressant tapering and discontinuation. A medication that is used at the normal, average doses may become toxic to the patient and this toxicity expresses itself with phenomena such as loss of clinical effect, where the patient is doing well on antidepressant and after a while of taking medication regularly, the antidepressant no longer works. If you try to increase the dosage, it may only help for a little while. So, loss of clinical effect and hypomanic episodesthat is the medication is really working too much and brings the patient to a state of hypomania or mania which is a symptom of bipolar disorderbut also a paradoxical fact that is that the antidepressant makes you more depressed.

In the book, I discuss the relationship between venlafaxine and apathy. This is an example of a paradoxical effect and resistance, the fact that these patients become resistant either to the same medication, when it’s prescribed again or to another medication. Withdrawal is part of behavioral toxicity and my view is quite different from that of other investigators in the field because as a clinician I know that all these manifestations of behavioral toxicity are related.

What I mean is that it’s likely that you have two or three, or even four of these manifestations together and this means that there is the same mechanism.

Moore: It’s hugely important, that concept, isn’t it, because if you’re a patient and you go to your doctor, you say, I’ve tried this antidepressant and it was working for a time, but then it stopped to work, you might get a label of treatment-resistant and the doctor might blame you as the patient not responding to treatment, where actually, what this might be is a physical drug effect caused by taking the drug itself.  So, you can’t really blame the patient if they haven’t responded.  It’s an effect of the drug, isn’t it, not an effect of the patient’s response to treatment. Is that right?

Fava: Right. It’s because, in today’s medicine, we have banned any iatrogenic thinking. We have been very well-educated by big pharma. So, there is this idea that the patient has to be blamed because they are not taking the medication regularly and really, it’s a very deceptive way of looking at things because the iatrogenic part is totally blind.

If you look at the psychiatric literature or papers that discuss iatrogenic disorders, probably one or two per cent that is the current trend. So, if no one has trained you to look at these issues, it’s quite hard to have a balanced view of the clinical progress.

Moore: I’d like to move on to the part of your book that talks about responding to antidepressant withdrawal. It’s a mine of really helpful information and really quite comprehensive in how it talks about responding to some of the difficulties that people have.
I wonder if we could start by what can we say, if anything, about the rate of tapering that might be helpful for people thinking about coming off antidepressants? As you’ve said, there is such disparity in the advice given out there. Professionals might choose to taper by 50% reduction every two weeks, but online advice might be, say, a 10% reduction per month, which is quite slow and can generate extremely long tapers.
Your clinical experience clearly informed your thinking of writing in the book.  I wondered what approach you typically adopt when you’re helping people?

Fava: The first thing is that psychiatrists neglect something that is common practice in other fields of medicine, dermatology, cardiology, endocrinology, which is a shared procedure.  Psychiatrists have a totally obsolete paternalistic approach. Let me decide what is good for you, but it’s a situation where you have to confront the patient with different possibilities. It’s described in the book, I practice a shared decision making. So the first point is to have the idea that there is no simple solution that applies to all patients.

I’ve criticized having this space in medicine and this approach, it applies to the average patient. Unfortunately, I never see the average patient in my practice.

Moore: They only seem to exist in studies, don’t they, never in the real world. 

Fava: I have no average patient, I see the most difficult cases. So, the point is this, when I have to discuss with a patient what to do, I explain, ‘first of all, we have to embrace a wider approach in terms of behavioral toxicity’ because the longer you keep the patient on a medication, the higher the toxicity that you provoke.  So, I say, the antidepressant which was maybe very good at the beginning has become toxic to you and is creating this problem.

So, we can reduce very slowly, if you wish, but be aware, by doing this, we prolong your exposure to the antidepressant. Or, we can do it in a gradual but faster way, and here comes my position, and I realize that it’s primarily my days of my practice and my experience, which is biased clinical experience no matter how extensive it is. It’s probably one of the most extensive in the world, but it’s biased. So, my bias, which I didn’t have at the beginning, is that it’s very difficult to discontinue an antidepressant, to de-prescribe if you don’t do some additional prescribing. If you don’t use some medications and psychotherapy.

So, when I discuss with a patient, I’ll say that most of the patients, 90% of the patients respond, “Please, get this medication out of my body as soon as you can.”  Then, we continue with that, but a basic problem which is not only in this field but in psychiatry and in medicine today is to believe that there is a procedure we should apply to all patients, and that is clinical practice shows that it’s not possible.

Moore: We live in a society that runs on guidelines. Everybody wants a guideline and yet, this is not a guideline-focused activity. It’s a person-centered activity, isn’t it? 

Fava: Then, behind the patient, there is a personal history, a treatment history, a unique combination of medications. If I have a patient who’s been treated with, I’m thinking of the worst antidepressants, paroxetine, venlafaxine, and maybe he’s also taking triazolam for sleeping, he is different from another patient who has not been taking these medications.  So, it’s very personalized.

Let’s not forget that personalized medicine is not simply genetics but it’s really getting into the person’s personal history.

Moore: Again, I was interested to read that you caution against re-instating an antidepressant if withdrawal symptoms have already occurred. I just wondered why that might exacerbate the problems the person is having?

Fava: This was a suggestion that was made in guidelines and became quite popular. If the patient is experiencing withdrawal, go back to the same medication. Of course, this does not solve anything and it may worsen the state of behavioral toxicity, but again, they want you to be very narrow-minded and just thinking of certain symptoms and not the general course of the disorder.

This idea, to go back to the same medication would not necessarily work again if you have discontinued the medication, it is not based on research evidence. These were simply claims that were made and key opinion leaders supported these claims, and it became quite popular, but there is no evidence whatsoever to support these strategies.

Moore: I guess reinstatement might, at best, dampen down some symptoms, but it still leaves that person with the challenge of getting off at some further point in the future, doesn’t it?

Fava: Yes, and it can certainly be worse because you have prolonged the exposure to the medication. This is a basic principle of toxicology about the substances. So yes, this is a strategy that leads to nowhere.

Moore: Thank you, that’s really helpful. Next, I think as we mentioned before, the book is one of the few I’ve read that gives equal importance to psychopharmacology and psychotherapy, and it would be perhaps nice to talk about your approach to psychotherapy when you’re helping people with dealing with antidepressant withdrawal and discontinuation. 
In the later sections of the book, you talk about three elements of psychological therapy that you employ as part of your staging process. There is explanatory therapy, CBT or cognitive behavioral therapy and well-being therapy.  Perhaps we could touch briefly on each part. 
First, you write about the importance of explanatory therapy at the start of the process of withdrawal. Could you tell us about explanatory therapy, what it is and why it’s important as the first step in the process that you follow?

Fava: Yes. Explanatory therapy is a term and approach which was introduced by a teacher of mine, Robert Kellner, for treating hypochondriasis and bodily preoccupations, and this was introduced many years ago. I adapted this approach to the process of tapering and discontinuation of antidepressants drugs in the sense that it’s extremely important for a patient to understand what is going on. In the book, in the first chapter, I describe the first patient with quite an acute withdrawal reaction and they ask me, “what’s going on here?”  Then I kept on asking myself, ‘what’s going on here?’, because in those days, I’m talking the mid-90s, there was no literature, nothing. So, we were really wandering in the darkness.

So, explanatory therapy means that you have to explain to the patient what’s going on, why you’re doing certain things, why you’re adding a medication. In the book, I’ve tried to put some clinical histories and cases and there are a lot of examples. I also mention something that quite a lot of patients describe, ‘it’s like being in a tunnel, it’s total darkness, you don’t know what’s going on and you don’t see any way out, you don’t understand how you got in’.  So, you need someone who can see you out of the tunnel and tell you, we are here, we are trying to go to another place and do these things. So, to have some sort of direction. This is explanatory therapy.

Cognitive behavioral therapy is, of course, very common but something that a lot of people forget is the fact that psychotherapy is the most biological form of treatment that is available. This is not a statement of mine. Eric Kandel, Nobel Prize winner in medicine for neuroscience, wrote a review on the biological effects of psychotherapy. I’m not questioning the importance of antidepressant drugs that I use in practice but their effects vanish when you stop them. Whereas, the tendency for psychotherapy is for the effects to persist.

Let me give you an example. Someone in their 20s with anxiety disorder and agoraphobia with panic attacks was given an SSRI and the SSRI worked. The panic got better, avoidance improved. What was the problem, again, not in every patient, is that when this young person wanted to discontinue and get rid of this medication, and there are many examples in the book about this, they simply couldn’t do it and it was a nightmare. Let’s assume that this young person is among the lucky people who don’t have withdrawal symptoms. By the way, this is really total neglect, a waste of clinical research in psychiatry, not addressing the biological aspects of withdrawal and not giving us a clue why certain patients develop symptoms and others don’t, but this is a different story.

So, let’s assume that this young patient is not having problems and no withdrawal with tapering and discontinuation, but in 90% of cases according to the literature, when they discontinue the medication, anxiety, agoraphobia and panic will come back again.

So, what you have to do is not simply de-prescribing, which is a term that I hate really because it’s so narrow-minded, but you have to perform an alternative prescribing. In this case, you have to treat with cognitive behavioral methods those anxiety disorders that were present at the beginning.

So, we need to prescribe psychotherapeutic approaches to deal with the basic symptoms.

The third component is called well-being therapy and this is a strategy that I developed over the years for increasing psychological well-being. In the book, I mention the case of a colleague and I wanted to discontinue antidepressants because it was not necessary at all, and she objected.  “I am a weak person.  I cannot survive without antidepressants.” This became another spectacular achievement of propaganda over the years but there are a lot of people, physicians and their patients, who believe that because they are inadequate, weak persons, they can never make it without the drugs.

So you need also some strategies, again, in an individualized process to address those aspects and to bring strong points that we have inside to flourish. So, it’s not de-prescribing, it’s alternative prescribing through psychotherapy in this case.

Moore: Thank you, Giovanni. I really like the focus on psychotherapy in the book because I know from personal experience that coming off of antidepressants can be a physically turbulent time, but it can also be an emotionally very turbulent time.  So, if you take someone’s antidepressant away without giving them a support mechanism via another route and you tackle these issues as they come up, I think it’s quite a difficult place for a person to be. So, I really like the focus on psychotherapy.

Fava: I mention that one of my teachers, Robert Kellner an outstanding clinician, but I should mention another of my teachers.  As a medical student, I had the privilege of working a summer with George Engle in Rochester, New York.  I remember Engle pointing out to me one thing. It was about a patient we saw in a ward and he said, “Giovanni, remember, there is no difference between this orthopedic patient and the psychiatric patient.”  That was the biopsychosocial model in practice. They are both reacting with their body, their soul, their mind to a certain situation, and of course, this is what I carried along and this is why I’ve been trying to pursue both psychopharmacology and psychotherapy because I am an Engle student.

Moore: In addition to psychotherapy, you talk also of utilizing clonazepam, a benzodiazepine, to help mitigate withdrawal symptoms. I wonder what your observation is of using a benzodiazepine in this way and do you taper that once the SSRI withdrawal symptoms have eased or reduced?

Fava: Thank you for addressing this issue. In my practice, at a certain point, I became convinced that it’s tremendously difficult to get rid of antidepressants without any other form of pharmacological support and of course, if you switch to another antidepressant, that may have a behavioral toxicity. You’re making no progress. I’ve been, as I write in the book, very much influenced by one of the most important psychopharmacologists, Guy Chouinard, and we discussed many times these issues. He suggested to me that we needed to associate with the tapering and discontinuation for some time an anti-epileptic drug, and I chose clonazepam for various reasons.

First, because it has very good anti-anxiety properties. See, Chouinard did a first study on alprazolam, but he concluded that this medication was giving a lot of dependence. It was not good and then he introduced clonazepam as an alternative.  Also because I have to deal with a lot of patients with anxiety disorders, I think that clonazepam may help by both decreasing, not eliminating, the new withdrawal symptoms that appear while also decreasing anxiety symptoms.

So, when we talk about benzodiazepines, we make another common mistake. We talk about a medication class as if they were all the same. They are not, and we have clinical evidence that there are benzodiazepinessuch as I mentioned alprazolam, I could mention triazolam, I could mention lorazepam—that have very strong addictive properties, and then there are benzodiazepines that have very low dependence liability, such as clonazepam.

In my personal experience, again, we’re talking about hundreds of cases treated with clonazepam, of course with gradual tapering at the beginning, but I never, ever had problems.

So, one should be very cautious about benzodiazepines altogether, antidepressants altogether. So, we’re talking about different medications that belong to the same class.

Moore: For people listening, who haven’t had access to the literature, there are many messages out there to try to make sense of. On the one hand, we’re often told in simple terms that SSRI and SNRI drugs are safe and effective and can be taken indefinitely or for long periods with no problems.  On the other hand, when in-depth investigation is done such as that in your book, the problems with the drugs are manifest and can be very serious for some.  Everything up to manic episodes, akathisia, increased risk of suicidal thinking. So, how can we, as consumers, reconcile these two views of psychotropics?

Fava: For a consumer, it’s not easy but let me point to a similarity and let me take the example of antibiotics. Of course, antibiotics are life-saving medications and one of the most important achievements of medicine, but they should be taken when there are precise indications and generally, not extended over a week or 10 days. You see the conclusion of my book is really something that goes against all current indications which is that antidepressant drugs are life-saving, important medications if you meet certain criteria for severity and persistence of depression.

So, limited to the most severe cases for the shortest possible time, which in cases of antidepressant drugs is no less than six months altogether, in realistic terms, and when you taper the medication you have to introduce something else.

Another position that I take then, not a very popular position, they should not be used for anxiety disorders, unless of course the only time where I may use them is when you have anxiety associated with severe depressive disorder, but if I have to use a medication anxiety disorder, I use benzodiazepines. They are far better, not all of them, as we discussed.  So, it’s something that we should acknowledge about all medication.

In my journal, a few years ago, we published a review on the long-term side effects of SSRIs and SNRIs and just devastating ways that these are medications that are not good for long-term use.

Moore: That goes back to something you mentioned earlier, which is that the way that these drugs are sold in terms of how they should be used. If people believe that they’ve got a chemical imbalance or a broken brain, or they are missing something that the antidepressants provide, then that signals that they need them long-term, doesn’t it, but if we sell them or give them as if this is a temporary solution to help you over a particularly difficult, problematic time in your life, they might help you over that with some psychotherapy alongside it, but they are not adding anything that you’re deficient in or correcting any brain abnormality.  Those two conceptions are quite different, aren’t they?

Fava: Yes. You’re doing explanatory therapy right now. Yes, this is what we need to exchange and let me add that this book actually reflects a lot of things that I’ve learned from patients and their insights because in this, as George Engle was teaching us, medicine is about interaction. It’s not about technology only. It’s the patient and the physician being part of the same process and this is what I try to do in the book and to see that okay, I may see things better than the person who is in the tunnel, but at the same time, I also have a lot of blind spots. I also have a lot of uncertainties. Things may go one way or the other way and the important thing is to transmit the idea that I’ve got the experience, I’ve got the knowledge to address different things that may happen during the course of the illness.

Moore: You’ve clearly put a great deal of time and effort with colleagues into the research that underpins the book.  So, what are your hopes now for how the book will be received or how it might end up being used by people who go on to prescribe SSRIs or maybe go on to help people withdraw?

Fava: Someone asked me recently, it was of course a joke, but do you think that the pharmaceutical companies are going to support the book, and I said “they might buy all copies to make it disappear”.

I’m aware that when it’s going to be released at the end of the month, I have a lot of people against me and not only those who are in pharmaceutical companies but the book expresses some views that are not shared by a lot of colleagues. When in ’94, I wrote an editorial, do antidepressants and antianxiety medications increase chronicity in mood anxiety disorders, of course, I knew I was going to have a lot of problems. When in the journal, we published the first paper on suicidal ideation and antidepressants analysis, I knew I was going to have a lot of problems, but at the same time, and when we published the systematic review on the SSRI and the editorial by Chouinard on the criteria, we thought well, let’s see what happens and we did not expect that we were going to hit the literature to a point that the term discontinuation syndrome is almost no longer used.

So, what I hope is the book and more than the book, the ideas, the experiences, the messages, what the patients tell through me in the book, may get widespread distribution and people start thinking about a lot of issues. I’d like to mention something funny. I was told that a physician who has a very high position in the pharmaceutical industry and certainly, an absolutely brilliant pharmacologist, said about me “If Giovanni Fava’s book about psychotherapy is out, I’ll be the first to come to listen to him. His insights, his self-therapy is absolutely fascinating. The problem is that it discusses also psychopharmacology and in a few minutes, it can induce irreversible damages.”

What are these irreversible damages? People start thinking. People start using their clinical judgment. People start wondering what’s going on here. Are we treating the patients the right way or maybe there is something else we can do.

I hope that Mad in America or Surviving Antidepressants or others will be spreading the word, but I am optimistic because I saw that two articles in a small journal were able to use a lot of changes.

Of course, here we are talking about different psychiatry, a different psychiatric model.  So, not something very simple.

Moore: The book calls for a revolution in our way of thinking, assessing and treating mood and anxiety disorders and you call for a different psychiatry.  Do you think that’s actually possible without somehow fundamentally rethinking the relationship between psychiatry as a profession and the pharmaceutical manufacturers?

Giovanni Fava: Yes, I call revolution because it needs some drastic changes in a way of looking at things. We need a different type of assessment, but the DSM, this diagnostic statistical manual that everyone uses, if we think about it, it’s for patients who no longer exist because the DSM is for patients who are drug-free.

In my practice, 95% of the new patients I see are already taking psychotropic drugs and these medications are changing the picture. The DSM does not consider this. So, it’s totally outdated, it’s a totally different approach to the assessment of the patient and its treatment, but of course, as any revolutionary approach, I know that I am going to have a rough time, but at the same time, it’s really more and more people may start thinking, reasoning and so on. So, let’s say I am reasonably optimistic that in the long run, don’t ask me how long, certain of these ideas will come true.

Let me close with something that impressed me so much. This is a message for the patients, for the people who are being left alone by official medicine and psychiatry because when you disregard major psychiatric, medical symptomatology, you’re really deserting all these people. So many times I’ve been asked this question. Shall I be back to the way I was? My answer is very simple. I hope not, this would be a disaster, you never go back.

This is the basic idea, and we always think of one of the most brilliant neuroscientists, Bruce McEwan at Rockefeller University is known for his landmark studies on neurons, but he was also a big supporter of social neuroscience. The point is that recovery is a one-way street.  You never go back to the situation. It’s not that because you taper very slowly and you go back to the point where you were before taking the drug. That’s no longer possible. You can only go forward. As one patient shared with me recently, “It has been hell, but at the same time, I understood so many things. I’ve grown so much that I think that there was also some good part. I am different.” So, the message is to go forward, to look at the future, but you need to build, you need to prescribe something different and not simply de-prescribe.

Thank you for your questions and I hope that the book will bring some helpful debate.

Moore: Giovanni, thank you. I am so grateful to you and your colleagues for all the effort that went into the book. It is very detailed, it is very technical, but everything is described very clearly with very strong examples.
In terms of how this book might be used by people like me, by consumers, it’s possible to read your book and become confident enough to start to have discussions with your doctors that might allow you to challenge some of their thinking, but from a perspective of someone that’s read some really good quality research. So, that’s where I see value for someone like me that it equips me with the kind of language and the kind of examples, and the kind of research that I need to go and say to a doctor, maybe an antidepressant isn’t the right thing for me. Maybe this would be a better approach for me.  Or, maybe we should approach withdrawal this way.
I thank you so much for writing the book and for all the effort that went into it. 

Fava: Thank you for this interview.


  1. James

    This was a very educational and thought provoking interview, AND I (as an anti-psychiatry activist) have much respect for Giovanni Fava as a doctor doing such serious and important work helping people recover from iatrogenic damage done by psychiatry and their Medical Model of so-called “treatment.” And Dr. Fava’s book sounds like an important book for many reasons, including its exposure of psychiatry’s current crimes prescribing harmful drugs and “gaslighting” its victims.

    I was really pleased to read the analysis of anti-depressant drug toxicity after a period of time on the drugs, and the cascade of negative consequences that can follow these prescriptions.

    Important questions, concerns and comments about the interview:

    1) The assessment of the role of benzodiazepines in treating anxiety and anti-depressant withdrawal was seriously lacking in some important analysis and overall warnings about dependency issues.

    2) The interview left the impression that (as opposed to other benzos) clonazapem – klonopin was both safe and effective. While I am not totally opposed to ever using benzos in such cases (I know Dr. Shipko also advocates their use) I DO NOT believe it is helpful to leave the impression that clonazapem is without serious risks. We know that there have been millions of people who have suffered from klonopin dependency – just ask Stevie Nicks.

    3) How long does Dr.Fava advocate the use of clonazepam? AND then, how soon, and for how long does he recommend for a period of withdrawal?

    4) Dr. Fava seems to imply that psychiatry could have a prosperous future if it would somehow shift to a more educated psychopharmacology with less use of drugs, combined with psychotherapy.

    5) Under a profit based capitalist system the Medical Model cannot, and WILL NOT, make any fundamental changes in its oppressive “treatment” model. Psychiatry has become far too valuable in maintaining the status quo by reinforcing the belief that human angst and psychological disturbance is genetically based. AND the sedative drugging (and incarceration) of key sections of a potentially rebellious society, helps to stave off future uprisings that could overturn the “powers that be.”

    6) Dissident psychiatrists like Dr. Fava could play a VERY positive role for many decades helping millions of victims get off of toxic psychiatric drugs and exposing their potential dangers.
    AND dissident psychiatrists could also play and important role shaking up and exposing the psychiatric establishment and their collusion with Big Pharma.

    7) But, as a medical specialty (in the long term) psychiatry needs to be abolished. It remains, overall, a very oppressive institution that does far more harm than good. There is no legitimate science to justify its existence as a medical specialty. Some of these doctors will have to shift over to either neurology (a legitimate science of brain functioning) or client centered therapy.


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    • Hi Richard, thank you so much for listening and for your very thoughtful and incisive comments. I agree that it is valuable and helpful to hear from clinicians who have seen and responded to withdrawal problems. It is a world away from the denial and minimisation that seems the norm in academic circles. As to the use of benzos to aid withdrawal problems, being someone whose fingers were burned by antidepressant withdrawal myself, had someone suggested this to me, I would have run a mile. Having said that, I know of people who have been helped by some additional short-term prescribing. I guess it comes down to how much honest information is shared, how long the additional prescribing is for, if they are helped to taper at the end and so on. We didn’t have the luxury of time but the book does delve into these issues in more detail. I can understand completely that some will be alarmed by this thought but I also believe that some might feel helped by some additional support be it pharmacological, therapeutic or both as long as agreement is reached together using shared-decision making and there is no coercion or dishonesty. As to the future, I’m not at all qualified to say what approach or model would best meet our needs and ease suffering without either causing more of it or forcing people into little diagnostic boxes, but I just hope we can change what we do now, as soon as possible. Thanks again.

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    • “iatrogenic damage done by psychiatry and their Medical Model of so-called ‘treatment.'”

      How can you be certain psychiatry and its medical model of treatment caused iatrogenic damage?

      If psychological therapy results in a worsened mental state, is that classified as an iatrogenic illness?

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      • If psychological therapy results in a worsened mental state, then obviously it is responsible for the worsened mental state based on what you’ve already said.

        What do you need to know that psychiatry has harmed someone? A study? When you read a study on the internet, you are not the one who has done it. You have not collected the data or done the analysis. How can you be certain that what’s contained in it is true? Do you personally know the life histories of those people? And how do you know the life histories of all the people who have not been in such studies? Went and talked to them personally? Did detective work? Seen their lives up close?

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  2. Good interview. I was concerned about the suggestion of clonazepam for dealing with SSRI withdrawal symptoms, but I see it’s been addressed by James at least.

    I just also note that the text of the interview has some discrepancies from the words in the audio. I don’t know who transcribed the interview, but there are transcription services like Rev to consider.

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    • Hi Christopher, thank you so much for taking the time to listen to/read the interview. In many of the transcripts of our podcast interviews we make small changes for the sake of clarity. This is because sometimes the written word can’t easily convey the emphasis made by the speaker. I hope that listeners will find that any adjustments made to the text don’t change the substance of the speaker’s point but assist those who choose to read rather than listen. Thanks for the feedback and suggestion of using Rev, I will look into this.

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  3. “Not only are these discontinuation syndromes and this means that you are going too fast, and you have to slow down, but if there is withdrawal, you should think of relapse and continue the medication again.”

    How do you distinguish them?

    Without significant evidence, without double-blind, controlled studies, how can we know what causes what?

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    Prozac comes with a 35-page warning label. It’s hard to imagine BP is trying to withhold concerns about potential dangers of this SSRI.

    More than 20 million prescriptions for antidepressants were written between October and December 2020 (that is 80,000,000 annually)— a 6% increase compared to the same three months in 2019 — according to statistics reported by the NHS Business Services Authority (NHSBSA).

    Overall, the statistics showed that 23% more patients received an antidepressant item in the third quarter of 2020–2021 compared to the same quarter in 2015–2016.

    It is hard for me to understand that anti-depressants do so little good and cause so much harm when 80,000,000 prescriptions are written for them yearly. What am I missing?

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    • Do you actually want to know the answer to that question?

      I would guess that most doctors have not ever read the 35 pages of warnings and could not tell you half of it. My father was almost killed by a doctor prescribing something when he was on blood thinners after a heart attack. He told the guy exactly what he was taking, and the drug warnings included a BOLDFACE warning NOT to prescribe this second drug with blood thinners because DEATH MAY RESULT! Yet the doctor prescribed it anyway, and my father luckily noticed he was getting bruises by simply resting his elbow on the table or pressing his arm with his finger. HE looked the drugs up in the PDR (the “internet drug site” equivalent of the 1960s) and discovered that the doctor had acted incredibly irresponsibly and could very well have killed him. A minor car accident, a fall in the garden, the most minor injury could have resulted in death. I have heard stories and had direct experiences myself over time to reinforce the idea that doctors don’t, and given the volume of new drugs, really CAN’T, know and convey the actual dangers of these drugs. I will NEVER take a drug that I have not personally checked out on more than one source.

      So no, it is not hard AT ALL to imagine doctors either not knowing these things, or not caring to communicate them, or intentionally NOT communicating the possible dangers because they are worried that the patient would decide not to take the drug if they knew the actual risks. I would assume it far more likely than not that the doctors would NOT communicate such things to me, based on personal experience.

      I’ll leave it to others to explain what ACTUALLY happened to them on antidepressants, though of course, you can easily find that out for yourself by searching this site. Sometimes other people have different experiences than you do. Maybe you could generate some interest in listening to them instead of dismissing their experiences as “hard for you to understand.”

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    • Enrico, thank you for your interest in this interview. As you probably know from listening, the main focus of this discussion was withdrawal from and dependence on antidepressants. In the 35-page document you kindly shared, the manufacturer has this to say about dependence…

      Dependence – PROZAC has not been systematically studied, in animals or humans, for its potential for abuse, tolerance, or physical dependence. While the premarketing clinical experience with PROZAC did not reveal any tendency for a withdrawal syndrome or any drug seeking behavior, these observations were not systematic and it is not possible to predict on the basis of this limited experience the extent to which a CNS active drug will be misused, diverted, and/or abused once marketed. Consequently, physicians should carefully evaluate patients for history of drug abuse and follow such patients closely, observing them for signs of misuse or abuse of PROZAC (e.g., development of tolerance, incrementation of dose, drug-seeking behavior).

      And this on withdrawal…

      Discontinuation of Treatment – Patients should be advised to take PROZAC exactly as prescribed, and to continue taking PROZAC as prescribed even after their symptoms improve. Patients should be advised that they should not alter their dosing regimen, or stop taking PROZAC without consulting their physician [see Warnings and Precautions (5.15)]. Patients should be advised to consult with their healthcare provider if their symptoms do not improve with PROZAC.

      It’s pretty clear from this woolly, vague and unhelpful text that the manufacturer is trying to avoid any responsibility for dependence/withdrawal problems whilst simultaneously spectacularly failing to give prescribers anything like the information they need to help patients avoid dependency or withdrawal problems. Surveys undertaken in the U.K. show that around 50% of those taking an antidepressant for more than a few months will experience difficulty getting off due to withdrawal symptoms. So the manufacturer is failing in its duty to warn users of the most likely adverse effect. It is absolutely withholding information which clearly should be provided in the interests of informed consent and it is intentional.

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    • Sadly, you are missing the truth and fact that these drugs, (all psychiatric drugs) cause not only horrific sad effects but brain damage. They can alter the metabolic systems of the body. They can cause significant weight gain and metabolic disorders in some. A few do experience significant weight loss. And the psychiatrist, not only psychiatrists, but general practioners, ob-gyn, internists, etc. hand them out like candy. Additionally, they sometimes get indiscrimately used in nursing homes and other congregate living facilities. Doctors think nothing of prescribing these drugs to children and pregnant women. Yes, you are right that psychotherapy is also dangerous. It is nothing but gaslighting and repeated accusations that the “patient” is sick, defective, needs drugs forever, etc. Psychiatric drugs and psychotherapy are a combustible combination. And, if you need evidence of this, please just read the articles, stories and posts of those who have been nearly irrevocably damaged by these psych drugs and the associated therapies. And the worst part is the lies that get you sucked into this system—like “we will make you feel better” and “we will help with your self-esteem,” and “we have your best interest at heart,” and “we’re here to help” No this is not help. I am not a bitter person, I just want everyone to know the truth and the fact of this dangerous practice that is stealing the lives and productivity of so many in America and the world. Thank you.

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  5. “………but at the same time, it’s really more and more people may start thinking, reasoning and so on.”
    I’m hoping psychiatry does not learn to “reason”, because that IS precisely what they think they have been doing.

    Thanks James for the interview.

    I guess I could pick on a few things, one being that “an orthopedic patient and a psych patient are the same”.
    A teacher saying such a thing might sound “enlightened” to a young gullible student.

    And at the end of the article I’m left with a kind of pressure. You know, you meet a “nice” guy and you shouldn’t say anything “negative” about him because you shall be known as a shit disturber.
    Certainly it’s great that Giovanni has clients who might fare better than if they were with a colleague.
    But I guarantee it will not accomplish in making anything “better” out of the pit that psychiatry lays in. Better is getting rid of all things DSM.

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