To be fair, Jim Phelps is among the more open-minded wing of psychiatry. Pleading not to throw the baby out with the bathwater, which has been a defense of psychiatry for at least 20 years, might be viewed as a request for moderation.
Pies, on the other hand…. And Aftab never did explain what he meant by critical psychiatry having “a Faustian bargain”, presumably with far-right ideologues, which certainly begs more than a few questions.
You might say that the conservative wing of psychiatry has retreated to a near-religious belief in its “medical model” and its employment of invasive treatment, primarily drugs. As this is irrational, they’ll say anything in psychiatry’s defense. Meanwhile, more street drugs are being repackaged as therapeutic psychiatric drugs, moving the field closer and closer to simply being purveyors of psychotropic highs for whatever ails you.
I realize that Dr. Aftab’s field is philosophy of psychiatry, and not clinical training.
However, in general psychiatrists, who almost always do nothing but prescribe drugs, are very weak in understanding the basic pharmacology, interactions, and adverse effects of the drugs they give the public every minute of every day.
No matter how philosophically sophisticated the psychiatrist, this practical barrier to providing responsible patient care cannot be overcome. The specialty is dangerously ignorant of the powerful psychotropics it wields with such abandon. Unfortunately, no amount of “conceptual competence” addresses this. Ultimately, it is irrelevant to patient care, and patients remain endangered by its silence on the underlying rotten paradigm leading to gross deficiencies in clinical training.
I respect Awais Aftab’s efforts. His recent tweets may mirror psychiatry’s cognitive dissonance as well as his own.
While in the past he has agreed publicly with all the points brought up in Moncrieff, et al., 2022, and may well agree in private with every point brought up by Bob Whitaker on MadinAmerica — he readily admits psychiatry needs to do serious soul-searching leading to change — he apparently fears that a disturbed hornet’s nest may make his work of persuading the hornets they need to become honeybees more difficult.
His outrage is that the kerfuffle ensuing from Moncrieff, et al., 2022 puts him, as a reformist centrist, in a difficult position. He wants to help, but as an astute politician, has to side with the dominant narrative to maintain his influence in the dominant culture.
Given the byzantine nature of medicine’s professional organizations, the copy on the APA’s “What is Depression?” page no doubt had to go through numerous approval levels. The page in question was no doubt deliberately constructed to imply that antidepressants lead in achieving a 80%-90% cure. Listing psychotherapy second must have occasioned a great deal of discussion. (Notably, the page does not mention how often untreated natural recovery occurs — a lot.)
I have no idea how the world might have been constructed differently to enable Dr. Aftab in his mission. Truth has a way of coming out, and even centrists have to deal with it. Psychiatry has been caught with its pants down, yet again, for something it should have corrected a couple of decades ago. There are plenty of other time bombs waiting to go off in psychiatry; the rotten places in the scientific literature indicate where. Its centrists may have to get used to the explosions.
Contemporary psychiatry is not a wrong turn, it follows the road laid out by Benjamin Rush, M.D. (1749-1813), the “father of modern psychiatry”. Rush thought “mental illness” was biological, a circulatory problem leading to an inflammation of the brain, and treated it with bloodletting, purging, alternating warm and cold baths, confinement to a “tranquilizing chair”, and a a gyrator board upon which patients were strapped and spun around — he invented the latter two therapies.
For psychiatry, it only took short hops from the trepanation of the Middle Ages to the phrenology of the 19th century (the foundation of neuropsychiatry) to prefrontal leucotomy and then lobotomy (1930s) or, after the electric chair was invented in the late 1880s, from Rush’s “tranquilizing chair” or gyrator to electroconvulsive therapy (ECT) (1930s).
After an early antibiotic, isoniazid, was observed to cause mood elevation in 1951, it was easy for psychiatry to envision invasive treatment of the brain using drugs rather than piercing instruments.
It was the psychoanalytic era that was a departure for psychiatry. Otherwise, psychiatry has been bouncing biological treatments off people for centuries based on bizarre theories with no scientific evidence, and without any effort to understand what experiences might be causing their emotional distress.
It hardly matters what changes are in the DSM-5-TR. Whatever is there will be vastly overdiagnosed and overtreated because few clinicians can actually distinguish the conditions it describes.
I don’t know who thinks “duration of use directly determines” the length of a taper except those ivory-tower experts who get what they know about antidepressant withdrawal from chatting with each other over drinks at conferences rather than observing or talking with patients.
Few “experts” have observed the period required to get people off psychiatric drugs except for the peer support groups, and their populations, who usually find their ways there after failed tapers, need a long time to gradually go off with minimal withdrawal symptoms.
It’s also an inaccurate generalization that the peer support groups force anyone to taper by a set amount. It’s not a monolithic subculture, and most advocate “listening to your body” to guide the rate of a taper. (Drug half-lives make “listening to your body” a bit tricky, as withdrawal symptoms may not emerge until some time after a reduction. This limits the speed of a taper. Many people learn about this the hard way; peer guides add value here with their expertise.)
Unfortunately, our intellectualized, medicalized, psychiatrized culture also has divorced people from attending to their bodily sensations and often people need to learn this all over again, initially being determined to charge their way through going off regardless of consequences. Error messages from their bodies then become unmistakable; this is the confused, unsettled state of many people who join peer support groups.
There are many misconceptions about the peer group subculture being voiced in connection with this article. I invite people to visit peer groups and see what goes on there rather than pulling their hypotheses out of the air. Administrators and moderators of these peer groups have to deal with a lot of difficult personalities even more difficult in distress, too. So walk a mile or two in their shoes….
Agree with the above by Resilient.
It’s unfortunate that you restrict your knowledge, which can be so valuable to the patients themselves.
I have no idea what you mean by “Withdrawal Education” classes. Who holds these?
As I noted above, I would be happy to hand over counseling people who want to go off their psychiatric drugs to someone who can “advise rather instruct” better. Volunteers, please write me at the e-mail address in https://doi.org/10.1177/2045125321991274
James, judging from the comments here and from some of my site members, people are reading your article above to mean if they want to go off their drugs, they might as well make it up as they go along. Moderators in the Facebook groups are getting the same kinds of questions.
This is back to 2000 again, when people didn’t know anything about tapering to go off.
If this worked, I’d be happy to close my site, knowing that people are not being injured by going off their drugs too fast or haphazardly. I wish this were the reality.
I would be very interested to hear how you would counsel someone who wants to go off their psychiatric psychotropics, Bananas. What practical, step-by-step advice would you give? What would their first reduction be? How would they decide on the next reduction? How do they decide when to stop taking the drug altogether?
I am always looking for people who are knowledgeable about how to go off psychiatric drugs with minimal discomfort and disruption to their normal lives, and can communicate clearly and sympathetically to my site members who are often frantic about failed tapers. If you have these abilities, please contact me.
My e-mail address is in my paper “What I have learnt from helping thousands of people to taper off antidepressants and other psychotropic medications” publicly available at https://doi.org/10.1177/2045125321991274 (viewed nearly 30,000 times).
The threshold for neurobiological adaptation to a psychiatric psychotropic is estimated to be about a month. Few would advise slow tapering for exposures shorter than a month. Usually abruptly quitting will be fine, but if this makes people nervous, stepping off by the customary half, half again, and then zero over a week or two makes sense.
It is an unfortunate fact that to avoid debilitating withdrawal symptoms, many people may need to taper psychiatric drugs for longer than the period they were on the drugs, and a minority may find that any amount of dosage reduction, however small, is torturous.
On the other hand, going off faster may result in having to cope with equally debilitating post-discontinuation symptoms for as long or longer that you would have spent tapering.
It is also true that some people who tapered carefully may still have post-discontinuation symptoms (but not likely if they had no withdrawal symptoms while tapering).
I suffered 11 years of protracted withdrawal after going off 10mg paroxetine over a few weeks in October 2004. I would not advise risking it by speedily going off a psychiatric psychotropic.
It cannot be predicted for an individual what kind of tapering will best suit them. You need to balance the risks. The most prudent route is a small reduction as a probe, followed by an observation period to test individual tolerance, then to adjust the method accordingly.
You have to start somewhere, and initial 10% reduction seems to work for most people. (Horowitz & Taylor, 2019 suggests an initial reduction of 25%-50% for SSRIs, as the effect on SERT receptor occupancy is relatively minor. To me, a 50% initial reduction seems too drastic. Drug plasma level decrease faster than SERT occupancy; a plunge in drug plasma level may be where acute withdrawal symptoms come from. If you’re taking a high dose, a 25% initial reduction may be less likely to cause withdrawal symptoms. However, after that, I’d advise smaller reductions, such as 10% exponential.)
Yes, adverse drug effects — what Breggin and Fava call toxicity and behavioral toxicity — tend to diminish as the dosage diminishes. If organs are not endangered, I would take the more cautious slow tapering route.
Having to choose between the uncertainty of tapering and the uncertainty of post-discontinuation syndrome is a difficult dilemma. Patients should not have to figure out how to back out from their unwitting physiological drug dependencies without medical advice, but that is the way it is. People generally have proven to be terrible at understanding the concept of risk. You pay your money and you take your choice.
Gratified to see Peter agrees with this article I wrote in 2012
Taking multiple psych drugs? Which drug to taper first?
“We all want relief — and all of a sudden we’re finding it in psychedelics. From underground parties to Silicon Valley, microdosing and psychedelic therapy have officially hit the mainstream. But what are we overlooking in our rush to feel better? Host iO Tillett Wright and collaborator Lily Kay Ross search for answers in Power Trip, the first season of New York Magazine’s newest podcast, Cover Story. The investigative series uncovers the secrets and exposes the darkest corners of the psychedelic revolution through a twisted, deeply personal tale at the intersection of mind, body, and control. The eight-episode series will be released on Tuesdays starting November 30.”
Great essay, Will. We know that when people are made vulnerable, it’s possible others will emerge to exploit them.
Unfortunately, that is part of human nature, too, and exists among psychotherapist, doctors, and others in the healing arts.
I say the following as someone who has personal experience with psychedelics, none of it bad (though some incapacitating). I believe that an occasional psychedelic trip is far safer than taking a psychiatric drug every day. BUT….
There’s far, far too much hype about psychedelics to cure emotional ills. It’s the hype that should be mistrusted — and those who would administer the drugs and control the patient’s environment (and the patient herself).
As neither psychiatry, even with its boasting of psychopharmacological prowess, or psychotherapists seem to understand the prescription psychotropics that are so abundant now, probability is low that they have any grasp of the upsides and downsides of psychedelics, or have the capacity of selfless caring to guide someone made vulnerable by a drug. (Agape is something not taught in medical school.)
As usual, they (and the public) are just itching to try the next new thing.
As you say, the effects of psychedelics, like other psychotropics, are unpredictable. Psychiatry’s promising a miracle cure from them is highly inappropriate and will come back as disillusionment from many trusting patients. I hope they are not also harmed.
Thanks, as ever, for the vote of confidence, Bananas. You might look at
Framer, A. (2021). What I have learnt from helping thousands of people to taper off antidepressants and other psychotropic medications. Therapeutic Advances in Psychopharmacology. https://doi.org/10.1177/2045125321991274
Hengartner, M. P., Schulthess, L., Sorensen, A., & Framer, A. (2020). Protracted withdrawal syndrome after stopping antidepressants: A descriptive quantitative analysis of consumer narratives from a large internet forum. Therapeutic Advances in Psychopharmacology. https://doi.org/10.1177/2045125320980573
Thank you for this fine article, Samantha.
I would like to clarify this point: “However, these symptoms are often misdiagnosed as a functional disorder or “relapse” back into mental illness.”
I do not know how often antidepressant withdrawal symptoms are misdiagnosed as a functional disorder (Functional Neurological Disorder or FND). I cannot recall any incidences of this on my Web site, which is based in the US, with a majority US membership.
In my opinion, misdiagnosis of withdrawal syndrome as “relapse” by GPs or psychiatrists is far, far more frequent — near total. Most likely, this misdiagnosis is so pervasive, it precludes most people suffering from withdrawal syndrome from advancing to see a neurologist.
It takes a stubborn patient to get to the neurologist specialty level. Of those on my Web site (including myself) who have taken their psychiatric drug withdrawal syndromes to neurologists, the most they get is a shrug rather than a diagnosis, and maybe a referral back to psychiatry.
There is no doubt that in this overdrugged world, training in recognizing iatrogenic syndromes needs to be introduced and even emphasized for neurologists.
To sum up, from what I’ve seen, a misdiagnosis of “relapse” for withdrawal syndrome is a clinical error occurring far more frequently than a diagnosis of FND. FND is a possible but not major withdrawal syndrome misdiagnosis.
Please do open your own private practice! Learn how to deprescribe and taper people off their ridiculous psychiatric drug regimens and you’ll be very successful on your own terms.
They’ll need counseling throughout the process and afterward to find their own narratives after their lifelong inculcation in psychiatric drug culture. You will find this very satisfying, too.
Contact me at SurvivingAntidepressants.org and I’ll put you in touch with a network of like-minded psychiatrists and other prescribers.
The Cochrane review observed the evidence base for antidepressant continuation also is doubtful, as it depends on the same and similar studies thoroughly confounded by withdrawal probably mistaken for relapse.
Not buying any psychiatric theory based on inflammation. Study may be compounded by association of diabetes with poverty or any number of other factors.
I would like to correct a possible misstatement I made (as Adele Framer) in this interview.
I am sure I *contacted* 50 psychiatrists or more in pursuit of treatment for my paroxetine withdrawal syndrome, over at least 4 years. I *visited* perhaps a dozen. None but one (Richard Shelton, author of several articles about antidepressant withdrawal, then at Vanderbilt University in Tennessee, whom I e-mailed) acknowledged that I might be suffering protracted withdrawal syndrome and none could help me.
From my personal experience and informal polling of the psychiatric profession, I concluded that ignorance about withdrawal syndrome ran wide and deep. I also see this reported every day on my Web site, SurvivingAntidepressants.org. I’m pretty sure my impressions are accurate.
Thank you to Amy for an excellent discussion and article.
PS I have also obtained more accurate statistics about visitors to my Web site, SurvivingAntidepressants.org: It receives upwards of 500,000 page views per month.
Thank you for this excellent article, Jennifer.
I would like to correct a possible misstatement I made (as Adele Framer) in the MIA interview article Surviving Antidepressants: An Interview with Adele Framer by Amy Biancolli, to which you link.
I am sure I *contacted* 50 psychiatrists or more in pursuit of treatment for my paroxetine withdrawal syndrome, over at least 4 years. I *visited* perhaps a dozen. None but one (Richard Shelton, author of several articles about antidepressant withdrawal, then at Vanderbilt University in Tennessee) acknowledged that I might be suffering protracted withdrawal syndrome and none could help me.
From my personal experience and informal polling of the psychiatric profession, I concluded that ignorance about withdrawal syndrome ran wide and deep. I also see this reported every day on my Web site, SurvivingAntidepressants.org
However, in terms of public health, as you point out, it is general practitioners who do the majority of the prescribing, putting ever-increasing numbers of people at risk. Although psychiatry assisted public health policymakers in laying out the map for psychiatric treatment by non-psychiatrists decades ago, psychiatry takes no responsibility whatsoever for the quality of that treatment or its outcomes. (This is particularly true in the US; in the UK, clinical care is a little more integrated.)
Consequently, when psychiatrists are confronted with evidence of avoidable harm from psychiatric prescribing, their defense is the necessity for treatment of the very most severe psychiatric conditions (which usual does fall to psychiatrists), with attendant risk of adverse effects, as though the vast negligible-to-moderate condition population served by GPs does not exist. (This defense is disingenuous; the practices of many psychiatrists are filled with working people with good health insurance and ambiguous diagnoses who probably are overtreated, not the most severe cases. Further, minimizing avoidable harm in treatment of the most severe conditions also has a long way to go.)
Though as a medical specialty, psychiatry should lead in calls for minimization of avoidable iatrogenic harm in ALL psychiatric prescribing, it retreats into a hidey-hole of hyperspecialization rather than critique the practices of non-psychiatrist prescribers and, not incidentally, its own members. It has evaded this responsibility for at least 20 years. As Christopher Lane said elsewhere on MIA, a reckoning is coming for psychiatry, as increasing numbers of people, some of them highly influential, suffer that avoidable iatrogenic harm.
Bananas:
“Change will not come if we wait for some other person or some other time. We are the ones we’ve been waiting for. We are the change that we seek.” — Barack Obama
I am honored to be invited to this panel. I am a very reluctant expert. As many know, I’ve given my time away under a pseudonym for more than a decade in providing what I’ve gleaned about psychiatric drug withdrawal based on interacting with thousands of people online and reading hundreds of journal articles. (I only came forward under my real name, as in this interview https://www.madinamerica.com/2020/11/surviving-antidepressants-adele-framer/)
You are correct. I have no formal credentials in the field at all, nor do I pretend to have them. I am what they call a patient expert or ePatient. You could look it up; there’s a body of research about this Internet-driven phenomenon, such as Nelson, R. (2016). Informatics: Empowering ePatients to Drive Health Care Reform. Online Journal of Issues in Nursing, 21(3), 9. https://doi.org/10.3912/OJIN.Vol21No03InfoCol01
As for my now doing public speaking: After more than 15 years begging medical authorities to attend to the issue of psychiatric drug withdrawal syndromes, I finally concluded I needed to come forward publicly myself to move the field along. The number of casualties gets larger all the time. The avoidable clinical error needs to stop. I can’t think of anyone better to state this than patient representatives. We are the change we seek.
I don’t call myself anti-psychiatry. I don’t care what happens to psychiatry. It can go up, down, or sideways for all I care. That psychiatry insists that we all worry about its future is yet another sign of the hubris of the profession.
What I want is injury to patients to stop — the sloppy diagnoses based on bad research, overprescription, disregard of adverse effects, and outright clinical error. Just cleaning up its own avoidable patient harm would revolutionize psychiatry. Eventually, this may reach GPs, the sorceror’s apprentices who actual provide most psychiatric drug treatment in the world, with even less knowledge and fewer patient safeguards.
Psychiatry could disappear tomorrow and there still would be millions of people stuck on the drugs with no clear way to go off. This is a gigantic public health mess of its own making.
“Are antidepressants addictive?” is the wrong question. Addiction is not due to a characteristic of a drug, it is a behavioral pattern of a person.
When ingested regularly, all psychotropics, prescribed or not, technically “addictive” or not, legal or not, will incur neurophysiological adaptation, neurophysiological dependency, neurophysiological tolerance and, when discontinued, may cause neurophysiological withdrawal symptoms. This is the Law of Psychotropics.
“Addiction” is a behavioral pattern that may or may not accompany neurophysiological dependency. This is spelled out in DSM-5, see O’Brien, C. (2011). Addiction and dependence in DSM-V. Addiction (Abingdon, England), 106(5). https://doi.org/10.1111/j.1360-0443.2010.03144.x
Since it’s long been trumpeted that antidepressants and most psychiatric drugs are not “addictive”, doctors have assumed they do not cause significant withdrawal. Nothing could be further from the truth. (One wonders how they have managed to ignore patient complaints of withdrawal symptoms for 25 years.)
The confusion about the meaning of “dependency” and “addiction” pervades all of medicine, psychiatry, and addiction medicine, too, leading to utter cluelessness about tapering and withdrawal syndrome from all psychotropics and truly senseless national drug policies.
With probably 15% of adults in wealthy countries taking antidepressants, plus more taking pain drugs and still others illegal psychotropics (not to mention the huge population of frequent ingesters of alcohol), it’s likely at least 25% of the adult population of wealthy countries are physiologically dependent on one psychotropic or a few. Medicine had better catch on to the Law of Psychotropics, fast.
Thanks for this article and your recent series about the history of antidepressant withdrawal, Chris.
I think one very important factor for the misrepresentation of antidepressant withdrawal syndrome since approximately the mid-1990s is that the pharmaceutical companies and psychiatry saw that the new-generation antidepressants were much better than the old antidepressants — MAOIs and TCAs — with which they had to work before. The new-generation antidepressants had fewer adverse effects *on startup* and dosing was not as tricky. In comparison to MAOIs and TCAs, “tolerabililty” of the newer drugs was much higher.
This made the mass-marketing of antidepressants possible. For its part, psychiatry saw the opportunity to move from a specialty treating a few people to a more central role in medicine treating millions.
This was even though 25%-30% of new-generation antidepressant efficacy study subjects quickly dropped out within a few weeks because of intolerable adverse effects. (This may indicate a substantial population, possibly defined by genetic characteristics, upon whom the drugs were not trialed at all before marketing. These individuals, however, are being prescribed the drugs like everybody else.)
Coincidentally, it’s long been known that 25%-30% of those prescribed antidepressants quit them within a month (Jung et al., 2016, “Times to Discontinue Antidepressants Over 6 Months in Patients with Major Depressive Disorder.”). When this was recognized in the mid-’90s, pharma and psychiatry united in stressing the important of “maintenance” beyond the startup period *despite adverse reactions*. This led to a well-funded effort from pharma to train doctors in techniques to keep patients on the drugs until they “work”, which supposedly takes 6 weeks. This campaign included presentations at psychiatry meetings and articles in psychiatry journals, e.g. Delgado, 2000, “Approaches to the Enhancement of Patient Adherence to Antidepressant Medication Treatment.” (in a pharma-sponsored supplement to the Journal of Clinical Psychiatry).
It’s also long been known that withdrawal risks increase after a month of regular antidepressant ingestion. A successful “maintenance” effort greater than 6 weeks would make withdrawal syndrome inevitable for some large proportion of patients. (We know now that experiencing withdrawal symptoms discourage people from trying to go off.) In 2006, Maurizio Fava (brother of Giovanni Fava; Maurizio went into consulting on drug development for pharma) estimated the rate of withdrawal syndrome for new-generation antidepressants to be 50%, in comparison with ~40% for TCAs. Therefore, the specter of withdrawal syndrome might diminish the antidepressant-based mass-market expectations of both pharma and psychiatry.
With these expections, it was important to both keep people on the drugs until they were hooked and minimize the risk and discomfort of withdrawal syndrome. Psychiatry participated enthusiastically in this. Lilly and then Wyeth, respectively, paid for “expert consensus panels” and hefty supplements in Journal of Clinical Psychiatry in 1997 and 2006:
Schatzberg, A. F., P. Haddad, E. M. Kaplan, M. Lejoyeux, J. F. Rosenbaum, A. H. Young, and J. Zajecka. “Serotonin Reuptake Inhibitor Discontinuation Syndrome: A Hypothetical Definition. Discontinuation Consensus Panel.” The Journal of Clinical Psychiatry 58 Suppl 7 (1997): 5–10.
Schatzberg, Alan F., Pierre Blier, Pedro L. Delgado, Maurizio Fava, Peter M. Haddad, and Richard C. Shelton. “Antidepressant Discontinuation Syndrome: Consensus Panel Recommendations for Clinical Management and Additional Research.” The Journal of Clinical Psychiatry 67 Suppl 4 (2006): 27–30.
It is remarkable that pharma saw it necessary to do this twice, both star-studded supplements communicating the same message: That new-generation antidepressant withdrawal syndrome was mild, transient, self-limiting, and could be expected to last only a couple of weeks and *anything after that was relapse*. Through various avenues, not the least Pharma-sponsored medical training programs and CME, this became the dominant narrative.
Those are 12 leaders of psychiatry who co-authored those 2 papers alone. After the 1997 supplement, Peter Haddad, an expert in adverse effects of psychiatric drugs, published a half-dozen papers about antidepressant withdrawal syndrome in which he took pains to state that there were exceptions to short, mild withdrawal, with some people experiencing severe and prolonged symptoms. In personal correspondence with Richard Shelton, coincidentally at the same time the 2006 supplement was published, Dr. Shelton acknowledged to me that some people do indeed experience severe and prolonged symptoms.
So those are two of the “expert consensus panel” who knew that those JClinPsych supplement articles were not telling the whole story. (On my birthday in July 2006, when I was 2 years into paroxetine withdrawal syndrome, Owen Wolkowitz, a UCSF faculty member and colleague of Schatzberg’s, verbally told me that of course Schatzberg knew about protracted antidepressant withdrawal syndrome, all the leading psychiatrists did.)
So how deliberate was it that psychiatry, a decentralized specialty disavowing defined leadership and highly resistant to enforceable guidelines, denied the larger danger of prolonged antidepressant withdrawal syndrome? Does the complicity of maybe 10 or 50 or 100 psychiatry thought leaders indict the whole profession? Why would an ordinary general psychiatrist, knowing that withdrawal from TCAs, MAOIs, and addictive drugs can be brutal, assume that antidepressant withdrawal syndrome would pass in a few weeks, and any symptoms after that, no matter how bizarre, be “relapse”? What is wrong with this profession?
I still miss Mickey. What a loss for us all.
Very unlikely these ominous correlations regarding melatonin supplementation have any clinical validity. In supplement form, melatonin has a half-life of only a few hours.
As little as 0.33mg melatonin has found to be effective to trigger sleep, especially if taken at night and surroundings are dark. That’s basically what it’s good for, because of the half-life, the effect wears off a few hours later, with natural circadian rhythm ending endogenous melatonin production and ramping up cortisol as dawn approaches. Melatonin is not a sleeping pill.
If use of the supplement is keep to minimally effective doses, adverse effects are probably close to zero.
I like Vice, but in fact, it is more of a tabloid than serious journalism. Shayla Love’s piece was a cut above its usual fare, but even “in depth”, very superficial in regards to the subject, and off-base when talking about the current state of “anti-psychiatry”, missing the substance of the protests of the injured patient movement entirely.
In this, one suspects her primary source was Joe Pierre, UCLA psychiatry professor and Acting Chief of Community Care Systems at the Veterans Administration West Los Angeles Healthcare Center, who is determined to ignore the potential of injury from psychiatric treatment. His position is rather fraught: Though he admits such injury might exist, he claims the way that people make noise about it on social media (primarily Twitter, because that’s where he hangs out) is inappropriate, thus justifying ignoring it.
There are some injured consumers on Twitter who have adopted the tactic of meanly trolling psychiatrists; from this, Dr. Pierre — a scientist of human emotion and behavior who fancies himself an expert on mass delusion — concludes there is a new “anti-psychiatry”, which he likens to anti-vaxxers.
Further, he (and 2 co-authors) claim consumers complaining of injury evidence a psychiatric disorder, an “attempt to find meaning in identity as an injured party”, described in a September 9, 2020 piece published on MedpageToday, “Op-Ed: Why Anti-Psychiatry Now Fails and Harms” (free registration), thus implying no such patient harm actually exists. (None of the 3 co-authors appear to have personally examined any of these consumers prior to coming to this diagnosis, instead referring to their experience of social media.)
Awais Aftab captured the consumer protest July 12, 2020 in an article on his own blog, “Primum non Nocere: A Psychiatrist’s Review of “Medicating Normal””.
Since new injured consumers are being generated by psychiatric treatment every day, we can be confident this consumer movement will not stop, and will continue to express itself on social media and elsewhere. Injured patients are injured patients, no amount of gaslighting from psychiatrists like Joe Pierre and Tyler Black will make them disappear.
Recently, the UK’s Cumberlege review found systemic error in ignoring treatment harm, generalizable across healthcare. An article about it, “Cumberlege review exposes stubborn and dangerous flaws in healthcare” was published August 6, 2020 in the BMJ:
“Perhaps most striking was the testimony from hundreds of patients reporting lack of informed consent for their initial treatment, followed by years of dismissal by clinicians and regulators who did not want to associate life altering symptoms or injured children with their medical interventions. In a press release Cumberlege said that in years of reviews and inquiries she had never encountered anything like the intensity of suffering of these medically injured families. The review panel found that healthcare providers’ dismissive attitude toward patients was underpinned by a reluctance in all parts of the system to collect evidence on potential harms, by a lack of coordination that would allow clinicians and agencies to interpret and act on that information, and by a culture of denial that failed to acknowledge harm and error, impeding learning and safety.
….
These patterns are already familiar to all patients who have been harmed by medical care. What the Cumberlege team has flagged is the stubborn flaw that lies at the heart of the practice of medicine. It is often called “culture.” But this type of embedded attitude seems to go beyond culture, beyond fear of liability, and beyond the profit motive when that exists. It is a patronising and insufficiently curious way of doing business that is often at odds with the realities of helping patients heal and is increasingly out of place in a connected modern world. How to change it is still an unsolved problem. There have been inquiries, reports, and recommendations over the years, but the fundamental issues around power, justice, and compassion are still with us.””
Thank you for this piece. My heart breaks when I think of our loss of David Foster Wallace. I fantasize if he had only known he had Nardil withdrawal syndrome, his brain wasn’t broken, and he might slowly recover over time, he might not have killed himself.
After all those drugs and ECT, I can just imagine how terrible he felt. His nervous system must have been shooting off warning signals constantly.
When grueling symptoms such as akathisia and sleeplessness have already set in, maneuvering is more limited — but we do have people who have recovered from this.
If I, a peer counselor with no formal medical background, can figure it out, a smart doctor could do it. I hope in the not-to-distant future, many will.
Sadly, although huge numbers are being overmedicated with all kinds of drugs, we’re still in the era where adverse drug reactions are considered very rare, with very little clinical training to deal with them. It is a failure in medical practice that so many patients cannot find a doctor with even a particle of understanding about drug adverse effects. They simply do not want to get entangled in this, especially when psychiatric drugs and purported “mental illness” are involved.
Even psychiatrists will shrug at adverse drug effects and mumble something about “but the drugs do so much good!” or some such irrelevancy.
This is perhaps the cut that hurts worse — feeling abandoned by medicine — left out on the ice floe, as it seems.
Hi, Bob. Don’t get me started about the New Yorker article. I, too, expected it to be a tipping point and was very disappointed. As everyone knows, I run the peer support site for tapering off psychiatric drugs, SurvivingAntidepressants.org, which was mentioned a couple of times in the article.
(The following remarks are about how Laura is represented in the story as a character, not the real Laura Delano, who, as Bob points out, has a somewhat different story.)
Reading without benefit of Laura’s backstory (which we know from MIA), I perceive Rachel Aviv’s story as written to be one of psychiatric overdrugging, polypharmacy, and potential misdiagnosis. While numerous psychiatric experts probably associated with Harvard (crux of biological psychiatry) were involved in a long trail of mistreatment, I believe psychiatrists will view Laura’s case as an outlier.
The article failed to convey how common psychiatric misdiagnosis, overdrugging, etc. is. It also glossed over how Laura came off the drugs, and since she had also overdosed and suffered from rhabdomyolysis, psychiatrists will attribute the cursory description of her post-withdrawal symptoms to that. So no game-changing there.
The general reader may be appalled by the description of prescription cascade, polypharmacy, and adverse effects, but not get the very important point: ANYONE can be taking even one psychiatric drug, have trouble coming off, and meet nothing but misdiagnosis and mistreatment of adverse reactions, particularly withdrawal symptoms.
The writer, Rachel Aviv, deliberately misrepresented the topic to me as a long, in-depth article about online peer support for coming off psychiatric drugs. (Beyond my site and Laura’s The Withdrawal Project, which shares much content with my site, there is an extensive peer support network serving hundreds of thousands if not millions of people.)
I perceived a New Yorker article about this could be a game-changer for finally handing off psychiatric drug tapering to physicians, where it belongs. Consequently, I spent many hours corresponding with Aviv, sending her dozens of journal articles, in which she seemed very interested. We went back and forth in congenial discussion about deep underlying controversies in psychiatry. She ended up quoting several of my sources.
Aviv knows the ground, but produced a rather superficial human interest story not much different from other psychiatric drug horror stories published in the New York Times, the Daily Mail, and elsewhere.
I also saw signs of stuff chopped out and awkward transitions. We should all have known better — issues in psychiatry flummoxed Louis Menand, an otherwise excellent writer, in a February, 2010 New Yorker article.
Not a tipping point, not a game-changer, just another one-off human interest story, and attenuated, as you point out, by unnecessary cant about the benefits of the drugs.
For the Web, the article was originally titled the clickbaity The Challenge of Going off Antidepressants — completely inappropriate, as Laura was taking a basket of psychiatric drugs other than antidepressants — if that tells you anything.
After the article was published, I expressed my disappointment to Rachel Aviv, who admitted she is also writing a book.
This whole experience has certainly changed my view of the New Yorker’s credibility.
PS I am now even more determined to transfer responsibility for getting people off psychiatric drugs to the professional medical community and put myself out of business. I am tweeting as @Altostrata with hashtag #Deprescribing.
Curiously, Andrew Solomon’s first episode of “agitated depression” was also misdiagnosed benzodiazepine withdrawal syndrome. Coming from a family fortune from the pharmaceutical industry, he was convinced that he needed serious psychiatric drug treatment. He went through years of antidepressant switches and more adverse reactions — no doubt also misdiagnosed as psychiatric symptoms — and now claims to be in a drug-balanced state.
He’s been preaching about the need to treat depression and the effectiveness of antidepressants ever since. Of course, he did delve into his history and found good reason for psychiatric disorder — very few among us do not have this!
David Foster Wallace experienced years of misdiagnosed Nardil withdrawal syndrome. He experienced round after round of additional psychiatric drugs. He was convinced the drugs were making him worse. Did he kill himself because he thought he had an incurable psychiatric condition?
“….In the late eighties, doctors had prescribed Nardil for Wallace’s depression. Nardil, an antidepressant developed in the late fifties, is a monoamine oxidase inhibitor that is rarely given for long periods of time, because of its side effects, which include low blood pressure and bloating. Nardil can also interact badly with many foods. One day in the spring of 2007, when Wallace was feeling stymied by the Long Thing, he ate at a Persian restaurant in Claremont, and afterward he went home ill. A doctor thought that Nardil might be responsible. For some time, Wallace had come to suspect that the drug was also interfering with his creative evolution. He worried that it muted his emotions, blocking the leap he was trying to make as a writer. He thought that removing the scrim of Nardil might help him see a way out of his creative impasse. Of course, as he recognized even then, maybe the drug wasn’t the problem; maybe he simply was distant, or maybe boredom was too hard a subject. He wondered if the novel was the right medium for what he was trying to say, and worried that he had lost the passion necessary to complete it.
That summer, Wallace went off the antidepressant. He hoped to be as drug free as Don Gately, and as calm. Wallace would finish the Long Thing with a clean brain. He entered this new period of life with what Franzen calls “a sense of optimism and a sense of terrible fear.”….”
D.T. Max later published a biography about Wallace with more detail.
After going off Nardil, Wallace embarked on the kind of hell anyone who has experienced antidepressant withdrawal syndrome will recognize, replete with misdiagnosis, denial, and hypersensitivity to subsequent psychiatric drugs. Since he had a long psychiatric history and prior suicide attempts, his suicide is attributed to his pre-existing mental condition.
In my experience, after reading thousands of reports from patients and collecting more than 6,000 longitudinal case histories of psychiatric drug tapering and withdrawal symptoms on my Web site Surviving Antidepressants http://survivingantidepressants.org/index.php?/forum/3-introductions-and-updates/ , physicians, including psychiatrists, generally do not recognize any psychiatric drug adverse effects and almost invariably misdiagnose withdrawal as relapse or emergence of a new, weird psychiatric disorder calling for high dosages of lots of drugs, which tend to make people worse.
Clearly, there is a longstanding area of physician error in misdiagnosis of psychiatric drug adverse reactions and withdrawal symptoms and consequent patient harm. My belief is they think such adverse reactions are so rare, they’d never see them in their patients. They presume everything is a horse, not a zebra. Too bad we’re losing so many zebras.
One important question is what is meant by “depression” in each clinical trial or study. Does the patient base include people who are in distressing situations, such as bad marriages, bad jobs, or grieving? Such situational depression tends to resolve on its own within months and used to be excluded from the diagnosis of “major depressive disorder” (MDD). Now MDD can be diagnosed in a ham sandwich.
For people with situational depression, a diagnosis of MDD might well convince them they have a permanent disease. Combined with drug side effects, they may well be impaired for a period beyond the normal course of recovery, while not experiencing much relief from the distress — they’re still in a situation that needs resolution. Pills rarely do this.
In other news about psychiatric drug efficacy:
Psychother Psychosom. 2019 Mar 20:1-9. doi: 10.1159/000496734. [Epub ahead of print]
Withdrawal Confounding in Randomized Controlled Trials of Antipsychotic, Antidepressant, and Stimulant Drugs, 2000-2017.
BACKGROUND:
Results of relapse prevention randomized controlled trials (RCTs) which discontinue psychotropic drug treatment from some participants may be confounded by drug withdrawal symptoms. We test for the confound by calculating whether ≥50% of the difference in relapse risk between drug-discontinued and drug-maintained groups is present at discontinuation time points (DCTs) with “short” and “long” assumptions regarding onset and duration of withdrawal symptoms.
METHODS:
In eligible RCTs of antidepressants, antipsychotics, and stimulants from 2000 to 2017 (n = 30) selected from a systematic review, differences in relapse risk were examined by arithmetic and graphical comparison of mean behavioral scores or survival plots.
RESULTS:
Only 14 studies (46.6%) with 15 analyses of relapse risk provided sufficient data. Under short and long DCTs, 9 of 13 (69.2%) and 7 of 9 (77.8%) interpretable analyses, respectively, suggested a withdrawal confound. The proportion of endpoint placebo-maintenance group difference present by the DCT averaged 69.1% (range, 58.7-148.0%, n = 13) for short DCT assumptions, and 79.0% (range, 51.5-183.3%, n = 9) under long DCTs. One study (3.33%) controlled for withdraw al effects, and 1 yielded inconclusive results.
CONCLUSIONS:
These results support suggestions that withdrawal symptoms confound the results of relapse prevention RCTs. Accounting for such symptoms in RCTs is an ethical, scientific, and clinical imperative. Justifications for relapse prevention RCTs employing a discontinuation procedure require more scrutiny.
Given the razor-thin margins for significance in findings for psychiatric drug efficacy, the confounding of withdrawal symptoms for relapse may well tip all of these studies into findings of no significant efficacy for each drug.
This book is the most helpful guide I’ve found for tapering psychiatric drugs.
If you have read Dr. Glenmullen’s The Antidepressant Solution (or, in the UK, Coming Off Antidepressants) and would like to suggest updates for a revision, please contact me at https://www.SurvivingAntidepressants.org/ (scroll down to bottom of page, click on Contact Us). Thank you.
Dr. Corrigan, please supply a full statement of your conflicts of interest regarding Alternative to Meds Center.
Did ATMC commission you to do this study? Thank you.
Hello, Catalyzt. I miss Mickey terribly, though the others…..
I do think things have changed a little, physicians in general have gotten a little more objective about the new generation of drugs and are not as quick to believe they’re wonder drugs.
It is bizarre that a spotlight on a serious adverse effect of a class of drugs is cast as a war on the drugs themselves.
The assumption that antidepressant withdrawal symptoms generally are mild, transitory, and last only a few weeks was promulgated in a pair of supplements to the Journal of Clinical Psychiatry in 1997 and 2006 arising from “expert” symposia sponsored by pharmaceutical manufacturers Lilly and Wyeth, respectively, and led by the notorious Dr. Alan Schatzberg.
The conclusions of the “consensus panel” were based only on the opinions of the participants. There was no data or real evidence involved. No citations were given for the statements about the severity of withdrawal syndrome.
These papers are buried in the citations of nearly all other medical literature about antidepressant withdrawal syndrome, with the erroneous assumptions circulated over and over until they calcified throughout psychiatry into “evidence.”
To his credit, one of the experts from Schatzberg’s “consensus panel,” the UK’s Dr. Peter Haddad, repeatedly has made an effort to remedy this misinformation, authoring many papers about withdrawal syndrome and warning about its misdiagnosis. He has pointed out repeatedly that withdrawal symptoms may be relatively mild only in most cases — there are exceptions, the extent of which is unknown.
As Dr. Haddad stated in 2001: “Discontinuation symptoms have received little systematic study with the result that most of the recommendations made here are based on anecdotal data or expert opinion.” (Haddad, P.M. Drug-Safety (2001) 24: 183. https://doi.org/10.2165/00002018-200124030-00003)
I also had personal correspondence in 2006 with another member of the expert panel, Dr. Richard Shelton, who admitted to me that some individuals can suffer severe and prolonged withdrawal syndrome. (Like Dr. Schatzberg, Dr. Shelton went on to a lucrative career as a pharmaceutical company consultant.)
The “experts” who presented their opinions as evidence informing medicine’s assumptions about psychiatric drug withdrawal are well aware they have not disclosed all the risks. Consequently, physicians everywhere have a false sense of safety about these drugs and are blind to the adverse effects.
However, given the extremely high rate of psychiatric prescription, the expedient gloss over the potential of injury has caused damage to millions of people.
In correspondence years ago with Dr. Haddad, he hinted that gathering case histories would be instructive in this debate. On my Web site, SurvivingAntidepressants.org, I have gathered almost 6,000 case histories of difficult psychiatric drug withdrawal, none of them mild, transient, and lasting a few weeks. You can see them here http://survivingantidepressants.org/index.php?/forum/3-introductions-and-updates/
These case histories also demonstrate the many, many ways people are being misdiagnosed and misprescribed. Taken together, they’re a landscape of the pitfalls in medical knowledge regarding psychiatric drugs and their adverse effects.
Another critic of the Read and Davies paper, Dr. Ronald Pies, recently contended in Psychiatric Times that psychiatrists know how to taper people slowly off drugs and therefore serious withdrawal syndrome as reported by Read and Davies is nearly non-existent.
“In my own practice, I would typically “wean” a patient off a chronically administered antidepressant over a period of 3 to 6 months and sometimes longer. To my knowledge, this period of tapering has rarely, if ever, been used in existing studies of antidepressants or in routine clinical practice.”
Dr. Pies knows very well that “proper psychiatric care” for tapering “managed appropriately” is virtually impossible for patients to find. This tends to confirm Read and Davies are on the right track. We need better ways to taper people off psychiatric drugs.
Of all the RCTs done on antidepressant efficacy and “discontinuation” studies purporting to demonstrate that people relapse when off the drugs, very few — perhaps 3 out of hundreds — contain any protocols for identifying withdrawal symptoms.
For example, the 2006 STAR*D (Sequenced Treatment Alternatives to Relieve Depression) study, which over 7 years switched about 3,000 people from one antidepressant to another in search of the most effective treatment for depression, reported 0 (zero) cases of withdrawal syndrome — a result that defies belief. (It has long been established that one may suffer withdrawal syndrome even when taking a replacement drug.)
(The STAR*D study’s methodology and statistical analysis have been heavily criticized. Yet, many doctors believe it is the gold standard for antidepressant treatment and to this very day are merrily switching people from one drug to another regardless of withdrawal effects.)
All of these studies contain methods to measure “depression.” If a patient, having no other way to report withdrawal symptoms, quite logically conveys the discomfort by marking up the depression questionnaire, the data from these studies would be replete with false positive results supporting the presupposition that what happens after discontinuation is “relapse.”
And this is so.
(Most patients in these trials would not be aware they are experiencing withdrawal symptoms; most likely, they thought they were experiencing some new species of mental disorder.)
That so few studies even differentiated withdrawal syndrome from relapse indicates that assumptions about antidepressant efficacy and the conclusion that people often relapse when off the drugs are incorrect. Most likely, a big chunk — maybe even most — of that “relapse” is withdrawal symptoms.
What most likely happens after discontinuation of a psychiatric drug taken for a month or more is most likely withdrawal rather than “relapse.”
References
Haddad, et al., 2000, Misdiagnosis of antidepressant discontinuation symptoms.
Deshauer, et al., 2008, Selective serotonin reuptake inhibitors for unipolar depression: a systematic review of classic long-term randomized controlled trials.
Baldessarini, et al., 2010, Illness Risk Following Rapid Versus Gradual Discontinuation of Antidepressants.
On SurvivingAntidepressants.org, a peer support site for tapering and withdrawal syndrome that I’ve been running since 2011, I use quite a different model than these outdated medical philosophies.
I myself recovered from Paxil withdrawal syndrome over 11 years. After about 5 years of research on my own, I concluded many of my symptoms were related to autonomic dysfunction. At that time, I happened to receive corroboration from a highly trained psychiatrist who had also come to that conclusion.
Dysautonomia fit my experience like a glove, I’m pretty sure it fits most in cases. I use the model of autonomic dysfunction in counseling people on my Web site every day. It aids in interpreting the many symptoms and the many ways people describe their symptoms on my site. (Our language is not quite up to capturing these events so novel to our poor nervous systems.)
I’ve collected and read thousands of longitudinal case studies of tapering and withdrawal syndrome. Sometimes people develop symptoms that are not dysautonomia; the stress of withdrawal may promote what may have been a subclinical condition that may never have blossomed into a full disorder, such as an autoimmune disease. And who knows what’s going on in the gut. But for the most common symptoms, it’s dysautonomia.
(As medical diagnoses go, dysautonomia is not much of one. It’s autonomic or parasympathetic; it has many manifestations and can morph from one to another; it can arise spontaneously, wax and wane, and disappear. Nobody knows how to treat it, except regular gentle exercise and sleep generally help.)
Understanding withdrawal symptoms as iatrogenic dysautonomia does not require either reductionist or exclusionist membership. One merely needs to be a realist. Withdrawal symptoms are unrelated to any mental illness except those DSM entries for withdrawal syndrome.
(Joanna Moncrieff’s 2005 paper, Rethinking Models of Psychotropic Drug Action, may be of use here.)
While we indubitably all live in a biopsychosocial model, my belief it that difficulties going off psychiatric drugs are mainly due to the biological effects of the drugs. People in all kinds of living situations, from the most supportive to the least, have similar difficulties.
It’s undeniable that psychiatric drugs act upon the nervous system, though for some it’s mysterious exactly how this happens. To say that psychotropics change neurology is tautological.
Therefore, while the drugs are ingested, the nervous system is affected and adapts. This includes autonomic and parasympathetic functions, with downriver effects on hormonal systems. Desirable effects are called therapeutic. Undesirable effects are called dysfunctions.
The very common drug side effect of sexual dysfunction is evidence of autonomic and possibly hormonal alteration. (Antidepressants cause this dysfunction far more reliably than they therapeutically lift mood.)
Similarly, through action on the body’s web of feedback loops, psychiatric drugs may derange insulin regulation and cause weight gain and even diabetes.
The body and its systems adapt, comfortably or not, to the presence of the drugs — incurring physiological dependency. When the drug dosage changes, those systems may again be disrupted.
Most frequently in withdrawal, autonomic symptoms, particularly a grueling sleeplessness, come to the forefront. This second wave of disruption may cause sexual dysfunction when taking the drug did not.
From what I’ve seen, “rebound” symptoms are coincidental, not a type of symptom. Who among us, for example, has not had a spell of deep unhappiness? Or the occasional spell of anxiety? This is even more so for those who sought treatment with psychiatric drugs. However, withdrawal syndrome can cause spontaneous waves of profound existential despair or terror in people who never had an inkling of such things.
That is an effect emanating from a dyregulated nervous system, not an emotional trigger. “Rebound” suggests these are the same old emotional symptoms, amplified. They are not, they are biochemically induced by the artificial state of withdrawal. (The content of the symptoms, however, might be the same old content, which no doubt will confuse the psychotherapists reading this.)
I am dubious that, across the board, psychotherapy is the secret sauce for going off psychiatric drugs with minimal autonomic dysregulation. (It’s slow tapering, and even that doesn’t always work.) As so very many people are taking psychiatric drugs for no good reason, not everyone has pre-existing distress to work through, and psychotherapy has little to say about withdrawal symptoms, except to coach people how to ride them out — if the therapist actually understands that’s what’s going on.
On the other hand, who among us wouldn’t like a little extra understanding when going through a trying time?
Oddly, although the Mad in America community has sympathy for all kinds of damage from psychiatric treatment, this conversation again demonstrates that somehow there is a great deal of resistance to the idea some people continue to suffer even when they are off the drugs — despite personal testimony from the sufferers. For example, would anyone state on MIA that people who claim they damaged from ECT did not in fact suffer such damage? Why are those who claim to have post-withdrawal syndrome subjected to suggestions they are perhaps deluded, mistaken, stupid, or merely experiencing some kind of relapse? In a community of psychiatric survivors, why are not those with post-withdrawal syndrome afforded the same respect and compassion as other psychiatric survivors? Why are they subjected to attacks on their personal credibility? If you didn’t like the way your doctor dismissed your understanding of yourself and your problems with psychiatric treatment, why are you doing that to other people? When it comes to post-withdrawal syndrome and the testimony of people who are suffering from it, where is the sympathy and compassion and RESPECT for fellow psychiatric survivors? Although unwitting (except for one person), the hypocrisy and meanness here hurts all the same. And it speaks poorly for the MIA community.
John, if you don’t believe what people who are suffering from post-withdrawal syndrome tell you about their condition, who are you going to believe?
Why don’t you dismiss us the way psychiatrists dismiss all their patients’ complaints about adverse drug effects? We’re very used to that.
Anyone who has realized he or she is suffering from post-withdrawal syndrome comes to that despite condemnation from their doctors, their families, their spouses, and callously uninformed comments on the Internet.
In response to Richard D. Lewis, JOHN T SHEA, mjk, researcher, Danny S —
Dr. Shipko is indeed correct in that some people, perhaps the very end of the bell curve, will have difficulty recovering from antidepressant withdrawal for a very long time. (I am one of them.)
Often these people have prior history of going on and off psychiatric drugs or being switched from drug to drug without cross-tapering.
It appears the nervous system is not made of rubber. With repeated jolts, it can be made exceptionally vulnerable to chemical and other stresses.
As Dr. Shipko observes, under these circumstances, application of other psychiatric drugs backfires. (One might speculate that this iatrogenic damage underlies so-called “treatment-resistant depression.”) An injured nervous system requires much more gentle treatment.
From my observation, these statements by Dr. Shipko are absolutely correct:
“…people who stop SSRIs often develop a NEW (my emphasis) onset of severe depression or anxiety months after stopping the drugs.”
“…the problems that sometimes occur when people try to stop an SSRI antidepressant are much more severe than the medical profession acknowledges, and there is NO (my emphasis) ‘antidote’ to these problems.”
Although the medical profession almost invariably mistakes any withdrawal symptoms as relapse, those tardive post-withdrawal symptom patterns (even “tardive dysphoria”) are distinct from relapse or any mental condition found in nature. They are not merely “depression” or “anxiety.”
It’s quite common that people who have no personal experience with withdrawal syndrome cannot imagine its sometimes bizarre neurological manifestations. I can assure you, it feels nothing like a normal state of mental distress.
Dr. Shipko brings up very valid points about the dangers of psychiatric drug withdrawal, which should be factored in to the risk-benefit assessment prior to prescription of any of these drugs but, because of pharma efforts to obscure them, are not.
Although he’s authored a paper on it, he hasn’t even mentioned Post-SSRI Sexual Dysfunction (PSSD), another post-withdrawal condition where the sufferer does not regain sexual sensation or functioning for a very long time, perhaps indefinitely, after stopping the drug.
Like withdrawal syndrome and post-withdrawal dysautonomia, PSSD should be recognized as a risk of psychiatric drugs and incorporated into informed consent PRIOR to prescription.
But that would require medicine to recognize these risks. I hope Dr. Shipko continues to direct his message towards doctors.
Dr. Shipko, thank you for your clarification up above in this thread. That you would continue to assist patients in tapering was not at all clear from your article.
I agree, they need to know that they may not get off the drugs without lengthy recovery afterward. The rest of medicine needs to know this, too.
Thank you very much, Dr. Shipko.
Cast as your findings regarding withdrawal, your article deserves a wider audience, perhaps on the Huffington Post or KevinMD, where it might be read by health professionals.
They are the ones who need greater knowledge of the risks of psychiatric drugs. They need to prescribe them much less often.
As I said up above, by the time patients get your informed consent, they’ve already been exposed to what perhaps might be unacceptable risks.
Dr. Shipko, I’m very disappointed by your approach to this problem.
First, you are offering “informed consent” for people who wish to go off antidepressants. According to your theory, by then, it’s too late for them. This doesn’t help those millions of patients who are caught in the trap at all.
You should be putting your efforts into educating doctors of your findings about the perils of withdrawal.
Second, you dismiss the importance of tapering to protect the nervous system. Clearly, many people can taper off antidepressants and do well afterward, as many, many anecdotes on the Web reveal. We also see people recover from those tardive symptoms to which you refer. It does take time.
As you are an expert in benzo tapering, I am confused as to why you would not apply the same reasoning to antidepressant tapering.
Third, you dismiss the efforts of “citizen scientists” and self-help Web sites supporting tapering, which exist only because of the vacuum of knowledge among doctors.
If these self-help resources did not exist, people who wish to go off the drugs would have no help in tapering, as few doctors even grasp the concept.
Whether you call the symptoms “prolonged withdrawal syndrome” (symptoms being continuous from discontinuation of the drug) or post-withdrawal syndrome or whatever you want to call it, medicine pays little attention to any long-term effects of psychiatric drugs. “Citizen scientists” do. Nit-picking about nomenclature makes no sense. We both know what we’re talking about. The rest of medicine couldn’t care less.
Fourth, the impact of your article is:
– Don’t go on the drugs.
– Don’t go off the drugs.
– If you run into a problem, don’t call me.
Is this really what you want to say?
With your background in neurology as well as psychiatry, you could help people who have experienced long-term post-withdrawal symptoms by focusing on ways to stabilize the autonomic nervous system.
(Tardive dyskinesia may not be the only analogy; see parallels to dyautonomia underlying chronic fatigue syndrome and fibromyalgia explored on the Beyond Meds blog http://beyondmeds.com/2013/07/24/ans-and-interaction/ There’s also traumatic brain injury, which takes a cycle of about 7 years for recovery.)
This is why your experiments with serotonin boosters such as SAM-e and tryptophan went nowhere — you simply tried to replace the antidepressant. How would this stabilize dysautonomia? The problem is downstream of the (most likely desensitized) serotonin receptors.
Just addressing the sleep issues alone would be of tremendous help to those suffering from withdrawal syndromes.
I have a great deal of respect for your concern about withdrawal problems and for what you may have observed in your practice. I fear your frustration and anger on behalf of injured patients has caused you to give up on treatment of post-withdrawal symptoms. There is a crying need for someone of your caliber to delve further into this. I beg you to persevere.
Therefore, anyone who goes cold turkey and is injured, or anyone who tapers too fast and is injured, has only himself or herself to blame.
The psychiatric survivor community — and certainly the medical community — offers no support or comfort to these people. They are on their own.
You go off too fast, you get injured, it’s your own tough luck.
See http://tinyurl.com/3o4k3j5 for what these injuries, which can take many months or years for recovery, are like.
True, many people can haphazardly go off their drugs and not suffer unduly.
However, others try this — skipping doses is a particularly risky way to go off — and hurt themselves terribly, with recovery taking months or years.
Given that no one can predict how any individual might react to a dosage reduction — previous withdrawals are NOT predictive — what is the safest, most compassionate advice for someone who wants to go off psychiatric drugs?
My position is that a conservative, gradual approach across the board minimizes risk for all, including the more sensitive nervous systems.
The stakes are so high, it’s worth being cautious.
Certainly, if withdrawal symptoms appear, updosing slightly is a good strategy. However, a reckless taper should NEVER be tried assuming this will be a fix — because sometimes updosing doesn’t work, the nervous system dysregulation is too great.
I really, really wish the psychiatric survivor community would take this issue seriously. People who have quit their drugs with little difficulty tend to dismiss or even deny the grievous injury suffered by others. Bad advice to do it whatever way you want keeps going around and around.
Think of this as protecting our community. Not every act of unprotected sex with strangers results in HIV infection, but what responsible AIDS activist would suggest using a condom only if you feel like it?
Friends urge friends to reduce risk by being careful. Please help me spread the gospel of gradual tapering.
Good suggestions, Jill. Personally, I believe low omega-3 status, due to nutrient depletion in factory farming. may be a large contributor to whatever distress drives people to consider treatment with psychiatric drugs in the first place.
However, please keep in mind that the greatest danger in withdrawing people from psychiatric drugs is not relapse of depression or whatever, which may be effectively treated with non-drug interventions, but destabilization of the nervous system and consequent hypersensitivities, about which medicine knows absolutely nothing.
Too-fast withdrawal resulting in nervous system destabilization is like Humpty-Dumpty falling off the wall. People suffering this mostly have to let time do the healing — and it can take a lot of time.
Omega-3 (and magnesium) supplementation seems to give many people some relief of withdrawal symptoms. We may surmise the nervous system may have been weakened by dietary deficiencies, but nervous system destabilization surpasses such remedies.
I appreciate your interest in this issue, but to correctly conceptualize the problem, please do not confound relapse with withdrawal syndrome. They are entirely different.
All physicians prescribing psychiatric drugs should be familiar with Adverse Syndromes and Psychiatric Drugs: A Clinical Guide, edited by Peter Haddad, who has widely published about withdrawal syndromes. There are several chapters on this in the book.
Note that patient advocates, along with Peter Breggin, are advocating much slower tapers than the medical sources. We see that decreases of 25% can be much too severe for some people and generally recommend decreases of 10%.
After all, it’s the peer counselors who are bearing this burden, which should be the responsibility of physicians, and listening to patients’ experiences.
Please also note that withdrawal symptoms do NOT always immediately appear after dose reduction. Sometimes it takes several weeks. Therefore, 10% decreases at intervals of about a month would be safest, allowing time to catch withdrawal symptoms before attempting another decrease, which would make the withdrawal symptoms worse.
Decreases are calculated on the last dosage, meaning the absolute amount of decrements gets smaller and smaller, maintaining a constant 10% relationship to the last dose. This creates a smooth but asymptotic curve never reaching zero.
When to quit altogether is based on the withdrawal history. Do not quit unless you have a solid track record of no withdrawal symptoms after a decrease. For most drugs, the jumping-off point will be a fraction of a milligram.
Fractional dosage is facilitated by utilizing liquid formulations, compounded liquids, homemade liquids, counting out beads (Effexor XR, Cymbalta), weighing powders on electronic jeweler’s scales, etc.
Pristiq is a special case in tapering — there is no way to reliably titrate it — and should never be prescribed solely on this basis. It is generating plenty of withdrawal injuries, right up there with Effexor XR, Paxil, and Cymbalta.
Just wanted to point out that folks are again mistaking underlying mental distress, which can re-emerge after drug discontinuation, for withdrawal syndrome.
Withdrawal syndrome is an iatrogenic (treatment-caused) condition. To my knowledge — and I would enthusiastically embrace any effective treatment of withdrawal syndrome — there are no alternative or natural programs that can take the place of individualized tapering schedules to reduce withdrawal symptoms.
Please think of withdrawal syndrome as iatrogenic neurological dysregulation rather than a psychiatric disorder.
On the other hand, many non-drug, alternative, dietary, etc. treatments can be effective to treat mental distress.
Confusing underlying mental distress with withdrawal syndrome gets these discussions off-track. Doctors need to make going off drugs much safer in terms of minimizing withdrawal symptoms. Society also needs to provide alternatives to treat mental distress.
People who have not seen or experienced withdrawal syndrome tend to overlook this distinction, which is extremely important. Some people can even cold-turkey off psychiatric drugs (NOT RECOMMENDED) with no symptoms. This is not true for those who are more sensitive to dosage reductions. (You don’t know if this applies to you until you hurt yourself by going off too fast.)
Withdrawal syndrome is real, it creates additional avoidable injuries in psychiatric treatment, and deserves to be recognized in the psychiatric survivor community rather than meeting a wall of denial.
I am merely a peer expert and someone who is still suffering from a too-fast 3-week taper of Paxil in 2004, but I have poured my knowledge into a hundreds of pages for Web site entirely about tapering off psychiatric drugs, SurvivingAntidepressants.org
To my knowledge, tapering at a rate tailored to the individual’s nervous system is the only way to minimize withdrawal symptoms. Withdrawal symptoms should be minimal. “Brain zaps,” disorientation, jolts of anxiety, and sleeplessness are not trivial and indicate the taper is too fast.
Once the nervous system is destabilized by withdrawal, the only remedy is time, as frequently the person has become hypersensitive to all neuroactive drugs, supplements, and even foods. Very, very gentle interventions might make withdrawal symptoms more bearable. Most people do well with fish oil and magnesium, which tend to reduce anxiety and probably reflects a pervasive dietary deficiency in these important nutrients.
It is a widespread medical falsehood that withdrawal syndrome is invariably mild, self-limiting, and lasts only a few weeks. If you look closely at the sources for this information, you will find pharma sponsorship.
Medicine’s refusal to take this issue seriously has grievously injured many people. There are hundreds of thousands of reports all over the Web of severe withdrawal syndrome lasting many months or years.
There are untold millions who are stuck on their drugs because they suffer withdrawal every time they reduce the dosage and their doctors do not know how to taper them properly.
This is truly an epidemic.
PS Dr. Joseph Glenmullen’s “The Antidepressant Solution” is probably the best text for doctors to learn proper tapering techniques and how to monitor for withdrawal symptoms. It was published in 2006. Isn’t it time for doctors to read it?
Very sensible decision, Sandy. I hope many clinics and doctors decide to spend their scarce dollars elsewhere.
No mind-body split here.
Beautiful piece, Monica. Love the photos. Heal on!
First of all, no self-respecting AIDS activist would say “you decide” when it comes to unprotected sex, except sarcastically.
With HIV/AIDS, an intensive world-wide health education campaign has done a pretty good job of telling people what will happen if “you decide” leads them to unprotected sex.
After many years of horror stories, they have been scared out of their pants and into condoms.
This was not facilitated by AIDS activists being wishy-washy with “sparse or contradictory” information — even when information was sparse and contradictory — or offering a libertarian “you decide,” but AIDS activists uniting and giving an unambiguous message: “It’s dangerous, don’t do it.”
Can you tell me how the general public is being educated about the dangers of cold turkey or too-fast discontinuation of psychiatric medications? Has the worst-case scenario been made explicit? Most doctors will deny it.
If you think people know what’s in store for them with severe withdrawal syndrome, read 10 of these stories http://tinyurl.com/3o4k3j5
Thank you for your support, PC.
Suppose I were an AIDS activist speaking to a crowd of sexually active people. Someone says, “Is it really crucial to use protection every time you have sex with strangers?” Suppose I answered, “Well, a lot of people have unprotected sex and do not get infected. It’s up to you to decide.” Would I be promoting unsafe sex?
I don’t know what Will Hall is saying in his public speaking these days. His post on MIA (linked in my comment above), uncharacteristically muddled, showed a great deal of ambivalence about cold turkey.
Yes, I do believe people who are speaking and writing for audiences who might be considering going off their psychiatric medications should be UNEQUIVOCAL about cold turkey.
I’ve given many examples of how to consider the risk. As I pointed out in HIV transmission, for any one unprotected sexual encounter, the risk is approximately 1 in 200. And yet what gay activist would be suggesting if people feel like having unprotected sex, they should go ahead and do it?
(By the way, in the early days of AIDS, there was quite a bit of resistance to the idea that one should always use protection, with the same kinds of rationalizations. In the general population, there still is.)
We are all horrified by the prescribing of psychiatric medications to pregnant women, yet in truth, the absolute risks to the developing baby are much, much smaller than the risk of damage after cold turkey.
Translated to psychiatric medications, this means Laura might meet 96 people who got away with cold turkey before she meets 4 who didn’t (if they were able to get out, that is).
What this conversation demonstrates is the inability of even intelligent people to grasp the idea of medical risk. It’s not a majority vote.
Laura and others should take this as a caution against making assumptions that their audiences 1) will do any research in the risk of cold turkey; 2) be able to assess such information about risk if they do find it; and 3) make logical decisions about going off psychiatric drugs.
I regret very much pounding on Will and Laura about this, but I believe the stakes are very high. People need to be reminded about how dangerous it can be to go off psychiatric drugs suddenly — they’re inclined to do it anyway. They don’t need additional approval or permission for a risky action.
My position is that people like Laura and Will Hall, who are sometimes in a position to influence large numbers of people in their speaking and writing, should not encourage cold turkey, implicitly or explicitly, because cold turkey is dangerous and creates lasting injuries.
I’d rather people be cautious in going off drugs so they DON’T end up on my Web site.
The warnings about cold turkey are already quite stern. This is what they amount to: DON’T DO IT.
This is one warning from the medical establishment that everyone on MIA should be supporting and yet it’s an uphill battle. Why?
Laura, this is the fourth or fifth or sixth time I’ve heard or read your phrase “There is simply no one right way to come off psychiatric drugs.”
Each time my reaction is the same: You have carefully formulated this phrase not to exclude cold turkey as a way to come off psychiatric drugs. (As I have discussed with you.)
What would it cost you to change this to “Tapering is the safest way to go off psychiatric drugs. Don’t cold turkey if you can possibly help it.”? Why do you deliberately and repeatedly give tacit approval to cold turkey? Is there a cold turkey lobby?
According to the HIV analogy, here’s your logic:
– There’s no one right way to have sex with strangers.
– Some people don’t get HIV when they have unprotected sex with strangers.
– Having unprotected sex with strangers might be perfectly fine, if that’s what you prefer.
What’s missing: Some people do get HIV from unprotected sex with strangers, and HIV is such a serious condition that you will take precautions against contracting it.
Seriously, who wouldn’t prefer having carefree, unprotected sex with strangers? Who wouldn’t prefer cold turkey off psychiatric drugs compared to the work of tapering?
People hardly need permission to cold turkey. They do it all the time. Nothing stops them — they don’t bother to educate themselves (until it’s too late). They hear stories of successful cold turkeys and they think great, I’ll do that too.
Maybe they secretly think if they get hurt, some nice doctor will give them a pill that will fix them right up.
Then, ouch, it doesn’t go so well. But unlike HIV, there is no medical support for withdrawal syndrome and darn little other support. Even in a community such as MIA, a person with withdrawal syndrome will be a pariah, because everyone here wants to believe you can simply go off psychiatric drugs if you want to change your life. Withdrawal syndrome is a reminder that it’s not so simple.
As long as you use “There is simply no one right way to come off psychiatric drugs,” in your speaking and writing, giving tacit approval to cold turkey, we will be working at cross-purposes.
By the way, what I said above was “If you can manage it, there is only one way — that is to taper at a rate your nervous system can tolerate.” By definition, cold turkey is not a tapering method, any more than black is white.
Yes, there are anecdotal reports of successful cold turkey, and there are anecdotal reports of disastrous cold turkey. No individual knows what will happen in advance should he or she take the irrevocable step of quitting suddenly.
Although medicine has been indolent about adverse effects of psychiatric drugs in general and pretty much covered up the potential severity of withdrawal syndrome, its injunction against cold turkey has been consistent and universal. Why?
In the beginning, cold turkey was the way everyone was taken off SSRIs, which were assumed to have no withdrawal issues. When the results of cold turkey surfaced — that would be in the Prozac era — they were so horrific that researchers united in warning against cold turkey. (Another myth: Prozac is “self-tapering.”)
If you read the journal literature about withdrawal syndrome, such as that authored by Peter Haddad, you will see that researchers allude to severe “morbidity” from too-fast discontinuation. However, those cases are unpublished. The evidence has been buried, all that remains is the warning.
Not that what psychiatry researchers think has any weight in this crowd; I’m pointing this out because even psychiatry researchers who would much rather ignore the problem felt compelled to warn against cold turkey, it was that serious.
Now let’s look at the validity of anecdotal information. That is all we have, because medicine got bored with psychiatric drug withdrawal syndromes in the mid-2000s. Unless someone does an epidemiological study, it’s unlikely any hard statistics will ever be produced about the danger of cold turkey.
So you know people who did well, and we all know people who did not. You’ve taken 3 years to recover, I’m in my 8th year of recovery (it’s taken a very bad turn lately). You can look forward to a new life, I’m older and my life has been destroyed.
No one who hasn’t experienced severe withdrawal syndrome understands how painful and debilitating it is. A positive attitude can’t erase the minute-by-minute torture. It comes down to a will to live. Few people can grasp the prospect of suffering with no options.
If you say any which way of coming off might suit, you must also take on the moral burden of explaining what happens when the bet goes bad. Otherwise, you present the benefit without the risk.
(Also, if any way of going off might suit, why even bother collating a directory of practitioners who support tapering? Anyone can improvise their own way of going off and take their chances.)
This discussion, which has played out several times on MadinAmerica, makes me discouraged and angry. I run a Web site that is one of the few offering support for people with prolonged withdrawal syndrome. Other sites exclude them. Their situation, which I share, is tragic.
Laura, your formulation “there is no one right way to come off of psychiatric drugs,” which you use in your speaking and writing, unintentionally drives business to my site that, frankly, I don’t want to have.
It is no mystery that most people do okay with going off psychiatric drugs. There’s the famous “2 weeks of mild symptoms” — right up there with “the check’s in the mail” as one of the great lies — that most people quitting SSRIs are supposed to experience.
But some hurt themselves very, very badly by going off too quickly. Perhaps Russian roulette is too romantic a metaphor. A better one might be having sex with strangers. Not every incident results in HIV infection; the risk is estimated at about 1 in 200 encounters.
That’s right — that’s what a huge worldwide public education campaign has been about, a campaign that’s changed the sexual behavior of millions of people, some of whom were quite resistant to that change.
Why, if the risk is only 1 in 200, are people urged to always use condoms? It’s because the outcome of a bad bet is so drastic. Taking precautions is important not because of frequency of infection but magnitude of damage.
I have absolutely no doubt that severe withdrawal following cold turkey occurs much more frequently than 1 in 200. Of the pregnant women I mentioned above, 30% reported “unbearable” symptoms and 12% ended up in the hospital. (What do you think happened to them there? If they were really, really lucky, their antidepressants were reinstated. Back to square one.)
That’s why encouraging people to taper to prevent withdrawal syndrome is so important. You only have one nervous system, and it’s not made of rubber.
And that is why I take exception, yet again, to your “each to his or her own” position. You are hiding the risk of withdrawal syndrome to make a rhetorical point: One can be free of psychiatric drugs. I agree with you on that, but I wish you would encourage people to taper rather than include cold turkey as just one of those preference things.
Beautiful writing, thank you, Laura.
As you know, when I likened cold turkey to Russian roulette, what I was saying was you could hurt yourself very badly by taking that risk.
Yes, it’s true some people play Russian roulette and win the bet. But others do not.
The successful cold turkey-ers testify about how they got away with it, and good for them. The ones who failed are wandering the Internet — or going from doctor to doctor — begging for a cure.
If you’re unlucky and shoot yourself in the head, you could end up with problems much worse than being poly-drugged.
There is no cure but time for severe withdrawal syndrome.
Every single failed cold turkey who’s come to me for advice and support had every intention of winning the game. Each and every one thought he or she would have, at most, a few weeks of feeling lousy and then be finally free.
For a glimpse of the odds of successful cold turkey, see this study:
J Psychiatry Neurosci 2001;26(1):44–8.
[b]Abrupt discontinuation of psychotropic drugs during pregnancy: fear of teratogenic risk and impact of counseling. [/b]
Einarson A, Selby P, Koren G.
Experiments in cold turkey are considered unethical because cold turkey is so thoroughly regarded as harmful. Therefore, observations need to be based on accidental cold turkey.
In the study, out of 34 women who quit abruptly
• 26 (70%) reported physical and psychological adverse effects
• 11 (30%) reported suicidal ideation “because of ‘unbearable’ symptoms,” and 4 were hospitalized
An additional 3 women “used some form of tapering off. This tapering was unsatisfactory, however, because even these patient suffered from adverse effects.”
“One woman had a therapeutic abortion because she did not feel she could go through the pregnancy feeling so awful….”, another considered it.
Correct — severe withdrawal syndrome caused 2 of 34 pregnant women, who had quit antidepressants to protect the babies they were carrying — to consider terminating their pregnancies.
As before, I respectfully and strongly disagree with your position that there is no one way to come off psychiatric medications. If you can manage it, there is only one way — that is to taper at a rate your nervous system can tolerate.
If you are a person who happened to have been successful at cold turkey, you were lucky. Unless you have developed an ability to predict the future, please do not urge others to take this risk.
(If you still insist cold turkey is a “right,” I invite you to join my site, SurvivingAntidepressants.org, and provide emotional support for the people who are suffering from cold turkey gone wrong.)
I am sorry to take this politically uncorrect position yet again on MadinAmerica.com. I am sorry that the prison of psychiatric treatment isn’t easier to escape. These drugs are pernicious from start to finish. It’s hard to get free. That’s just the way it is, and it does no good to anyone to pretend the reality is otherwise.
Talk about strange bedfellows!
Very, very few studies on relapse after discontinuation (or, in this case, relapse after inconsistent dosing) include protocols to distinguish withdrawal symptoms from relapse.
(In fact, out of dozens of relapse studies, I’ve seen only one that recognized withdrawal symptoms.)
Therefore, all such studies are confounded by withdrawal symptoms mistaken for relapse.
The expectation of relapse after drug discontinuation permeates the entire practice of psychiatry, and may be false, or at least overblown, by this confounding.
Given the very great difficulty psychiatrists have in recognizing any kind of adverse effects, often blaming them on the person’s psychiatric disorder, I suggest any statistics of relapse in these situations be taken with a large dose of salt.
As for rebound psychosis — as I’ve suggested in comments elsewhere, a nervous system destabilized by withdrawal expresses itself in a wide range of symptoms. Even people who never had any hint of psychosis pre-drug, as in people taking antidepressants or benzos, can have “psychotic” symptoms in withdrawal.
If the person is otherwise asymptomatic on medication, and “psychotic” symptoms appear after withdrawal, I suggest this is not evidence that the drug is needed to control such symptoms but that tapering was too fast, precipitating nervous system destabilization. The withdrawal symptoms may match earlier “psychotic” symptoms because of the particular sensitivities of that person’s nervous system.
Another excellent article, thank you, Sandy.
Once someone has been on any of these drugs for longer than a few weeks, withdrawal symptoms should be suspected whenever doses are skipped.
Could you tell me what protocols in those studies were in place to distinguish “relapse” from withdrawal symptoms?
From what I’ve seen, any type of distress is called relapse, and withdrawal symptoms can cause a lot of distress.
This tautology, which is vintage Pies, is as circular as an argument can get. And yet he says “the medicalization narrative is philosophically naive and clinically unhelpful.”
I also see your comments on http://www.psychiatrictimes.com/blog/pies/content/article/10168/2135248 . Here Pies touts (yet again) psychiatry as a scientific “systematic methodology based on evidence,” ignoring (yet again) the extensive, indisputable findings that much of psychiatric “evidence” is pharma propaganda.
As for stigma, he maintains that psychiatric diagnoses are merely innocent words, it’s society that supplies the stigma, thereby making the terms context-free. (As though no physician ever applied a psychiatric diagnosis out of prejudice or ignorance!!)
This type of semantic reductionism is also vintage Pies. Words, e.g. DSM-5 diagnoses, are innocent! Stigma is in the interpretation!
Could someone please let Dr. Pies know words have no meaning without interpretation?
You may enjoy jousting with Dr. Pies, but be forewarned — his articles are a compendium of rhetological fallacies ( http://www.informationisbeautiful.net/visualizations/rhetological-fallacies/ ), as you would expect from someone suffering from anosognosia regarding the profession he’s spent a lifetime defending (as Dr. Nardo’s March 30 comment implies).
And, please, let us not forget the relationship, found in studies, between post-partum depression and the new mother feeling socially isolated and not having assistance at home with the infant.
This is another symptom of nuclear families living apart from the extended family, long-time community ties, and traditional support systems. No wonder new mothers feel overwhelmed.
What prospective mothers might very well need is friends like them. They should be guided into peer support networks as part of their prenatal care.
I disagree with Mr. Pies that psychiatry is not responsible for the status quo. Where are the American Psychiatric Association initiatives on gathering post-marketing data on psychiatric drugs, for example?
However, as Dr. Moffic found, you need to speak sense to this crowd. Posturing and claiming authority doesn’t cut it.
Did Dr. Pies have all comments that were not complimentary about him removed?
I agree, Sandy. Thanks for putting so much effort into a thoughtful consideration of the problem.
Fish oil might be a fad, but it can do something good for some people. When I was suffering the worst of antidepressant withdrawal syndrome and was at the height of hypersensitivity, after I took my fish oil capsules, I could feel its soothing effect.
I’ve been taking 2,000-4,000mg DHA and EPA daily for many years. My good cholesterol is so high, I’ve been exempted from being harassed to take statins for cholesterol control.
I would not be without my fish oil. I’d love to get my omega-3s from food, particularly fish. If they weren’t a mercury hazard and mostly endangered, I’d eat them every day. Unfortunately, it would have to be as sushi — because cooking destroys the omega-3 fatty acids, as you would expect.
As it is, I eat sushi every chance I can get. I wish I could afford more of it.
[[attacking remarks removed]]
No wonder. The author is a psychoanalyst.
“Dr Blum is a psychiatrist and psychoanalyst in private practice in Philadelphia. He is on the faculty of the Psychoanalytic Center of Philadelphia and is Clinical Assistant Professor of Psychiatry at the University of Pennsylvania.”
Even addiction specialists are confused about the distinction between physical dependence and psychological dependence on drugs.
According to the semantic medico-legal distinction between addictive and non-addictive, which sometimes doesn’t make any sense, being addicted to a drug means you have both physical dependency and psychological dependency.
When it comes to benzos, this distinction is particularly unclear. Benzos can be truly addictive. People can become dependent on benzos in either purely physical or physical-psychological ways. They can be innocently taking exactly the prescribed dosages and get physically dependent, or they can be going for more and more of the psychic numbing and become textbook addicted.
Textbook addicted or not, it is the physical dependency that causes withdrawal symptoms.
Doctors and addiction medicine specialists have difficulty distinguishing between the two. All they know is benzos are addictive, if you have trouble going off them, you must be an addict. They think dependency of any type is addiction.
From what I’ve seen, one distinction between people who meet the definition of addicts and those who are victims of medical ignorance about psychiatric drugs causing dependency is that, once they get off the drugs, the non-addicts never want to go anywhere near them again, and quite often develop an aversion to the entire medical profession as well.
Excellent approach, David. The key is educating doctors.
Good point, AA.
At least the show has the value of perhaps educating PCPs and their patients about how sloppy PCPs can be with antidepressants.
I believe the idea that “autism boils down to affected cellular pathways” is a variation on the “diseased brain circuit” theories of psychiatric disorders now in fashion.
Yes, she’s come long way since she prescribed Prozac for me in the 1990s for PMS!
I don’t believe you did, Sandy. That was my little quip about what I think of a this decade’s “chemical imbalance” theory.
This doesn’t seem too strong to me. Try an appeal at HuffPost.
Michael Cornwall hugs them.
I’d like to see Sandy (or anyone) prove the “diseased neurocircuit” theory of psychiatric disorders myself!
Yes, my OB/GYN is much more aware of adverse effects of psychiatric drugs on women than most psychiatrists. She said she’s seen lots of adult withdrawal syndrome and neonatal withdrawal syndrome.
She’s totally anti-psych drug now, a pharma skeptic among the best of them! She loved the copy of Anatomy of an Epidemic I gave her.
Neonatal withdrawal syndrome is well documented. Like adult withdrawal syndrome, it is assumed to last only a few weeks. In neonates, this is when the baby stops continually crying and spasming.
The authors of the above-referenced paper, based on anecdotal patient reports, refer to a “postwithdrawal phase, consisting of tardive receptor supersensitivity disorders.”
We really don’t know what’s going on with neonatal withdrawal syndrome. The baby might stop crying and twitching, but may be suffering the newborn version of depersonalization (for example) for months or years, as adults do.
Let us hope that neonatal neuroplasticity compensates and accelerates recovery from the supersensitivity disorders, and does not devolve into, say, autism.
Allow me to add: Hypersensitivity to various stimuli and neuroactive drugs, supplements, and even foods is a very, very common withdrawal symptom when adults go off antidepressants too precipitously. Who knows what these tiny babies are experiencing?
Excellent points, Hermes. For that reason, I wonder how ofter true “relapse” occurs off the drugs.
Health industry group: Replace psychiatrists with vending machines
Measure to reduce health care costs
1 April 2013 Health Insurance Times (Dubuque, Iowa) A health care industry thinktank, US Health Insurance Consortium on Cost, advocates replacing psychiatrists and other doctors with vending machines to prescribe and dispense antidepressants.
“We believe this will cut the cost of psychiatric services significantly,” Uli Arnowsky, spokesperson for USHICost, said. “Our studies show the diagnosis and prescription process can be automated, with no loss in quality of care. Specialist costs are just not necessary for this type of treatment, and psychiatrists are overworked anyway.”
USHICost’s plan is to make the Psychiatric Diagnostic Screening Questionnaire (PDSQ), based on the new diagnostic manual DSM-5, available online to health plan members. Answers would be captured in a database and analyzed to produce a recommendation for a prescription. A psychiatric nurse reviews the recommendations and authorizes the prescription, which is then attached to the patient’s database record.
Vending machines, in convenient medical center locations and on a secure network, would be stocked with the most common generic antidepressants.
“We prefer the generics,” Arnowsky said. “They’re part of the cost-cutting. Our studies show they’re just as effective as the name-brand drugs.”
According to Arnowsky, to get a prescription filled, a patient would input a health plan ID and a password at a vending machine. The machine would look in the database, dispense the authorized prescription, and charge the copay to a credit card on file in the patient’s health plan record.
“We really like the way this system keeps electronic medical records, too,” Aronowsky said. “It’s a win-win-win for all concerned.”
Patients reporting side effects would be advised to see their doctors, who could then adjust the prescription if needed.
“There’s a lot of trial and error in prescribing antidepressants already,” he said. “This system is no more error-prone than present prescribing practices. In fact, we put fuzzy logic in the system to rotate prescriptions among the antidepressants, because we’ve found doctors prescribe them in an almost random fashion. We built the human element right into the system — it thinks just like a doctor about these drugs.”
He stated that USHICost’s studies had shown diagnosis by PDSQ was at least as accurate as by doctors, including psychiatrists. “This will take a big burden off primary care physicians, too, who are bearing the brunt of prescribing antidepressants,” he noted.
I believe disruption of homeostasis, whatever the mechanism, is the key to how psychiatric drugs “work” (if they can be said to work). Some people interpret the disruption as beneficial, others adverse, and others don’t feel it.
Disruption of nervous system homeostasis often has unintended consequences far from the therapy target, e.g. sexual disfunction.
Once the entire organism accommodates to an artificial hormonal elevation, whether by psychiatric drugs or steroids, a second homeostasis is created that depends on continued application of the drug.
As Hochberg, et al, say in Endocrine Withdrawal Syndromes http://edrv.endojournals.org/content/24/4/523.long#ref-166
“Long-term adaptations to hormones may involve relatively persistent changes in molecular switches, including common intracellular signaling systems, from membrane receptors to transcription factors.”
(The authors believe, erroneously, that rather than throwing another wrench into the works, antidepressants will ease the withdrawal transition. Why can’t they figure out these represent another excessive hormonal therapy?)
Removal of the artificial hormonal elevation by drug withdrawal requires re-adaptation to yet another homeostasis tending toward normal functioning. As medicine is largely willfully ignorant of these iatrogenic effects, how long that might take — or how complete it might be — is a mystery.
This is true in adult and neonatal psychiatric drug withdrawal syndromes. Depending on the discipline, that iatrogenic state of autonomic dysregulation is variously described as post-acute withdrawal syndrome, supersensitivity psychosis, kindling, and HPA axis dysregulation.
What that final post-drug homeostasis might feel like probably varies among individuals. Given the influence of the drugs and the passage of time, it is unlikely that the nervous system reverts to factory settings. You can’t step in the same river twice, especially if it’s been flooded with artificial hormones.
What this argues if, if drug intervention is required, the absolute minimum effective dosage be used to minimize disruption to the original nervous system homeostasis. The usual dosages in psychiatry are more like bludgeons to the nervous system rather than subtle corrections.
Somehow, I left out the citation for the above — that must have seemed very puzzling!
Dan Med Bull. 2011 Sep;58(9):A4303.
Paediatric outcomes following intrauterine exposure to serotonin reuptake inhibitors: a systematic review.
Fenger-Grøn J, Thomsen M, Andersen KS, Nielsen RG.
The use of serotonine reuptake inhibitors (SRIs) is increasing among Danish pregnant women. This systematic review addresses the potential adverse effects on the foetus and child of maternal SRI medication. The literature indicates a slightly increased risk of cardiovascular malformations and persistent pulmonary hypertension of the new-born, while evidence regarding the risk of preterm labour, low birth weight, low Apgar score, prolonged QT interval and miscarriage is less clear. An estimated 20-30% of infants will have neonatal symptoms following intrauterine SRI exposure. The symptoms may be caused by SRI withdrawal, toxicity or their overlap, but symptom aetiology basically remains controversial. The infants may exhibit neurological, gastrointestinal, autonomic, endocrine or respiratory symptoms. Although the symptoms are self-limited, the families may be seriously affected. In general, studies do not address this important aspect. Evidence concerning long-term effects is surprisingly sparse and many studies have important methodological limitations. However, present evidence does not convincingly indicate detrimental long-term effects. Until sufficient safety studies have been carried out, SRI must be used with caution in pregnancy and every treatment of the pregnant woman should be thoroughly considered.
Please allow me to say again: The assumption that neonatal withdrawal symptoms are “self-limited” is based on very limited evidence. The same assumption pertaining to adults is contradicted by hundreds of thousands of reports on the Web of withdrawal syndrome lasting many months or years.
I am wondering about the dopamine supersensitivity hypothesis.
What we are seeing when people withdraw from SSRIs and SNRIs too precipitously — even when they had no withdrawal symptoms while tapering or for months afterwards — is a recognizable supersensitivity to stress, evidenced by unprecedented symptoms described as anxiety surges, panic attacks, and a harsh sleeplessness over days or weeks.
Anxiety surges in the early morning are a common feature, an exaggeration of the diurnal cortisol peak that normally gets us ready to wake up and start our days.
As SSRIs and SNRIs have only an indirect effect on dopamine, it’s unlikely that dopamine alone is the culprit for these tardive symptoms. Rather, they’re due to a more generalized disruption of autonomic regulatory systems resulting in over-representation of alerting activity.
These psychiatric drug withdrawal symptoms have a lot in common with endocrine withdrawal symptoms, see
“….Interestingly, hormones with completely different physiological effects can produce similar withdrawal syndromes, whereas some of the clinical manifestations that are due to the chronic presence of high hormone levels or withdrawal syndromes are also observed with drugs of abuse. This review postulates that changes of the hypothalamic-pituitary-adrenal (HPA) axis and the central opioid peptide, noradrenergic and dopaminergic systems act as shared features in the pathogenesis of several endocrine withdrawal syndromes…..”
They repeatedly advise slow tapering to avoid such symptoms.
Although the authors are struggling to associate particular symptoms with putative hormonal mechanisms, which I believe is barking up the wrong tree (the right tree being a more generalized autonomic disruption), the overlap of endocrine withdrawal symptoms with what we know of antidepressant withdrawal syndrome is striking (see Figure 2 in the paper http://edrv.endojournals.org/content/24/4/523/F2.large.jpg ).
In terms of autonomic disruption, there may be no real distinction between playing with levels of neurohormones and playing with endocrine hormones.
I suggest that the supersensitivity psychosis seen after even apparently uneventful withdrawal of antipsychotics is parallel to the stress hypersensitivities very frequently seen in SSRI and SNRI post-withdrawal syndromes, but expressed as “psychotic” symptoms reflecting the particular neurological variability of those who came in hearing voices, etc.
As quoted by Bob Whitaker, Harrow and Jobe say: “The discontinuation effect includes the potential of medication-generated buildup, prior to discontinuation, of supersensitive dopamine receptors, or the buildup of excess dopamine receptors, or supersensitive psychosis….” which would suggest some “relapse” is a withdrawal effect.
Those elevations in inflammatory markers seen in the “treatment refractory” (if they exist) may be the result of repeated insult by serial medications.
Has anyone considered not meddling in brain chemistry of these people for a while to see if such markers decrease?
I agree there’s a lot of value in alternative medicine. A true healer is hard to find in any modality.
How excellent that Martin Harrow revisits his own study and elaborates on his interpretation of his own findings!
You bet, some “relapse” is withdrawal syndrome, as Harrow and Jobe say: “The discontinuation effect includes the potential of medication-generated buildup, prior to discontinuation, of supersensitive dopamine receptors, or the buildup of excess dopamine receptors, or supersensitive psychosis….”
Hermes, this is an endless discussion, and off-topic attached to Sandy’s blog post, but I would challenge that antidepressants have any magical effect on depression specifically.
Rather, like amphetamines and other psychoactive substances, they are stimulating or cause other neurological noise (such as emotional anesthesia) that some people report as relieving symptoms of “depression” (whatever that is). Others report effects that they feel as adverse, including — quite commonly — overstimulation.
Antidepressants don’t “work” for depression any more than, say, LSD “works” for depression.
To be fair, Jim Phelps is among the more open-minded wing of psychiatry. Pleading not to throw the baby out with the bathwater, which has been a defense of psychiatry for at least 20 years, might be viewed as a request for moderation.
Pies, on the other hand…. And Aftab never did explain what he meant by critical psychiatry having “a Faustian bargain”, presumably with far-right ideologues, which certainly begs more than a few questions.
You might say that the conservative wing of psychiatry has retreated to a near-religious belief in its “medical model” and its employment of invasive treatment, primarily drugs. As this is irrational, they’ll say anything in psychiatry’s defense. Meanwhile, more street drugs are being repackaged as therapeutic psychiatric drugs, moving the field closer and closer to simply being purveyors of psychotropic highs for whatever ails you.
I realize that Dr. Aftab’s field is philosophy of psychiatry, and not clinical training.
However, in general psychiatrists, who almost always do nothing but prescribe drugs, are very weak in understanding the basic pharmacology, interactions, and adverse effects of the drugs they give the public every minute of every day.
No matter how philosophically sophisticated the psychiatrist, this practical barrier to providing responsible patient care cannot be overcome. The specialty is dangerously ignorant of the powerful psychotropics it wields with such abandon. Unfortunately, no amount of “conceptual competence” addresses this. Ultimately, it is irrelevant to patient care, and patients remain endangered by its silence on the underlying rotten paradigm leading to gross deficiencies in clinical training.
I respect Awais Aftab’s efforts. His recent tweets may mirror psychiatry’s cognitive dissonance as well as his own.
While in the past he has agreed publicly with all the points brought up in Moncrieff, et al., 2022, and may well agree in private with every point brought up by Bob Whitaker on MadinAmerica — he readily admits psychiatry needs to do serious soul-searching leading to change — he apparently fears that a disturbed hornet’s nest may make his work of persuading the hornets they need to become honeybees more difficult.
His outrage is that the kerfuffle ensuing from Moncrieff, et al., 2022 puts him, as a reformist centrist, in a difficult position. He wants to help, but as an astute politician, has to side with the dominant narrative to maintain his influence in the dominant culture.
Given the byzantine nature of medicine’s professional organizations, the copy on the APA’s “What is Depression?” page no doubt had to go through numerous approval levels. The page in question was no doubt deliberately constructed to imply that antidepressants lead in achieving a 80%-90% cure. Listing psychotherapy second must have occasioned a great deal of discussion. (Notably, the page does not mention how often untreated natural recovery occurs — a lot.)
I have no idea how the world might have been constructed differently to enable Dr. Aftab in his mission. Truth has a way of coming out, and even centrists have to deal with it. Psychiatry has been caught with its pants down, yet again, for something it should have corrected a couple of decades ago. There are plenty of other time bombs waiting to go off in psychiatry; the rotten places in the scientific literature indicate where. Its centrists may have to get used to the explosions.
Contemporary psychiatry is not a wrong turn, it follows the road laid out by Benjamin Rush, M.D. (1749-1813), the “father of modern psychiatry”. Rush thought “mental illness” was biological, a circulatory problem leading to an inflammation of the brain, and treated it with bloodletting, purging, alternating warm and cold baths, confinement to a “tranquilizing chair”, and a a gyrator board upon which patients were strapped and spun around — he invented the latter two therapies.
For psychiatry, it only took short hops from the trepanation of the Middle Ages to the phrenology of the 19th century (the foundation of neuropsychiatry) to prefrontal leucotomy and then lobotomy (1930s) or, after the electric chair was invented in the late 1880s, from Rush’s “tranquilizing chair” or gyrator to electroconvulsive therapy (ECT) (1930s).
After an early antibiotic, isoniazid, was observed to cause mood elevation in 1951, it was easy for psychiatry to envision invasive treatment of the brain using drugs rather than piercing instruments.
It was the psychoanalytic era that was a departure for psychiatry. Otherwise, psychiatry has been bouncing biological treatments off people for centuries based on bizarre theories with no scientific evidence, and without any effort to understand what experiences might be causing their emotional distress.
It hardly matters what changes are in the DSM-5-TR. Whatever is there will be vastly overdiagnosed and overtreated because few clinicians can actually distinguish the conditions it describes.
I don’t know who thinks “duration of use directly determines” the length of a taper except those ivory-tower experts who get what they know about antidepressant withdrawal from chatting with each other over drinks at conferences rather than observing or talking with patients.
Few “experts” have observed the period required to get people off psychiatric drugs except for the peer support groups, and their populations, who usually find their ways there after failed tapers, need a long time to gradually go off with minimal withdrawal symptoms.
It’s also an inaccurate generalization that the peer support groups force anyone to taper by a set amount. It’s not a monolithic subculture, and most advocate “listening to your body” to guide the rate of a taper. (Drug half-lives make “listening to your body” a bit tricky, as withdrawal symptoms may not emerge until some time after a reduction. This limits the speed of a taper. Many people learn about this the hard way; peer guides add value here with their expertise.)
Unfortunately, our intellectualized, medicalized, psychiatrized culture also has divorced people from attending to their bodily sensations and often people need to learn this all over again, initially being determined to charge their way through going off regardless of consequences. Error messages from their bodies then become unmistakable; this is the confused, unsettled state of many people who join peer support groups.
There are many misconceptions about the peer group subculture being voiced in connection with this article. I invite people to visit peer groups and see what goes on there rather than pulling their hypotheses out of the air. Administrators and moderators of these peer groups have to deal with a lot of difficult personalities even more difficult in distress, too. So walk a mile or two in their shoes….
Agree with the above by Resilient.
It’s unfortunate that you restrict your knowledge, which can be so valuable to the patients themselves.
I have no idea what you mean by “Withdrawal Education” classes. Who holds these?
As I noted above, I would be happy to hand over counseling people who want to go off their psychiatric drugs to someone who can “advise rather instruct” better. Volunteers, please write me at the e-mail address in https://doi.org/10.1177/2045125321991274
James, judging from the comments here and from some of my site members, people are reading your article above to mean if they want to go off their drugs, they might as well make it up as they go along. Moderators in the Facebook groups are getting the same kinds of questions.
This is back to 2000 again, when people didn’t know anything about tapering to go off.
If this worked, I’d be happy to close my site, knowing that people are not being injured by going off their drugs too fast or haphazardly. I wish this were the reality.
Hello, the correct URL for the journal article is https://www1.racgp.org.au/ajgp/2021/december/antidepressant-prescribing-in-general-practice
It is open-access.
I would be very interested to hear how you would counsel someone who wants to go off their psychiatric psychotropics, Bananas. What practical, step-by-step advice would you give? What would their first reduction be? How would they decide on the next reduction? How do they decide when to stop taking the drug altogether?
I am always looking for people who are knowledgeable about how to go off psychiatric drugs with minimal discomfort and disruption to their normal lives, and can communicate clearly and sympathetically to my site members who are often frantic about failed tapers. If you have these abilities, please contact me.
My e-mail address is in my paper “What I have learnt from helping thousands of people to taper off antidepressants and other psychotropic medications” publicly available at https://doi.org/10.1177/2045125321991274 (viewed nearly 30,000 times).
The threshold for neurobiological adaptation to a psychiatric psychotropic is estimated to be about a month. Few would advise slow tapering for exposures shorter than a month. Usually abruptly quitting will be fine, but if this makes people nervous, stepping off by the customary half, half again, and then zero over a week or two makes sense.
It is an unfortunate fact that to avoid debilitating withdrawal symptoms, many people may need to taper psychiatric drugs for longer than the period they were on the drugs, and a minority may find that any amount of dosage reduction, however small, is torturous.
On the other hand, going off faster may result in having to cope with equally debilitating post-discontinuation symptoms for as long or longer that you would have spent tapering.
It is also true that some people who tapered carefully may still have post-discontinuation symptoms (but not likely if they had no withdrawal symptoms while tapering).
I suffered 11 years of protracted withdrawal after going off 10mg paroxetine over a few weeks in October 2004. I would not advise risking it by speedily going off a psychiatric psychotropic.
It cannot be predicted for an individual what kind of tapering will best suit them. You need to balance the risks. The most prudent route is a small reduction as a probe, followed by an observation period to test individual tolerance, then to adjust the method accordingly.
You have to start somewhere, and initial 10% reduction seems to work for most people. (Horowitz & Taylor, 2019 suggests an initial reduction of 25%-50% for SSRIs, as the effect on SERT receptor occupancy is relatively minor. To me, a 50% initial reduction seems too drastic. Drug plasma level decrease faster than SERT occupancy; a plunge in drug plasma level may be where acute withdrawal symptoms come from. If you’re taking a high dose, a 25% initial reduction may be less likely to cause withdrawal symptoms. However, after that, I’d advise smaller reductions, such as 10% exponential.)
Yes, adverse drug effects — what Breggin and Fava call toxicity and behavioral toxicity — tend to diminish as the dosage diminishes. If organs are not endangered, I would take the more cautious slow tapering route.
Having to choose between the uncertainty of tapering and the uncertainty of post-discontinuation syndrome is a difficult dilemma. Patients should not have to figure out how to back out from their unwitting physiological drug dependencies without medical advice, but that is the way it is. People generally have proven to be terrible at understanding the concept of risk. You pay your money and you take your choice.
Gratified to see Peter agrees with this article I wrote in 2012
Taking multiple psych drugs? Which drug to taper first?
https://www.survivingantidepressants.org/topic/2207-taking-multiple-psych-drugs-which-drug-to-taper-first/
New York Magazine has picked up this topic for a podcast https://www.thecut.com/2021/11/introducing-cover-story-podcast-trailer.html
“We all want relief — and all of a sudden we’re finding it in psychedelics. From underground parties to Silicon Valley, microdosing and psychedelic therapy have officially hit the mainstream. But what are we overlooking in our rush to feel better? Host iO Tillett Wright and collaborator Lily Kay Ross search for answers in Power Trip, the first season of New York Magazine’s newest podcast, Cover Story. The investigative series uncovers the secrets and exposes the darkest corners of the psychedelic revolution through a twisted, deeply personal tale at the intersection of mind, body, and control. The eight-episode series will be released on Tuesdays starting November 30.”
Great essay, Will. We know that when people are made vulnerable, it’s possible others will emerge to exploit them.
Unfortunately, that is part of human nature, too, and exists among psychotherapist, doctors, and others in the healing arts.
I say the following as someone who has personal experience with psychedelics, none of it bad (though some incapacitating). I believe that an occasional psychedelic trip is far safer than taking a psychiatric drug every day. BUT….
There’s far, far too much hype about psychedelics to cure emotional ills. It’s the hype that should be mistrusted — and those who would administer the drugs and control the patient’s environment (and the patient herself).
As neither psychiatry, even with its boasting of psychopharmacological prowess, or psychotherapists seem to understand the prescription psychotropics that are so abundant now, probability is low that they have any grasp of the upsides and downsides of psychedelics, or have the capacity of selfless caring to guide someone made vulnerable by a drug. (Agape is something not taught in medical school.)
As usual, they (and the public) are just itching to try the next new thing.
As you say, the effects of psychedelics, like other psychotropics, are unpredictable. Psychiatry’s promising a miracle cure from them is highly inappropriate and will come back as disillusionment from many trusting patients. I hope they are not also harmed.
Thanks, as ever, for the vote of confidence, Bananas. You might look at
Framer, A. (2021). What I have learnt from helping thousands of people to taper off antidepressants and other psychotropic medications. Therapeutic Advances in Psychopharmacology. https://doi.org/10.1177/2045125321991274
Hengartner, M. P., Schulthess, L., Sorensen, A., & Framer, A. (2020). Protracted withdrawal syndrome after stopping antidepressants: A descriptive quantitative analysis of consumer narratives from a large internet forum. Therapeutic Advances in Psychopharmacology. https://doi.org/10.1177/2045125320980573
Thank you for this fine article, Samantha.
I would like to clarify this point: “However, these symptoms are often misdiagnosed as a functional disorder or “relapse” back into mental illness.”
I do not know how often antidepressant withdrawal symptoms are misdiagnosed as a functional disorder (Functional Neurological Disorder or FND). I cannot recall any incidences of this on my Web site, which is based in the US, with a majority US membership.
In my opinion, misdiagnosis of withdrawal syndrome as “relapse” by GPs or psychiatrists is far, far more frequent — near total. Most likely, this misdiagnosis is so pervasive, it precludes most people suffering from withdrawal syndrome from advancing to see a neurologist.
It takes a stubborn patient to get to the neurologist specialty level. Of those on my Web site (including myself) who have taken their psychiatric drug withdrawal syndromes to neurologists, the most they get is a shrug rather than a diagnosis, and maybe a referral back to psychiatry.
A diagnosis of FND for people with psychiatric drug-induced movement disorders may be misguided but it may be a portal to the best treatment these people can get, since psychiatry is notably blasé about those movement disorders. The danger in not taking drug withdrawal syndromes into account in a FND diagnosis is that psychiatric drugs are one of the treatment options, and when applied to a nervous system already sensitized by drugs, may cause further damage.
There is no doubt that in this overdrugged world, training in recognizing iatrogenic syndromes needs to be introduced and even emphasized for neurologists.
To sum up, from what I’ve seen, a misdiagnosis of “relapse” for withdrawal syndrome is a clinical error occurring far more frequently than a diagnosis of FND. FND is a possible but not major withdrawal syndrome misdiagnosis.
Please do open your own private practice! Learn how to deprescribe and taper people off their ridiculous psychiatric drug regimens and you’ll be very successful on your own terms.
They’ll need counseling throughout the process and afterward to find their own narratives after their lifelong inculcation in psychiatric drug culture. You will find this very satisfying, too.
Contact me at SurvivingAntidepressants.org and I’ll put you in touch with a network of like-minded psychiatrists and other prescribers.
The Cochrane review observed the evidence base for antidepressant continuation also is doubtful, as it depends on the same and similar studies thoroughly confounded by withdrawal probably mistaken for relapse.
Not buying any psychiatric theory based on inflammation. Study may be compounded by association of diabetes with poverty or any number of other factors.
I would like to correct a possible misstatement I made (as Adele Framer) in this interview.
I am sure I *contacted* 50 psychiatrists or more in pursuit of treatment for my paroxetine withdrawal syndrome, over at least 4 years. I *visited* perhaps a dozen. None but one (Richard Shelton, author of several articles about antidepressant withdrawal, then at Vanderbilt University in Tennessee, whom I e-mailed) acknowledged that I might be suffering protracted withdrawal syndrome and none could help me.
From my personal experience and informal polling of the psychiatric profession, I concluded that ignorance about withdrawal syndrome ran wide and deep. I also see this reported every day on my Web site, SurvivingAntidepressants.org. I’m pretty sure my impressions are accurate.
Thank you to Amy for an excellent discussion and article.
PS I have also obtained more accurate statistics about visitors to my Web site, SurvivingAntidepressants.org: It receives upwards of 500,000 page views per month.
Thank you for this excellent article, Jennifer.
I would like to correct a possible misstatement I made (as Adele Framer) in the MIA interview article Surviving Antidepressants: An Interview with Adele Framer by Amy Biancolli, to which you link.
I am sure I *contacted* 50 psychiatrists or more in pursuit of treatment for my paroxetine withdrawal syndrome, over at least 4 years. I *visited* perhaps a dozen. None but one (Richard Shelton, author of several articles about antidepressant withdrawal, then at Vanderbilt University in Tennessee) acknowledged that I might be suffering protracted withdrawal syndrome and none could help me.
From my personal experience and informal polling of the psychiatric profession, I concluded that ignorance about withdrawal syndrome ran wide and deep. I also see this reported every day on my Web site, SurvivingAntidepressants.org
However, in terms of public health, as you point out, it is general practitioners who do the majority of the prescribing, putting ever-increasing numbers of people at risk. Although psychiatry assisted public health policymakers in laying out the map for psychiatric treatment by non-psychiatrists decades ago, psychiatry takes no responsibility whatsoever for the quality of that treatment or its outcomes. (This is particularly true in the US; in the UK, clinical care is a little more integrated.)
Consequently, when psychiatrists are confronted with evidence of avoidable harm from psychiatric prescribing, their defense is the necessity for treatment of the very most severe psychiatric conditions (which usual does fall to psychiatrists), with attendant risk of adverse effects, as though the vast negligible-to-moderate condition population served by GPs does not exist. (This defense is disingenuous; the practices of many psychiatrists are filled with working people with good health insurance and ambiguous diagnoses who probably are overtreated, not the most severe cases. Further, minimizing avoidable harm in treatment of the most severe conditions also has a long way to go.)
Though as a medical specialty, psychiatry should lead in calls for minimization of avoidable iatrogenic harm in ALL psychiatric prescribing, it retreats into a hidey-hole of hyperspecialization rather than critique the practices of non-psychiatrist prescribers and, not incidentally, its own members. It has evaded this responsibility for at least 20 years. As Christopher Lane said elsewhere on MIA, a reckoning is coming for psychiatry, as increasing numbers of people, some of them highly influential, suffer that avoidable iatrogenic harm.
Bananas:
“Change will not come if we wait for some other person or some other time. We are the ones we’ve been waiting for. We are the change that we seek.” — Barack Obama
I am honored to be invited to this panel. I am a very reluctant expert. As many know, I’ve given my time away under a pseudonym for more than a decade in providing what I’ve gleaned about psychiatric drug withdrawal based on interacting with thousands of people online and reading hundreds of journal articles. (I only came forward under my real name, as in this interview https://www.madinamerica.com/2020/11/surviving-antidepressants-adele-framer/)
You are correct. I have no formal credentials in the field at all, nor do I pretend to have them. I am what they call a patient expert or ePatient. You could look it up; there’s a body of research about this Internet-driven phenomenon, such as Nelson, R. (2016). Informatics: Empowering ePatients to Drive Health Care Reform. Online Journal of Issues in Nursing, 21(3), 9. https://doi.org/10.3912/OJIN.Vol21No03InfoCol01
As for my now doing public speaking: After more than 15 years begging medical authorities to attend to the issue of psychiatric drug withdrawal syndromes, I finally concluded I needed to come forward publicly myself to move the field along. The number of casualties gets larger all the time. The avoidable clinical error needs to stop. I can’t think of anyone better to state this than patient representatives. We are the change we seek.
I don’t call myself anti-psychiatry. I don’t care what happens to psychiatry. It can go up, down, or sideways for all I care. That psychiatry insists that we all worry about its future is yet another sign of the hubris of the profession.
What I want is injury to patients to stop — the sloppy diagnoses based on bad research, overprescription, disregard of adverse effects, and outright clinical error. Just cleaning up its own avoidable patient harm would revolutionize psychiatry. Eventually, this may reach GPs, the sorceror’s apprentices who actual provide most psychiatric drug treatment in the world, with even less knowledge and fewer patient safeguards.
Psychiatry could disappear tomorrow and there still would be millions of people stuck on the drugs with no clear way to go off. This is a gigantic public health mess of its own making.
“Are antidepressants addictive?” is the wrong question. Addiction is not due to a characteristic of a drug, it is a behavioral pattern of a person.
When ingested regularly, all psychotropics, prescribed or not, technically “addictive” or not, legal or not, will incur neurophysiological adaptation, neurophysiological dependency, neurophysiological tolerance and, when discontinued, may cause neurophysiological withdrawal symptoms. This is the Law of Psychotropics.
“Addiction” is a behavioral pattern that may or may not accompany neurophysiological dependency. This is spelled out in DSM-5, see O’Brien, C. (2011). Addiction and dependence in DSM-V. Addiction (Abingdon, England), 106(5). https://doi.org/10.1111/j.1360-0443.2010.03144.x
Since it’s long been trumpeted that antidepressants and most psychiatric drugs are not “addictive”, doctors have assumed they do not cause significant withdrawal. Nothing could be further from the truth. (One wonders how they have managed to ignore patient complaints of withdrawal symptoms for 25 years.)
The confusion about the meaning of “dependency” and “addiction” pervades all of medicine, psychiatry, and addiction medicine, too, leading to utter cluelessness about tapering and withdrawal syndrome from all psychotropics and truly senseless national drug policies.
With probably 15% of adults in wealthy countries taking antidepressants, plus more taking pain drugs and still others illegal psychotropics (not to mention the huge population of frequent ingesters of alcohol), it’s likely at least 25% of the adult population of wealthy countries are physiologically dependent on one psychotropic or a few. Medicine had better catch on to the Law of Psychotropics, fast.
Thanks for this article and your recent series about the history of antidepressant withdrawal, Chris.
I think one very important factor for the misrepresentation of antidepressant withdrawal syndrome since approximately the mid-1990s is that the pharmaceutical companies and psychiatry saw that the new-generation antidepressants were much better than the old antidepressants — MAOIs and TCAs — with which they had to work before. The new-generation antidepressants had fewer adverse effects *on startup* and dosing was not as tricky. In comparison to MAOIs and TCAs, “tolerabililty” of the newer drugs was much higher.
This made the mass-marketing of antidepressants possible. For its part, psychiatry saw the opportunity to move from a specialty treating a few people to a more central role in medicine treating millions.
This was even though 25%-30% of new-generation antidepressant efficacy study subjects quickly dropped out within a few weeks because of intolerable adverse effects. (This may indicate a substantial population, possibly defined by genetic characteristics, upon whom the drugs were not trialed at all before marketing. These individuals, however, are being prescribed the drugs like everybody else.)
Coincidentally, it’s long been known that 25%-30% of those prescribed antidepressants quit them within a month (Jung et al., 2016, “Times to Discontinue Antidepressants Over 6 Months in Patients with Major Depressive Disorder.”). When this was recognized in the mid-’90s, pharma and psychiatry united in stressing the important of “maintenance” beyond the startup period *despite adverse reactions*. This led to a well-funded effort from pharma to train doctors in techniques to keep patients on the drugs until they “work”, which supposedly takes 6 weeks. This campaign included presentations at psychiatry meetings and articles in psychiatry journals, e.g. Delgado, 2000, “Approaches to the Enhancement of Patient Adherence to Antidepressant Medication Treatment.” (in a pharma-sponsored supplement to the Journal of Clinical Psychiatry).
It’s also long been known that withdrawal risks increase after a month of regular antidepressant ingestion. A successful “maintenance” effort greater than 6 weeks would make withdrawal syndrome inevitable for some large proportion of patients. (We know now that experiencing withdrawal symptoms discourage people from trying to go off.) In 2006, Maurizio Fava (brother of Giovanni Fava; Maurizio went into consulting on drug development for pharma) estimated the rate of withdrawal syndrome for new-generation antidepressants to be 50%, in comparison with ~40% for TCAs. Therefore, the specter of withdrawal syndrome might diminish the antidepressant-based mass-market expectations of both pharma and psychiatry.
With these expections, it was important to both keep people on the drugs until they were hooked and minimize the risk and discomfort of withdrawal syndrome. Psychiatry participated enthusiastically in this. Lilly and then Wyeth, respectively, paid for “expert consensus panels” and hefty supplements in Journal of Clinical Psychiatry in 1997 and 2006:
Schatzberg, A. F., P. Haddad, E. M. Kaplan, M. Lejoyeux, J. F. Rosenbaum, A. H. Young, and J. Zajecka. “Serotonin Reuptake Inhibitor Discontinuation Syndrome: A Hypothetical Definition. Discontinuation Consensus Panel.” The Journal of Clinical Psychiatry 58 Suppl 7 (1997): 5–10.
Schatzberg, Alan F., Pierre Blier, Pedro L. Delgado, Maurizio Fava, Peter M. Haddad, and Richard C. Shelton. “Antidepressant Discontinuation Syndrome: Consensus Panel Recommendations for Clinical Management and Additional Research.” The Journal of Clinical Psychiatry 67 Suppl 4 (2006): 27–30.
It is remarkable that pharma saw it necessary to do this twice, both star-studded supplements communicating the same message: That new-generation antidepressant withdrawal syndrome was mild, transient, self-limiting, and could be expected to last only a couple of weeks and *anything after that was relapse*. Through various avenues, not the least Pharma-sponsored medical training programs and CME, this became the dominant narrative.
Those are 12 leaders of psychiatry who co-authored those 2 papers alone. After the 1997 supplement, Peter Haddad, an expert in adverse effects of psychiatric drugs, published a half-dozen papers about antidepressant withdrawal syndrome in which he took pains to state that there were exceptions to short, mild withdrawal, with some people experiencing severe and prolonged symptoms. In personal correspondence with Richard Shelton, coincidentally at the same time the 2006 supplement was published, Dr. Shelton acknowledged to me that some people do indeed experience severe and prolonged symptoms.
So those are two of the “expert consensus panel” who knew that those JClinPsych supplement articles were not telling the whole story. (On my birthday in July 2006, when I was 2 years into paroxetine withdrawal syndrome, Owen Wolkowitz, a UCSF faculty member and colleague of Schatzberg’s, verbally told me that of course Schatzberg knew about protracted antidepressant withdrawal syndrome, all the leading psychiatrists did.)
So how deliberate was it that psychiatry, a decentralized specialty disavowing defined leadership and highly resistant to enforceable guidelines, denied the larger danger of prolonged antidepressant withdrawal syndrome? Does the complicity of maybe 10 or 50 or 100 psychiatry thought leaders indict the whole profession? Why would an ordinary general psychiatrist, knowing that withdrawal from TCAs, MAOIs, and addictive drugs can be brutal, assume that antidepressant withdrawal syndrome would pass in a few weeks, and any symptoms after that, no matter how bizarre, be “relapse”? What is wrong with this profession?
I still miss Mickey. What a loss for us all.
Very unlikely these ominous correlations regarding melatonin supplementation have any clinical validity. In supplement form, melatonin has a half-life of only a few hours.
As little as 0.33mg melatonin has found to be effective to trigger sleep, especially if taken at night and surroundings are dark. That’s basically what it’s good for, because of the half-life, the effect wears off a few hours later, with natural circadian rhythm ending endogenous melatonin production and ramping up cortisol as dawn approaches. Melatonin is not a sleeping pill.
If use of the supplement is keep to minimally effective doses, adverse effects are probably close to zero.
I like Vice, but in fact, it is more of a tabloid than serious journalism. Shayla Love’s piece was a cut above its usual fare, but even “in depth”, very superficial in regards to the subject, and off-base when talking about the current state of “anti-psychiatry”, missing the substance of the protests of the injured patient movement entirely.
In this, one suspects her primary source was Joe Pierre, UCLA psychiatry professor and Acting Chief of Community Care Systems at the Veterans Administration West Los Angeles Healthcare Center, who is determined to ignore the potential of injury from psychiatric treatment. His position is rather fraught: Though he admits such injury might exist, he claims the way that people make noise about it on social media (primarily Twitter, because that’s where he hangs out) is inappropriate, thus justifying ignoring it.
There are some injured consumers on Twitter who have adopted the tactic of meanly trolling psychiatrists; from this, Dr. Pierre — a scientist of human emotion and behavior who fancies himself an expert on mass delusion — concludes there is a new “anti-psychiatry”, which he likens to anti-vaxxers.
Further, he (and 2 co-authors) claim consumers complaining of injury evidence a psychiatric disorder, an “attempt to find meaning in identity as an injured party”, described in a September 9, 2020 piece published on MedpageToday, “Op-Ed: Why Anti-Psychiatry Now Fails and Harms” (free registration), thus implying no such patient harm actually exists. (None of the 3 co-authors appear to have personally examined any of these consumers prior to coming to this diagnosis, instead referring to their experience of social media.)
Awais Aftab captured the consumer protest July 12, 2020 in an article on his own blog, “Primum non Nocere: A Psychiatrist’s Review of “Medicating Normal””.
Since new injured consumers are being generated by psychiatric treatment every day, we can be confident this consumer movement will not stop, and will continue to express itself on social media and elsewhere. Injured patients are injured patients, no amount of gaslighting from psychiatrists like Joe Pierre and Tyler Black will make them disappear.
Recently, the UK’s Cumberlege review found systemic error in ignoring treatment harm, generalizable across healthcare. An article about it, “Cumberlege review exposes stubborn and dangerous flaws in healthcare” was published August 6, 2020 in the BMJ:
“Perhaps most striking was the testimony from hundreds of patients reporting lack of informed consent for their initial treatment, followed by years of dismissal by clinicians and regulators who did not want to associate life altering symptoms or injured children with their medical interventions. In a press release Cumberlege said that in years of reviews and inquiries she had never encountered anything like the intensity of suffering of these medically injured families. The review panel found that healthcare providers’ dismissive attitude toward patients was underpinned by a reluctance in all parts of the system to collect evidence on potential harms, by a lack of coordination that would allow clinicians and agencies to interpret and act on that information, and by a culture of denial that failed to acknowledge harm and error, impeding learning and safety.
….
These patterns are already familiar to all patients who have been harmed by medical care. What the Cumberlege team has flagged is the stubborn flaw that lies at the heart of the practice of medicine. It is often called “culture.” But this type of embedded attitude seems to go beyond culture, beyond fear of liability, and beyond the profit motive when that exists. It is a patronising and insufficiently curious way of doing business that is often at odds with the realities of helping patients heal and is increasingly out of place in a connected modern world. How to change it is still an unsolved problem. There have been inquiries, reports, and recommendations over the years, but the fundamental issues around power, justice, and compassion are still with us.””
Thank you for this piece. My heart breaks when I think of our loss of David Foster Wallace. I fantasize if he had only known he had Nardil withdrawal syndrome, his brain wasn’t broken, and he might slowly recover over time, he might not have killed himself.
After all those drugs and ECT, I can just imagine how terrible he felt. His nervous system must have been shooting off warning signals constantly.
This is terrible. I don’t know if we would have been able to help Zel Dolinsky, but on SurvivingAntidepressants.org we have a protocol to taper polypharmacy and routinely help people go off their drug cocktails. It’s not easy and it can take a long time, but it can be done. (FYI, an outline of the protocol is here https://www.survivingantidepressants.org/topic/2207-taking-multiple-psych-drugs-which-drug-to-taper-first/)
When grueling symptoms such as akathisia and sleeplessness have already set in, maneuvering is more limited — but we do have people who have recovered from this.
If I, a peer counselor with no formal medical background, can figure it out, a smart doctor could do it. I hope in the not-to-distant future, many will.
Sadly, although huge numbers are being overmedicated with all kinds of drugs, we’re still in the era where adverse drug reactions are considered very rare, with very little clinical training to deal with them. It is a failure in medical practice that so many patients cannot find a doctor with even a particle of understanding about drug adverse effects. They simply do not want to get entangled in this, especially when psychiatric drugs and purported “mental illness” are involved.
Even psychiatrists will shrug at adverse drug effects and mumble something about “but the drugs do so much good!” or some such irrelevancy.
This is perhaps the cut that hurts worse — feeling abandoned by medicine — left out on the ice floe, as it seems.
Hi, Bob. Don’t get me started about the New Yorker article. I, too, expected it to be a tipping point and was very disappointed. As everyone knows, I run the peer support site for tapering off psychiatric drugs, SurvivingAntidepressants.org, which was mentioned a couple of times in the article.
(The following remarks are about how Laura is represented in the story as a character, not the real Laura Delano, who, as Bob points out, has a somewhat different story.)
Reading without benefit of Laura’s backstory (which we know from MIA), I perceive Rachel Aviv’s story as written to be one of psychiatric overdrugging, polypharmacy, and potential misdiagnosis. While numerous psychiatric experts probably associated with Harvard (crux of biological psychiatry) were involved in a long trail of mistreatment, I believe psychiatrists will view Laura’s case as an outlier.
The article failed to convey how common psychiatric misdiagnosis, overdrugging, etc. is. It also glossed over how Laura came off the drugs, and since she had also overdosed and suffered from rhabdomyolysis, psychiatrists will attribute the cursory description of her post-withdrawal symptoms to that. So no game-changing there.
The general reader may be appalled by the description of prescription cascade, polypharmacy, and adverse effects, but not get the very important point: ANYONE can be taking even one psychiatric drug, have trouble coming off, and meet nothing but misdiagnosis and mistreatment of adverse reactions, particularly withdrawal symptoms.
The writer, Rachel Aviv, deliberately misrepresented the topic to me as a long, in-depth article about online peer support for coming off psychiatric drugs. (Beyond my site and Laura’s The Withdrawal Project, which shares much content with my site, there is an extensive peer support network serving hundreds of thousands if not millions of people.)
I perceived a New Yorker article about this could be a game-changer for finally handing off psychiatric drug tapering to physicians, where it belongs. Consequently, I spent many hours corresponding with Aviv, sending her dozens of journal articles, in which she seemed very interested. We went back and forth in congenial discussion about deep underlying controversies in psychiatry. She ended up quoting several of my sources.
Aviv knows the ground, but produced a rather superficial human interest story not much different from other psychiatric drug horror stories published in the New York Times, the Daily Mail, and elsewhere.
I also saw signs of stuff chopped out and awkward transitions. We should all have known better — issues in psychiatry flummoxed Louis Menand, an otherwise excellent writer, in a February, 2010 New Yorker article.
Not a tipping point, not a game-changer, just another one-off human interest story, and attenuated, as you point out, by unnecessary cant about the benefits of the drugs.
For the Web, the article was originally titled the clickbaity The Challenge of Going off Antidepressants — completely inappropriate, as Laura was taking a basket of psychiatric drugs other than antidepressants — if that tells you anything.
After the article was published, I expressed my disappointment to Rachel Aviv, who admitted she is also writing a book.
This whole experience has certainly changed my view of the New Yorker’s credibility.
PS I am now even more determined to transfer responsibility for getting people off psychiatric drugs to the professional medical community and put myself out of business. I am tweeting as @Altostrata with hashtag #Deprescribing.
Curiously, Andrew Solomon’s first episode of “agitated depression” was also misdiagnosed benzodiazepine withdrawal syndrome. Coming from a family fortune from the pharmaceutical industry, he was convinced that he needed serious psychiatric drug treatment. He went through years of antidepressant switches and more adverse reactions — no doubt also misdiagnosed as psychiatric symptoms — and now claims to be in a drug-balanced state.
He’s been preaching about the need to treat depression and the effectiveness of antidepressants ever since. Of course, he did delve into his history and found good reason for psychiatric disorder — very few among us do not have this!
His journey into psychiatric drugs is recounted in an article he wrote for the January 4, 1998 New Yorker, Anatomy of Melancholy https://www.newyorker.com/magazine/1998/01/12/anatomy-of-melancholy
David Foster Wallace experienced years of misdiagnosed Nardil withdrawal syndrome. He experienced round after round of additional psychiatric drugs. He was convinced the drugs were making him worse. Did he kill himself because he thought he had an incurable psychiatric condition?
These circumstances are contained in a February 28, 2009 New Yorker piece by D.T. Max https://www.newyorker.com/magazine/2009/03/09/the-unfinished
“….In the late eighties, doctors had prescribed Nardil for Wallace’s depression. Nardil, an antidepressant developed in the late fifties, is a monoamine oxidase inhibitor that is rarely given for long periods of time, because of its side effects, which include low blood pressure and bloating. Nardil can also interact badly with many foods. One day in the spring of 2007, when Wallace was feeling stymied by the Long Thing, he ate at a Persian restaurant in Claremont, and afterward he went home ill. A doctor thought that Nardil might be responsible. For some time, Wallace had come to suspect that the drug was also interfering with his creative evolution. He worried that it muted his emotions, blocking the leap he was trying to make as a writer. He thought that removing the scrim of Nardil might help him see a way out of his creative impasse. Of course, as he recognized even then, maybe the drug wasn’t the problem; maybe he simply was distant, or maybe boredom was too hard a subject. He wondered if the novel was the right medium for what he was trying to say, and worried that he had lost the passion necessary to complete it.
That summer, Wallace went off the antidepressant. He hoped to be as drug free as Don Gately, and as calm. Wallace would finish the Long Thing with a clean brain. He entered this new period of life with what Franzen calls “a sense of optimism and a sense of terrible fear.”….”
D.T. Max later published a biography about Wallace with more detail.
After going off Nardil, Wallace embarked on the kind of hell anyone who has experienced antidepressant withdrawal syndrome will recognize, replete with misdiagnosis, denial, and hypersensitivity to subsequent psychiatric drugs. Since he had a long psychiatric history and prior suicide attempts, his suicide is attributed to his pre-existing mental condition.
In my experience, after reading thousands of reports from patients and collecting more than 6,000 longitudinal case histories of psychiatric drug tapering and withdrawal symptoms on my Web site Surviving Antidepressants http://survivingantidepressants.org/index.php?/forum/3-introductions-and-updates/ , physicians, including psychiatrists, generally do not recognize any psychiatric drug adverse effects and almost invariably misdiagnose withdrawal as relapse or emergence of a new, weird psychiatric disorder calling for high dosages of lots of drugs, which tend to make people worse.
Clearly, there is a longstanding area of physician error in misdiagnosis of psychiatric drug adverse reactions and withdrawal symptoms and consequent patient harm. My belief is they think such adverse reactions are so rare, they’d never see them in their patients. They presume everything is a horse, not a zebra. Too bad we’re losing so many zebras.
One important question is what is meant by “depression” in each clinical trial or study. Does the patient base include people who are in distressing situations, such as bad marriages, bad jobs, or grieving? Such situational depression tends to resolve on its own within months and used to be excluded from the diagnosis of “major depressive disorder” (MDD). Now MDD can be diagnosed in a ham sandwich.
For people with situational depression, a diagnosis of MDD might well convince them they have a permanent disease. Combined with drug side effects, they may well be impaired for a period beyond the normal course of recovery, while not experiencing much relief from the distress — they’re still in a situation that needs resolution. Pills rarely do this.
In other news about psychiatric drug efficacy:
Psychother Psychosom. 2019 Mar 20:1-9. doi: 10.1159/000496734. [Epub ahead of print]
Withdrawal Confounding in Randomized Controlled Trials of Antipsychotic, Antidepressant, and Stimulant Drugs, 2000-2017.
RĂ©calt AM, Cohen D.
Abstract at https://www.ncbi.nlm.nih.gov/pubmed/30893683
BACKGROUND:
Results of relapse prevention randomized controlled trials (RCTs) which discontinue psychotropic drug treatment from some participants may be confounded by drug withdrawal symptoms. We test for the confound by calculating whether ≥50% of the difference in relapse risk between drug-discontinued and drug-maintained groups is present at discontinuation time points (DCTs) with “short” and “long” assumptions regarding onset and duration of withdrawal symptoms.
METHODS:
In eligible RCTs of antidepressants, antipsychotics, and stimulants from 2000 to 2017 (n = 30) selected from a systematic review, differences in relapse risk were examined by arithmetic and graphical comparison of mean behavioral scores or survival plots.
RESULTS:
Only 14 studies (46.6%) with 15 analyses of relapse risk provided sufficient data. Under short and long DCTs, 9 of 13 (69.2%) and 7 of 9 (77.8%) interpretable analyses, respectively, suggested a withdrawal confound. The proportion of endpoint placebo-maintenance group difference present by the DCT averaged 69.1% (range, 58.7-148.0%, n = 13) for short DCT assumptions, and 79.0% (range, 51.5-183.3%, n = 9) under long DCTs. One study (3.33%) controlled for withdraw al effects, and 1 yielded inconclusive results.
CONCLUSIONS:
These results support suggestions that withdrawal symptoms confound the results of relapse prevention RCTs. Accounting for such symptoms in RCTs is an ethical, scientific, and clinical imperative. Justifications for relapse prevention RCTs employing a discontinuation procedure require more scrutiny.
Given the razor-thin margins for significance in findings for psychiatric drug efficacy, the confounding of withdrawal symptoms for relapse may well tip all of these studies into findings of no significant efficacy for each drug.
This book is the most helpful guide I’ve found for tapering psychiatric drugs.
If you have read Dr. Glenmullen’s The Antidepressant Solution (or, in the UK, Coming Off Antidepressants) and would like to suggest updates for a revision, please contact me at https://www.SurvivingAntidepressants.org/ (scroll down to bottom of page, click on Contact Us). Thank you.
Dr. Corrigan, please supply a full statement of your conflicts of interest regarding Alternative to Meds Center.
Here is the report you provided https://www.alternativetomeds.com/wp-content/uploads/2019/01/ATMC_OutcomeStudy2018.pdf as Vice President, Multi-Dimensional Education Inc.
More about your company here http://www.mdedinc.com/httpdocs/about_us
Did ATMC commission you to do this study? Thank you.
Hello, Catalyzt. I miss Mickey terribly, though the others…..
I do think things have changed a little, physicians in general have gotten a little more objective about the new generation of drugs and are not as quick to believe they’re wonder drugs.
It is bizarre that a spotlight on a serious adverse effect of a class of drugs is cast as a war on the drugs themselves.
The assumption that antidepressant withdrawal symptoms generally are mild, transitory, and last only a few weeks was promulgated in a pair of supplements to the Journal of Clinical Psychiatry in 1997 and 2006 arising from “expert” symposia sponsored by pharmaceutical manufacturers Lilly and Wyeth, respectively, and led by the notorious Dr. Alan Schatzberg.
The conclusions of the “consensus panel” were based only on the opinions of the participants. There was no data or real evidence involved. No citations were given for the statements about the severity of withdrawal syndrome.
These papers are buried in the citations of nearly all other medical literature about antidepressant withdrawal syndrome, with the erroneous assumptions circulated over and over until they calcified throughout psychiatry into “evidence.”
To his credit, one of the experts from Schatzberg’s “consensus panel,” the UK’s Dr. Peter Haddad, repeatedly has made an effort to remedy this misinformation, authoring many papers about withdrawal syndrome and warning about its misdiagnosis. He has pointed out repeatedly that withdrawal symptoms may be relatively mild only in most cases — there are exceptions, the extent of which is unknown.
As Dr. Haddad stated in 2001: “Discontinuation symptoms have received little systematic study with the result that most of the recommendations made here are based on anecdotal data or expert opinion.” (Haddad, P.M. Drug-Safety (2001) 24: 183. https://doi.org/10.2165/00002018-200124030-00003)
I also had personal correspondence in 2006 with another member of the expert panel, Dr. Richard Shelton, who admitted to me that some individuals can suffer severe and prolonged withdrawal syndrome. (Like Dr. Schatzberg, Dr. Shelton went on to a lucrative career as a pharmaceutical company consultant.)
The “experts” who presented their opinions as evidence informing medicine’s assumptions about psychiatric drug withdrawal are well aware they have not disclosed all the risks. Consequently, physicians everywhere have a false sense of safety about these drugs and are blind to the adverse effects.
However, given the extremely high rate of psychiatric prescription, the expedient gloss over the potential of injury has caused damage to millions of people.
In correspondence years ago with Dr. Haddad, he hinted that gathering case histories would be instructive in this debate. On my Web site, SurvivingAntidepressants.org, I have gathered almost 6,000 case histories of difficult psychiatric drug withdrawal, none of them mild, transient, and lasting a few weeks. You can see them here http://survivingantidepressants.org/index.php?/forum/3-introductions-and-updates/
These case histories also demonstrate the many, many ways people are being misdiagnosed and misprescribed. Taken together, they’re a landscape of the pitfalls in medical knowledge regarding psychiatric drugs and their adverse effects.
Another critic of the Read and Davies paper, Dr. Ronald Pies, recently contended in Psychiatric Times that psychiatrists know how to taper people slowly off drugs and therefore serious withdrawal syndrome as reported by Read and Davies is nearly non-existent.
Dr. Pies’s claims are based solely on his own 2012 paper, in its prolix entirety at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3398684/, in which he states:
“In my own practice, I would typically “wean” a patient off a chronically administered antidepressant over a period of 3 to 6 months and sometimes longer. To my knowledge, this period of tapering has rarely, if ever, been used in existing studies of antidepressants or in routine clinical practice.”
Dr. Pies knows very well that “proper psychiatric care” for tapering “managed appropriately” is virtually impossible for patients to find. This tends to confirm Read and Davies are on the right track. We need better ways to taper people off psychiatric drugs.
Of all the RCTs done on antidepressant efficacy and “discontinuation” studies purporting to demonstrate that people relapse when off the drugs, very few — perhaps 3 out of hundreds — contain any protocols for identifying withdrawal symptoms.
For example, the 2006 STAR*D (Sequenced Treatment Alternatives to Relieve Depression) study, which over 7 years switched about 3,000 people from one antidepressant to another in search of the most effective treatment for depression, reported 0 (zero) cases of withdrawal syndrome — a result that defies belief. (It has long been established that one may suffer withdrawal syndrome even when taking a replacement drug.)
(The STAR*D study’s methodology and statistical analysis have been heavily criticized. Yet, many doctors believe it is the gold standard for antidepressant treatment and to this very day are merrily switching people from one drug to another regardless of withdrawal effects.)
All of these studies contain methods to measure “depression.” If a patient, having no other way to report withdrawal symptoms, quite logically conveys the discomfort by marking up the depression questionnaire, the data from these studies would be replete with false positive results supporting the presupposition that what happens after discontinuation is “relapse.”
And this is so.
(Most patients in these trials would not be aware they are experiencing withdrawal symptoms; most likely, they thought they were experiencing some new species of mental disorder.)
That so few studies even differentiated withdrawal syndrome from relapse indicates that assumptions about antidepressant efficacy and the conclusion that people often relapse when off the drugs are incorrect. Most likely, a big chunk — maybe even most — of that “relapse” is withdrawal symptoms.
What most likely happens after discontinuation of a psychiatric drug taken for a month or more is most likely withdrawal rather than “relapse.”
References
Haddad, et al., 2000, Misdiagnosis of antidepressant discontinuation symptoms.
Deshauer, et al., 2008, Selective serotonin reuptake inhibitors for unipolar depression: a systematic review of classic long-term randomized controlled trials.
Baldessarini, et al., 2010, Illness Risk Following Rapid Versus Gradual Discontinuation of Antidepressants.
On SurvivingAntidepressants.org, a peer support site for tapering and withdrawal syndrome that I’ve been running since 2011, I use quite a different model than these outdated medical philosophies.
I myself recovered from Paxil withdrawal syndrome over 11 years. After about 5 years of research on my own, I concluded many of my symptoms were related to autonomic dysfunction. At that time, I happened to receive corroboration from a highly trained psychiatrist who had also come to that conclusion.
Dysautonomia fit my experience like a glove, I’m pretty sure it fits most in cases. I use the model of autonomic dysfunction in counseling people on my Web site every day. It aids in interpreting the many symptoms and the many ways people describe their symptoms on my site. (Our language is not quite up to capturing these events so novel to our poor nervous systems.)
I’ve collected and read thousands of longitudinal case studies of tapering and withdrawal syndrome. Sometimes people develop symptoms that are not dysautonomia; the stress of withdrawal may promote what may have been a subclinical condition that may never have blossomed into a full disorder, such as an autoimmune disease. And who knows what’s going on in the gut. But for the most common symptoms, it’s dysautonomia.
(As medical diagnoses go, dysautonomia is not much of one. It’s autonomic or parasympathetic; it has many manifestations and can morph from one to another; it can arise spontaneously, wax and wane, and disappear. Nobody knows how to treat it, except regular gentle exercise and sleep generally help.)
Understanding withdrawal symptoms as iatrogenic dysautonomia does not require either reductionist or exclusionist membership. One merely needs to be a realist. Withdrawal symptoms are unrelated to any mental illness except those DSM entries for withdrawal syndrome.
(Joanna Moncrieff’s 2005 paper, Rethinking Models of Psychotropic Drug Action, may be of use here.)
While we indubitably all live in a biopsychosocial model, my belief it that difficulties going off psychiatric drugs are mainly due to the biological effects of the drugs. People in all kinds of living situations, from the most supportive to the least, have similar difficulties.
It’s undeniable that psychiatric drugs act upon the nervous system, though for some it’s mysterious exactly how this happens. To say that psychotropics change neurology is tautological.
Therefore, while the drugs are ingested, the nervous system is affected and adapts. This includes autonomic and parasympathetic functions, with downriver effects on hormonal systems. Desirable effects are called therapeutic. Undesirable effects are called dysfunctions.
The very common drug side effect of sexual dysfunction is evidence of autonomic and possibly hormonal alteration. (Antidepressants cause this dysfunction far more reliably than they therapeutically lift mood.)
Similarly, through action on the body’s web of feedback loops, psychiatric drugs may derange insulin regulation and cause weight gain and even diabetes.
The body and its systems adapt, comfortably or not, to the presence of the drugs — incurring physiological dependency. When the drug dosage changes, those systems may again be disrupted.
Most frequently in withdrawal, autonomic symptoms, particularly a grueling sleeplessness, come to the forefront. This second wave of disruption may cause sexual dysfunction when taking the drug did not.
From what I’ve seen, “rebound” symptoms are coincidental, not a type of symptom. Who among us, for example, has not had a spell of deep unhappiness? Or the occasional spell of anxiety? This is even more so for those who sought treatment with psychiatric drugs. However, withdrawal syndrome can cause spontaneous waves of profound existential despair or terror in people who never had an inkling of such things.
That is an effect emanating from a dyregulated nervous system, not an emotional trigger. “Rebound” suggests these are the same old emotional symptoms, amplified. They are not, they are biochemically induced by the artificial state of withdrawal. (The content of the symptoms, however, might be the same old content, which no doubt will confuse the psychotherapists reading this.)
I am dubious that, across the board, psychotherapy is the secret sauce for going off psychiatric drugs with minimal autonomic dysregulation. (It’s slow tapering, and even that doesn’t always work.) As so very many people are taking psychiatric drugs for no good reason, not everyone has pre-existing distress to work through, and psychotherapy has little to say about withdrawal symptoms, except to coach people how to ride them out — if the therapist actually understands that’s what’s going on.
On the other hand, who among us wouldn’t like a little extra understanding when going through a trying time?
Oddly, although the Mad in America community has sympathy for all kinds of damage from psychiatric treatment, this conversation again demonstrates that somehow there is a great deal of resistance to the idea some people continue to suffer even when they are off the drugs — despite personal testimony from the sufferers. For example, would anyone state on MIA that people who claim they damaged from ECT did not in fact suffer such damage? Why are those who claim to have post-withdrawal syndrome subjected to suggestions they are perhaps deluded, mistaken, stupid, or merely experiencing some kind of relapse? In a community of psychiatric survivors, why are not those with post-withdrawal syndrome afforded the same respect and compassion as other psychiatric survivors? Why are they subjected to attacks on their personal credibility? If you didn’t like the way your doctor dismissed your understanding of yourself and your problems with psychiatric treatment, why are you doing that to other people? When it comes to post-withdrawal syndrome and the testimony of people who are suffering from it, where is the sympathy and compassion and RESPECT for fellow psychiatric survivors? Although unwitting (except for one person), the hypocrisy and meanness here hurts all the same. And it speaks poorly for the MIA community.
John, if you don’t believe what people who are suffering from post-withdrawal syndrome tell you about their condition, who are you going to believe?
Why don’t you dismiss us the way psychiatrists dismiss all their patients’ complaints about adverse drug effects? We’re very used to that.
Anyone who has realized he or she is suffering from post-withdrawal syndrome comes to that despite condemnation from their doctors, their families, their spouses, and callously uninformed comments on the Internet.
Here’s the link to case histories http://tinyurl.com/3o4k3j5 and it is working.
In response to Richard D. Lewis, JOHN T SHEA, mjk, researcher, Danny S —
Dr. Shipko is indeed correct in that some people, perhaps the very end of the bell curve, will have difficulty recovering from antidepressant withdrawal for a very long time. (I am one of them.)
Often these people have prior history of going on and off psychiatric drugs or being switched from drug to drug without cross-tapering.
It appears the nervous system is not made of rubber. With repeated jolts, it can be made exceptionally vulnerable to chemical and other stresses.
As Dr. Shipko observes, under these circumstances, application of other psychiatric drugs backfires. (One might speculate that this iatrogenic damage underlies so-called “treatment-resistant depression.”) An injured nervous system requires much more gentle treatment.
From my observation, these statements by Dr. Shipko are absolutely correct:
“…people who stop SSRIs often develop a NEW (my emphasis) onset of severe depression or anxiety months after stopping the drugs.”
“…the problems that sometimes occur when people try to stop an SSRI antidepressant are much more severe than the medical profession acknowledges, and there is NO (my emphasis) ‘antidote’ to these problems.”
Although the medical profession almost invariably mistakes any withdrawal symptoms as relapse, those tardive post-withdrawal symptom patterns (even “tardive dysphoria”) are distinct from relapse or any mental condition found in nature. They are not merely “depression” or “anxiety.”
It’s quite common that people who have no personal experience with withdrawal syndrome cannot imagine its sometimes bizarre neurological manifestations. I can assure you, it feels nothing like a normal state of mental distress.
You may read many case histories here http://bit.ly/jAjLKr
Dr. Shipko brings up very valid points about the dangers of psychiatric drug withdrawal, which should be factored in to the risk-benefit assessment prior to prescription of any of these drugs but, because of pharma efforts to obscure them, are not.
Although he’s authored a paper on it, he hasn’t even mentioned Post-SSRI Sexual Dysfunction (PSSD), another post-withdrawal condition where the sufferer does not regain sexual sensation or functioning for a very long time, perhaps indefinitely, after stopping the drug.
Like withdrawal syndrome and post-withdrawal dysautonomia, PSSD should be recognized as a risk of psychiatric drugs and incorporated into informed consent PRIOR to prescription.
But that would require medicine to recognize these risks. I hope Dr. Shipko continues to direct his message towards doctors.
Dr. Shipko, thank you for your clarification up above in this thread. That you would continue to assist patients in tapering was not at all clear from your article.
I agree, they need to know that they may not get off the drugs without lengthy recovery afterward. The rest of medicine needs to know this, too.
Thank you very much, Dr. Shipko.
Cast as your findings regarding withdrawal, your article deserves a wider audience, perhaps on the Huffington Post or KevinMD, where it might be read by health professionals.
They are the ones who need greater knowledge of the risks of psychiatric drugs. They need to prescribe them much less often.
As I said up above, by the time patients get your informed consent, they’ve already been exposed to what perhaps might be unacceptable risks.
I agree with you, Dawn, more needs t be known.
I’ve collected many journal articles about withdrawal here http://survivingantidepressants.org/index.php?/forum/16-from-journals-and-scientific-sources/
Dr. Shipko, I’m very disappointed by your approach to this problem.
First, you are offering “informed consent” for people who wish to go off antidepressants. According to your theory, by then, it’s too late for them. This doesn’t help those millions of patients who are caught in the trap at all.
You should be putting your efforts into educating doctors of your findings about the perils of withdrawal.
Second, you dismiss the importance of tapering to protect the nervous system. Clearly, many people can taper off antidepressants and do well afterward, as many, many anecdotes on the Web reveal. We also see people recover from those tardive symptoms to which you refer. It does take time.
As you are an expert in benzo tapering, I am confused as to why you would not apply the same reasoning to antidepressant tapering.
Third, you dismiss the efforts of “citizen scientists” and self-help Web sites supporting tapering, which exist only because of the vacuum of knowledge among doctors.
If these self-help resources did not exist, people who wish to go off the drugs would have no help in tapering, as few doctors even grasp the concept.
Whether you call the symptoms “prolonged withdrawal syndrome” (symptoms being continuous from discontinuation of the drug) or post-withdrawal syndrome or whatever you want to call it, medicine pays little attention to any long-term effects of psychiatric drugs. “Citizen scientists” do. Nit-picking about nomenclature makes no sense. We both know what we’re talking about. The rest of medicine couldn’t care less.
Fourth, the impact of your article is:
– Don’t go on the drugs.
– Don’t go off the drugs.
– If you run into a problem, don’t call me.
Is this really what you want to say?
With your background in neurology as well as psychiatry, you could help people who have experienced long-term post-withdrawal symptoms by focusing on ways to stabilize the autonomic nervous system.
(Tardive dyskinesia may not be the only analogy; see parallels to dyautonomia underlying chronic fatigue syndrome and fibromyalgia explored on the Beyond Meds blog http://beyondmeds.com/2013/07/24/ans-and-interaction/ There’s also traumatic brain injury, which takes a cycle of about 7 years for recovery.)
This is why your experiments with serotonin boosters such as SAM-e and tryptophan went nowhere — you simply tried to replace the antidepressant. How would this stabilize dysautonomia? The problem is downstream of the (most likely desensitized) serotonin receptors.
Just addressing the sleep issues alone would be of tremendous help to those suffering from withdrawal syndromes.
I have a great deal of respect for your concern about withdrawal problems and for what you may have observed in your practice. I fear your frustration and anger on behalf of injured patients has caused you to give up on treatment of post-withdrawal symptoms. There is a crying need for someone of your caliber to delve further into this. I beg you to persevere.
Dr. Shorter’s e-mail address http://www.history.utoronto.ca/faculty/facultyprofiles/shorter.html
Re June 27, 2013 at 9:17 pm comment:
Therefore, anyone who goes cold turkey and is injured, or anyone who tapers too fast and is injured, has only himself or herself to blame.
The psychiatric survivor community — and certainly the medical community — offers no support or comfort to these people. They are on their own.
You go off too fast, you get injured, it’s your own tough luck.
See http://tinyurl.com/3o4k3j5 for what these injuries, which can take many months or years for recovery, are like.
True, many people can haphazardly go off their drugs and not suffer unduly.
However, others try this — skipping doses is a particularly risky way to go off — and hurt themselves terribly, with recovery taking months or years.
Given that no one can predict how any individual might react to a dosage reduction — previous withdrawals are NOT predictive — what is the safest, most compassionate advice for someone who wants to go off psychiatric drugs?
My position is that a conservative, gradual approach across the board minimizes risk for all, including the more sensitive nervous systems.
The stakes are so high, it’s worth being cautious.
Certainly, if withdrawal symptoms appear, updosing slightly is a good strategy. However, a reckless taper should NEVER be tried assuming this will be a fix — because sometimes updosing doesn’t work, the nervous system dysregulation is too great.
I really, really wish the psychiatric survivor community would take this issue seriously. People who have quit their drugs with little difficulty tend to dismiss or even deny the grievous injury suffered by others. Bad advice to do it whatever way you want keeps going around and around.
Think of this as protecting our community. Not every act of unprotected sex with strangers results in HIV infection, but what responsible AIDS activist would suggest using a condom only if you feel like it?
Friends urge friends to reduce risk by being careful. Please help me spread the gospel of gradual tapering.
Good suggestions, Jill. Personally, I believe low omega-3 status, due to nutrient depletion in factory farming. may be a large contributor to whatever distress drives people to consider treatment with psychiatric drugs in the first place.
However, please keep in mind that the greatest danger in withdrawing people from psychiatric drugs is not relapse of depression or whatever, which may be effectively treated with non-drug interventions, but destabilization of the nervous system and consequent hypersensitivities, about which medicine knows absolutely nothing.
Too-fast withdrawal resulting in nervous system destabilization is like Humpty-Dumpty falling off the wall. People suffering this mostly have to let time do the healing — and it can take a lot of time.
Omega-3 (and magnesium) supplementation seems to give many people some relief of withdrawal symptoms. We may surmise the nervous system may have been weakened by dietary deficiencies, but nervous system destabilization surpasses such remedies.
I appreciate your interest in this issue, but to correctly conceptualize the problem, please do not confound relapse with withdrawal syndrome. They are entirely different.
All physicians prescribing psychiatric drugs should be familiar with Adverse Syndromes and Psychiatric Drugs: A Clinical Guide, edited by Peter Haddad, who has widely published about withdrawal syndromes. There are several chapters on this in the book.
http://www.amazon.com/Adverse-Syndromes-Psychiatric-Drugs-Publications/dp/0198527489
You can get this used from Abe’s Books, etc.
Various official and semi-official guides to tapering psychiatric medication are listed here:
http://survivingantidepressants.org/index.php?/topic/2930-guides-to-tapering-off-psychiatric-medications/
Note that patient advocates, along with Peter Breggin, are advocating much slower tapers than the medical sources. We see that decreases of 25% can be much too severe for some people and generally recommend decreases of 10%.
After all, it’s the peer counselors who are bearing this burden, which should be the responsibility of physicians, and listening to patients’ experiences.
Please also note that withdrawal symptoms do NOT always immediately appear after dose reduction. Sometimes it takes several weeks. Therefore, 10% decreases at intervals of about a month would be safest, allowing time to catch withdrawal symptoms before attempting another decrease, which would make the withdrawal symptoms worse.
Decreases are calculated on the last dosage, meaning the absolute amount of decrements gets smaller and smaller, maintaining a constant 10% relationship to the last dose. This creates a smooth but asymptotic curve never reaching zero.
When to quit altogether is based on the withdrawal history. Do not quit unless you have a solid track record of no withdrawal symptoms after a decrease. For most drugs, the jumping-off point will be a fraction of a milligram.
Fractional dosage is facilitated by utilizing liquid formulations, compounded liquids, homemade liquids, counting out beads (Effexor XR, Cymbalta), weighing powders on electronic jeweler’s scales, etc.
Pristiq is a special case in tapering — there is no way to reliably titrate it — and should never be prescribed solely on this basis. It is generating plenty of withdrawal injuries, right up there with Effexor XR, Paxil, and Cymbalta.
Just wanted to point out that folks are again mistaking underlying mental distress, which can re-emerge after drug discontinuation, for withdrawal syndrome.
Withdrawal syndrome is an iatrogenic (treatment-caused) condition. To my knowledge — and I would enthusiastically embrace any effective treatment of withdrawal syndrome — there are no alternative or natural programs that can take the place of individualized tapering schedules to reduce withdrawal symptoms.
Please think of withdrawal syndrome as iatrogenic neurological dysregulation rather than a psychiatric disorder.
On the other hand, many non-drug, alternative, dietary, etc. treatments can be effective to treat mental distress.
Confusing underlying mental distress with withdrawal syndrome gets these discussions off-track. Doctors need to make going off drugs much safer in terms of minimizing withdrawal symptoms. Society also needs to provide alternatives to treat mental distress.
People who have not seen or experienced withdrawal syndrome tend to overlook this distinction, which is extremely important. Some people can even cold-turkey off psychiatric drugs (NOT RECOMMENDED) with no symptoms. This is not true for those who are more sensitive to dosage reductions. (You don’t know if this applies to you until you hurt yourself by going off too fast.)
Withdrawal syndrome is real, it creates additional avoidable injuries in psychiatric treatment, and deserves to be recognized in the psychiatric survivor community rather than meeting a wall of denial.
I am merely a peer expert and someone who is still suffering from a too-fast 3-week taper of Paxil in 2004, but I have poured my knowledge into a hundreds of pages for Web site entirely about tapering off psychiatric drugs, SurvivingAntidepressants.org
Case histories: http://tinyurl.com/3o4k3j5
Tapering techniques for specific drugs: http://tinyurl.com/42ewlrl
Discussion of withdrawal symptoms and self-help: http://tinyurl.com/3hq949z
Scientific papers: http://tinyurl.com/aqg3bjo
To my knowledge, tapering at a rate tailored to the individual’s nervous system is the only way to minimize withdrawal symptoms. Withdrawal symptoms should be minimal. “Brain zaps,” disorientation, jolts of anxiety, and sleeplessness are not trivial and indicate the taper is too fast.
Once the nervous system is destabilized by withdrawal, the only remedy is time, as frequently the person has become hypersensitive to all neuroactive drugs, supplements, and even foods. Very, very gentle interventions might make withdrawal symptoms more bearable. Most people do well with fish oil and magnesium, which tend to reduce anxiety and probably reflects a pervasive dietary deficiency in these important nutrients.
It is a widespread medical falsehood that withdrawal syndrome is invariably mild, self-limiting, and lasts only a few weeks. If you look closely at the sources for this information, you will find pharma sponsorship.
Medicine’s refusal to take this issue seriously has grievously injured many people. There are hundreds of thousands of reports all over the Web of severe withdrawal syndrome lasting many months or years.
There are untold millions who are stuck on their drugs because they suffer withdrawal every time they reduce the dosage and their doctors do not know how to taper them properly.
This is truly an epidemic.
PS Dr. Joseph Glenmullen’s “The Antidepressant Solution” is probably the best text for doctors to learn proper tapering techniques and how to monitor for withdrawal symptoms. It was published in 2006. Isn’t it time for doctors to read it?
Very sensible decision, Sandy. I hope many clinics and doctors decide to spend their scarce dollars elsewhere.
No mind-body split here.
Beautiful piece, Monica. Love the photos. Heal on!
First of all, no self-respecting AIDS activist would say “you decide” when it comes to unprotected sex, except sarcastically.
With HIV/AIDS, an intensive world-wide health education campaign has done a pretty good job of telling people what will happen if “you decide” leads them to unprotected sex.
After many years of horror stories, they have been scared out of their pants and into condoms.
This was not facilitated by AIDS activists being wishy-washy with “sparse or contradictory” information — even when information was sparse and contradictory — or offering a libertarian “you decide,” but AIDS activists uniting and giving an unambiguous message: “It’s dangerous, don’t do it.”
Can you tell me how the general public is being educated about the dangers of cold turkey or too-fast discontinuation of psychiatric medications? Has the worst-case scenario been made explicit? Most doctors will deny it.
If you think people know what’s in store for them with severe withdrawal syndrome, read 10 of these stories http://tinyurl.com/3o4k3j5
Thank you for your support, PC.
Suppose I were an AIDS activist speaking to a crowd of sexually active people. Someone says, “Is it really crucial to use protection every time you have sex with strangers?” Suppose I answered, “Well, a lot of people have unprotected sex and do not get infected. It’s up to you to decide.” Would I be promoting unsafe sex?
I don’t know what Will Hall is saying in his public speaking these days. His post on MIA (linked in my comment above), uncharacteristically muddled, showed a great deal of ambivalence about cold turkey.
Yes, I do believe people who are speaking and writing for audiences who might be considering going off their psychiatric medications should be UNEQUIVOCAL about cold turkey.
I’ve given many examples of how to consider the risk. As I pointed out in HIV transmission, for any one unprotected sexual encounter, the risk is approximately 1 in 200. And yet what gay activist would be suggesting if people feel like having unprotected sex, they should go ahead and do it?
(By the way, in the early days of AIDS, there was quite a bit of resistance to the idea that one should always use protection, with the same kinds of rationalizations. In the general population, there still is.)
We are all horrified by the prescribing of psychiatric medications to pregnant women, yet in truth, the absolute risks to the developing baby are much, much smaller than the risk of damage after cold turkey.
For example, the risk of an autism spectrum disorder after valproate treatment is put at 4.42 percent according to a recent study http://www.medicalnewstoday.com/articles/259597.php
Translated to psychiatric medications, this means Laura might meet 96 people who got away with cold turkey before she meets 4 who didn’t (if they were able to get out, that is).
What this conversation demonstrates is the inability of even intelligent people to grasp the idea of medical risk. It’s not a majority vote.
Laura and others should take this as a caution against making assumptions that their audiences 1) will do any research in the risk of cold turkey; 2) be able to assess such information about risk if they do find it; and 3) make logical decisions about going off psychiatric drugs.
I regret very much pounding on Will and Laura about this, but I believe the stakes are very high. People need to be reminded about how dangerous it can be to go off psychiatric drugs suddenly — they’re inclined to do it anyway. They don’t need additional approval or permission for a risky action.
My position is that people like Laura and Will Hall, who are sometimes in a position to influence large numbers of people in their speaking and writing, should not encourage cold turkey, implicitly or explicitly, because cold turkey is dangerous and creates lasting injuries.
I’d rather people be cautious in going off drugs so they DON’T end up on my Web site.
The warnings about cold turkey are already quite stern. This is what they amount to: DON’T DO IT.
This is one warning from the medical establishment that everyone on MIA should be supporting and yet it’s an uphill battle. Why?
Laura, this is the fourth or fifth or sixth time I’ve heard or read your phrase “There is simply no one right way to come off psychiatric drugs.”
Each time my reaction is the same: You have carefully formulated this phrase not to exclude cold turkey as a way to come off psychiatric drugs. (As I have discussed with you.)
What would it cost you to change this to “Tapering is the safest way to go off psychiatric drugs. Don’t cold turkey if you can possibly help it.”? Why do you deliberately and repeatedly give tacit approval to cold turkey? Is there a cold turkey lobby?
According to the HIV analogy, here’s your logic:
– There’s no one right way to have sex with strangers.
– Some people don’t get HIV when they have unprotected sex with strangers.
– Having unprotected sex with strangers might be perfectly fine, if that’s what you prefer.
What’s missing: Some people do get HIV from unprotected sex with strangers, and HIV is such a serious condition that you will take precautions against contracting it.
(For what it’s worth, Will Hall ran aground on the same argument here https://www.madinamerica.com/2012/11/medication-withdrawal-or-medicationtapering-a-harm-reduction-approach/ )
Seriously, who wouldn’t prefer having carefree, unprotected sex with strangers? Who wouldn’t prefer cold turkey off psychiatric drugs compared to the work of tapering?
People hardly need permission to cold turkey. They do it all the time. Nothing stops them — they don’t bother to educate themselves (until it’s too late). They hear stories of successful cold turkeys and they think great, I’ll do that too.
Maybe they secretly think if they get hurt, some nice doctor will give them a pill that will fix them right up.
Then, ouch, it doesn’t go so well. But unlike HIV, there is no medical support for withdrawal syndrome and darn little other support. Even in a community such as MIA, a person with withdrawal syndrome will be a pariah, because everyone here wants to believe you can simply go off psychiatric drugs if you want to change your life. Withdrawal syndrome is a reminder that it’s not so simple.
As long as you use “There is simply no one right way to come off psychiatric drugs,” in your speaking and writing, giving tacit approval to cold turkey, we will be working at cross-purposes.
By the way, what I said above was “If you can manage it, there is only one way — that is to taper at a rate your nervous system can tolerate.” By definition, cold turkey is not a tapering method, any more than black is white.
Yes, there are anecdotal reports of successful cold turkey, and there are anecdotal reports of disastrous cold turkey. No individual knows what will happen in advance should he or she take the irrevocable step of quitting suddenly.
Although medicine has been indolent about adverse effects of psychiatric drugs in general and pretty much covered up the potential severity of withdrawal syndrome, its injunction against cold turkey has been consistent and universal. Why?
In the beginning, cold turkey was the way everyone was taken off SSRIs, which were assumed to have no withdrawal issues. When the results of cold turkey surfaced — that would be in the Prozac era — they were so horrific that researchers united in warning against cold turkey. (Another myth: Prozac is “self-tapering.”)
If you read the journal literature about withdrawal syndrome, such as that authored by Peter Haddad, you will see that researchers allude to severe “morbidity” from too-fast discontinuation. However, those cases are unpublished. The evidence has been buried, all that remains is the warning.
Not that what psychiatry researchers think has any weight in this crowd; I’m pointing this out because even psychiatry researchers who would much rather ignore the problem felt compelled to warn against cold turkey, it was that serious.
Now let’s look at the validity of anecdotal information. That is all we have, because medicine got bored with psychiatric drug withdrawal syndromes in the mid-2000s. Unless someone does an epidemiological study, it’s unlikely any hard statistics will ever be produced about the danger of cold turkey.
So you know people who did well, and we all know people who did not. You’ve taken 3 years to recover, I’m in my 8th year of recovery (it’s taken a very bad turn lately). You can look forward to a new life, I’m older and my life has been destroyed.
No one who hasn’t experienced severe withdrawal syndrome understands how painful and debilitating it is. A positive attitude can’t erase the minute-by-minute torture. It comes down to a will to live. Few people can grasp the prospect of suffering with no options.
If you say any which way of coming off might suit, you must also take on the moral burden of explaining what happens when the bet goes bad. Otherwise, you present the benefit without the risk.
(Also, if any way of going off might suit, why even bother collating a directory of practitioners who support tapering? Anyone can improvise their own way of going off and take their chances.)
This discussion, which has played out several times on MadinAmerica, makes me discouraged and angry. I run a Web site that is one of the few offering support for people with prolonged withdrawal syndrome. Other sites exclude them. Their situation, which I share, is tragic.
Laura, your formulation “there is no one right way to come off of psychiatric drugs,” which you use in your speaking and writing, unintentionally drives business to my site that, frankly, I don’t want to have.
It is no mystery that most people do okay with going off psychiatric drugs. There’s the famous “2 weeks of mild symptoms” — right up there with “the check’s in the mail” as one of the great lies — that most people quitting SSRIs are supposed to experience.
But some hurt themselves very, very badly by going off too quickly. Perhaps Russian roulette is too romantic a metaphor. A better one might be having sex with strangers. Not every incident results in HIV infection; the risk is estimated at about 1 in 200 encounters.
That’s right — that’s what a huge worldwide public education campaign has been about, a campaign that’s changed the sexual behavior of millions of people, some of whom were quite resistant to that change.
Why, if the risk is only 1 in 200, are people urged to always use condoms? It’s because the outcome of a bad bet is so drastic. Taking precautions is important not because of frequency of infection but magnitude of damage.
I have absolutely no doubt that severe withdrawal following cold turkey occurs much more frequently than 1 in 200. Of the pregnant women I mentioned above, 30% reported “unbearable” symptoms and 12% ended up in the hospital. (What do you think happened to them there? If they were really, really lucky, their antidepressants were reinstated. Back to square one.)
That’s why encouraging people to taper to prevent withdrawal syndrome is so important. You only have one nervous system, and it’s not made of rubber.
And that is why I take exception, yet again, to your “each to his or her own” position. You are hiding the risk of withdrawal syndrome to make a rhetorical point: One can be free of psychiatric drugs. I agree with you on that, but I wish you would encourage people to taper rather than include cold turkey as just one of those preference things.
Beautiful writing, thank you, Laura.
As you know, when I likened cold turkey to Russian roulette, what I was saying was you could hurt yourself very badly by taking that risk.
Yes, it’s true some people play Russian roulette and win the bet. But others do not.
The successful cold turkey-ers testify about how they got away with it, and good for them. The ones who failed are wandering the Internet — or going from doctor to doctor — begging for a cure.
If you’re unlucky and shoot yourself in the head, you could end up with problems much worse than being poly-drugged.
There is no cure but time for severe withdrawal syndrome.
Every single failed cold turkey who’s come to me for advice and support had every intention of winning the game. Each and every one thought he or she would have, at most, a few weeks of feeling lousy and then be finally free.
For a glimpse of the odds of successful cold turkey, see this study:
J Psychiatry Neurosci 2001;26(1):44–8.
[b]Abrupt discontinuation of psychotropic drugs during pregnancy: fear of teratogenic risk and impact of counseling. [/b]
Einarson A, Selby P, Koren G.
Abstract at http://www.ncbi.nlm.nih.gov/pubmed/11212593 with free full text.
Experiments in cold turkey are considered unethical because cold turkey is so thoroughly regarded as harmful. Therefore, observations need to be based on accidental cold turkey.
In the study, out of 34 women who quit abruptly
• 26 (70%) reported physical and psychological adverse effects
• 11 (30%) reported suicidal ideation “because of ‘unbearable’ symptoms,” and 4 were hospitalized
An additional 3 women “used some form of tapering off. This tapering was unsatisfactory, however, because even these patient suffered from adverse effects.”
“One woman had a therapeutic abortion because she did not feel she could go through the pregnancy feeling so awful….”, another considered it.
Correct — severe withdrawal syndrome caused 2 of 34 pregnant women, who had quit antidepressants to protect the babies they were carrying — to consider terminating their pregnancies.
As before, I respectfully and strongly disagree with your position that there is no one way to come off psychiatric medications. If you can manage it, there is only one way — that is to taper at a rate your nervous system can tolerate.
If you are a person who happened to have been successful at cold turkey, you were lucky. Unless you have developed an ability to predict the future, please do not urge others to take this risk.
(If you still insist cold turkey is a “right,” I invite you to join my site, SurvivingAntidepressants.org, and provide emotional support for the people who are suffering from cold turkey gone wrong.)
I am sorry to take this politically uncorrect position yet again on MadinAmerica.com. I am sorry that the prison of psychiatric treatment isn’t easier to escape. These drugs are pernicious from start to finish. It’s hard to get free. That’s just the way it is, and it does no good to anyone to pretend the reality is otherwise.
Talk about strange bedfellows!
Very, very few studies on relapse after discontinuation (or, in this case, relapse after inconsistent dosing) include protocols to distinguish withdrawal symptoms from relapse.
(In fact, out of dozens of relapse studies, I’ve seen only one that recognized withdrawal symptoms.)
Therefore, all such studies are confounded by withdrawal symptoms mistaken for relapse.
The expectation of relapse after drug discontinuation permeates the entire practice of psychiatry, and may be false, or at least overblown, by this confounding.
Given the very great difficulty psychiatrists have in recognizing any kind of adverse effects, often blaming them on the person’s psychiatric disorder, I suggest any statistics of relapse in these situations be taken with a large dose of salt.
As for rebound psychosis — as I’ve suggested in comments elsewhere, a nervous system destabilized by withdrawal expresses itself in a wide range of symptoms. Even people who never had any hint of psychosis pre-drug, as in people taking antidepressants or benzos, can have “psychotic” symptoms in withdrawal.
If the person is otherwise asymptomatic on medication, and “psychotic” symptoms appear after withdrawal, I suggest this is not evidence that the drug is needed to control such symptoms but that tapering was too fast, precipitating nervous system destabilization. The withdrawal symptoms may match earlier “psychotic” symptoms because of the particular sensitivities of that person’s nervous system.
Another excellent article, thank you, Sandy.
Once someone has been on any of these drugs for longer than a few weeks, withdrawal symptoms should be suspected whenever doses are skipped.
Could you tell me what protocols in those studies were in place to distinguish “relapse” from withdrawal symptoms?
From what I’ve seen, any type of distress is called relapse, and withdrawal symptoms can cause a lot of distress.
Dr. OBrien, I see your posts on the most recent Pies article http://www.psychiatrictimes.com/blog/pies/content/article/10168/2138321 . In this article, Pies asserts what he always asserts: If psychiatry is done properly, it accomplishes “the relief of suffering and incapacity.”
This tautology, which is vintage Pies, is as circular as an argument can get. And yet he says “the medicalization narrative is philosophically naive and clinically unhelpful.”
I also see your comments on http://www.psychiatrictimes.com/blog/pies/content/article/10168/2135248 . Here Pies touts (yet again) psychiatry as a scientific “systematic methodology based on evidence,” ignoring (yet again) the extensive, indisputable findings that much of psychiatric “evidence” is pharma propaganda.
As for stigma, he maintains that psychiatric diagnoses are merely innocent words, it’s society that supplies the stigma, thereby making the terms context-free. (As though no physician ever applied a psychiatric diagnosis out of prejudice or ignorance!!)
This type of semantic reductionism is also vintage Pies. Words, e.g. DSM-5 diagnoses, are innocent! Stigma is in the interpretation!
Could someone please let Dr. Pies know words have no meaning without interpretation?
You may enjoy jousting with Dr. Pies, but be forewarned — his articles are a compendium of rhetological fallacies ( http://www.informationisbeautiful.net/visualizations/rhetological-fallacies/ ), as you would expect from someone suffering from anosognosia regarding the profession he’s spent a lifetime defending (as Dr. Nardo’s March 30 comment implies).
And, please, let us not forget the relationship, found in studies, between post-partum depression and the new mother feeling socially isolated and not having assistance at home with the infant.
This is another symptom of nuclear families living apart from the extended family, long-time community ties, and traditional support systems. No wonder new mothers feel overwhelmed.
What prospective mothers might very well need is friends like them. They should be guided into peer support networks as part of their prenatal care.
I disagree with Mr. Pies that psychiatry is not responsible for the status quo. Where are the American Psychiatric Association initiatives on gathering post-marketing data on psychiatric drugs, for example?
Here are some more slices of Pies:
Critics of psychiatry are people who just want others to suffer:
http://psychcentral.com/blog/archives/2011/09/13/are-the-puritans-behind-the-war-on-antidepressants/
Here he embarrasses himself with the non-credible claim that psychiatrists never espoused the “chemical imbalance” theory:
http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1902106 (free registration required)
Trying to dig himself out of the hole he’d dug in the earlier article, he says psychiatrists lied about “chemical imbalance” only to make patients feel better:
http://psychcentral.com/blog/archives/2011/08/04/doctor-is-my-mood-disorder-due-to-a-chemical-imbalance/
And, for the whipped cream on Pies, his colleague Steve Moffic, “da man in psychiatric ethics,” on the importance of informed consent:
http://www.behavioral.net/blogs/h-steven-moffic/preventing-epidemic-psychopharmacology-lawsuits
However, as Dr. Moffic found, you need to speak sense to this crowd. Posturing and claiming authority doesn’t cut it.
Did Dr. Pies have all comments that were not complimentary about him removed?
I agree, Sandy. Thanks for putting so much effort into a thoughtful consideration of the problem.
Fish oil might be a fad, but it can do something good for some people. When I was suffering the worst of antidepressant withdrawal syndrome and was at the height of hypersensitivity, after I took my fish oil capsules, I could feel its soothing effect.
I’ve been taking 2,000-4,000mg DHA and EPA daily for many years. My good cholesterol is so high, I’ve been exempted from being harassed to take statins for cholesterol control.
I would not be without my fish oil. I’d love to get my omega-3s from food, particularly fish. If they weren’t a mercury hazard and mostly endangered, I’d eat them every day. Unfortunately, it would have to be as sushi — because cooking destroys the omega-3 fatty acids, as you would expect.
As it is, I eat sushi every chance I can get. I wish I could afford more of it.
[[attacking remarks removed]]
No wonder. The author is a psychoanalyst.
“Dr Blum is a psychiatrist and psychoanalyst in private practice in Philadelphia. He is on the faculty of the Psychoanalytic Center of Philadelphia and is Clinical Assistant Professor of Psychiatry at the University of Pennsylvania.”
Even addiction specialists are confused about the distinction between physical dependence and psychological dependence on drugs.
According to the semantic medico-legal distinction between addictive and non-addictive, which sometimes doesn’t make any sense, being addicted to a drug means you have both physical dependency and psychological dependency.
When it comes to benzos, this distinction is particularly unclear. Benzos can be truly addictive. People can become dependent on benzos in either purely physical or physical-psychological ways. They can be innocently taking exactly the prescribed dosages and get physically dependent, or they can be going for more and more of the psychic numbing and become textbook addicted.
Textbook addicted or not, it is the physical dependency that causes withdrawal symptoms.
Doctors and addiction medicine specialists have difficulty distinguishing between the two. All they know is benzos are addictive, if you have trouble going off them, you must be an addict. They think dependency of any type is addiction.
From what I’ve seen, one distinction between people who meet the definition of addicts and those who are victims of medical ignorance about psychiatric drugs causing dependency is that, once they get off the drugs, the non-addicts never want to go anywhere near them again, and quite often develop an aversion to the entire medical profession as well.
Excellent approach, David. The key is educating doctors.
Good point, AA.
At least the show has the value of perhaps educating PCPs and their patients about how sloppy PCPs can be with antidepressants.
I believe the idea that “autism boils down to affected cellular pathways” is a variation on the “diseased brain circuit” theories of psychiatric disorders now in fashion.
Yes, she’s come long way since she prescribed Prozac for me in the 1990s for PMS!
I don’t believe you did, Sandy. That was my little quip about what I think of a this decade’s “chemical imbalance” theory.
This doesn’t seem too strong to me. Try an appeal at HuffPost.
Michael Cornwall hugs them.
I’d like to see Sandy (or anyone) prove the “diseased neurocircuit” theory of psychiatric disorders myself!
Yes, my OB/GYN is much more aware of adverse effects of psychiatric drugs on women than most psychiatrists. She said she’s seen lots of adult withdrawal syndrome and neonatal withdrawal syndrome.
She’s totally anti-psych drug now, a pharma skeptic among the best of them! She loved the copy of Anatomy of an Epidemic I gave her.
As I commented on Dr. Kelly Brogan’s post regarding medicating pregnant women http://www.madinamerica.com/2013/03/to-medicate-or-not-to-medicate-that-is-not-the-question/ :
Neonatal withdrawal syndrome is well documented. Like adult withdrawal syndrome, it is assumed to last only a few weeks. In neonates, this is when the baby stops continually crying and spasming.
However, in adults, withdrawal syndrome may last quite a bit longer than a few weeks, sometimes into a lengthy post-acute withdrawal syndrome (PAWS) phase, as with other drugs of dependency — see http://www.madinamerica.com/2013/03/alarming-report-on-antidepressant-side-effects/ .
The authors of the above-referenced paper, based on anecdotal patient reports, refer to a “postwithdrawal phase, consisting of tardive receptor supersensitivity disorders.”
We really don’t know what’s going on with neonatal withdrawal syndrome. The baby might stop crying and twitching, but may be suffering the newborn version of depersonalization (for example) for months or years, as adults do.
Let us hope that neonatal neuroplasticity compensates and accelerates recovery from the supersensitivity disorders, and does not devolve into, say, autism.
Allow me to add: Hypersensitivity to various stimuli and neuroactive drugs, supplements, and even foods is a very, very common withdrawal symptom when adults go off antidepressants too precipitously. Who knows what these tiny babies are experiencing?
Excellent points, Hermes. For that reason, I wonder how ofter true “relapse” occurs off the drugs.
Health industry group: Replace psychiatrists with vending machines
Measure to reduce health care costs
1 April 2013 Health Insurance Times (Dubuque, Iowa) A health care industry thinktank, US Health Insurance Consortium on Cost, advocates replacing psychiatrists and other doctors with vending machines to prescribe and dispense antidepressants.
“We believe this will cut the cost of psychiatric services significantly,” Uli Arnowsky, spokesperson for USHICost, said. “Our studies show the diagnosis and prescription process can be automated, with no loss in quality of care. Specialist costs are just not necessary for this type of treatment, and psychiatrists are overworked anyway.”
USHICost’s plan is to make the Psychiatric Diagnostic Screening Questionnaire (PDSQ), based on the new diagnostic manual DSM-5, available online to health plan members. Answers would be captured in a database and analyzed to produce a recommendation for a prescription. A psychiatric nurse reviews the recommendations and authorizes the prescription, which is then attached to the patient’s database record.
Vending machines, in convenient medical center locations and on a secure network, would be stocked with the most common generic antidepressants.
“We prefer the generics,” Arnowsky said. “They’re part of the cost-cutting. Our studies show they’re just as effective as the name-brand drugs.”
According to Arnowsky, to get a prescription filled, a patient would input a health plan ID and a password at a vending machine. The machine would look in the database, dispense the authorized prescription, and charge the copay to a credit card on file in the patient’s health plan record.
“We really like the way this system keeps electronic medical records, too,” Aronowsky said. “It’s a win-win-win for all concerned.”
Patients reporting side effects would be advised to see their doctors, who could then adjust the prescription if needed.
“There’s a lot of trial and error in prescribing antidepressants already,” he said. “This system is no more error-prone than present prescribing practices. In fact, we put fuzzy logic in the system to rotate prescriptions among the antidepressants, because we’ve found doctors prescribe them in an almost random fashion. We built the human element right into the system — it thinks just like a doctor about these drugs.”
He stated that USHICost’s studies had shown diagnosis by PDSQ was at least as accurate as by doctors, including psychiatrists. “This will take a big burden off primary care physicians, too, who are bearing the brunt of prescribing antidepressants,” he noted.
I believe disruption of homeostasis, whatever the mechanism, is the key to how psychiatric drugs “work” (if they can be said to work). Some people interpret the disruption as beneficial, others adverse, and others don’t feel it.
Disruption of nervous system homeostasis often has unintended consequences far from the therapy target, e.g. sexual disfunction.
Once the entire organism accommodates to an artificial hormonal elevation, whether by psychiatric drugs or steroids, a second homeostasis is created that depends on continued application of the drug.
As Hochberg, et al, say in Endocrine Withdrawal Syndromes http://edrv.endojournals.org/content/24/4/523.long#ref-166
“Long-term adaptations to hormones may involve relatively persistent changes in molecular switches, including common intracellular signaling systems, from membrane receptors to transcription factors.”
(The authors believe, erroneously, that rather than throwing another wrench into the works, antidepressants will ease the withdrawal transition. Why can’t they figure out these represent another excessive hormonal therapy?)
Removal of the artificial hormonal elevation by drug withdrawal requires re-adaptation to yet another homeostasis tending toward normal functioning. As medicine is largely willfully ignorant of these iatrogenic effects, how long that might take — or how complete it might be — is a mystery.
This is true in adult and neonatal psychiatric drug withdrawal syndromes. Depending on the discipline, that iatrogenic state of autonomic dysregulation is variously described as post-acute withdrawal syndrome, supersensitivity psychosis, kindling, and HPA axis dysregulation.
What that final post-drug homeostasis might feel like probably varies among individuals. Given the influence of the drugs and the passage of time, it is unlikely that the nervous system reverts to factory settings. You can’t step in the same river twice, especially if it’s been flooded with artificial hormones.
What this argues if, if drug intervention is required, the absolute minimum effective dosage be used to minimize disruption to the original nervous system homeostasis. The usual dosages in psychiatry are more like bludgeons to the nervous system rather than subtle corrections.
Somehow, I left out the citation for the above — that must have seemed very puzzling!
Endocr Rev. 2003 Aug;24(4):523-38.
Endocrine withdrawal syndromes.
Hochberg Z, Pacak K, Chrousos GP.
Abstract at http://www.ncbi.nlm.nih.gov/pubmed/12920153 Full text at http://edrv.endojournals.org/content/24/4/523.long#ref-166
Just published:
Dan Med Bull. 2011 Sep;58(9):A4303.
Paediatric outcomes following intrauterine exposure to serotonin reuptake inhibitors: a systematic review.
Fenger-Grøn J, Thomsen M, Andersen KS, Nielsen RG.
Abstract and free full text at http://www.ncbi.nlm.nih.gov/pubmed/21893008
The use of serotonine reuptake inhibitors (SRIs) is increasing among Danish pregnant women. This systematic review addresses the potential adverse effects on the foetus and child of maternal SRI medication. The literature indicates a slightly increased risk of cardiovascular malformations and persistent pulmonary hypertension of the new-born, while evidence regarding the risk of preterm labour, low birth weight, low Apgar score, prolonged QT interval and miscarriage is less clear. An estimated 20-30% of infants will have neonatal symptoms following intrauterine SRI exposure. The symptoms may be caused by SRI withdrawal, toxicity or their overlap, but symptom aetiology basically remains controversial. The infants may exhibit neurological, gastrointestinal, autonomic, endocrine or respiratory symptoms. Although the symptoms are self-limited, the families may be seriously affected. In general, studies do not address this important aspect. Evidence concerning long-term effects is surprisingly sparse and many studies have important methodological limitations. However, present evidence does not convincingly indicate detrimental long-term effects. Until sufficient safety studies have been carried out, SRI must be used with caution in pregnancy and every treatment of the pregnant woman should be thoroughly considered.
Please allow me to say again: The assumption that neonatal withdrawal symptoms are “self-limited” is based on very limited evidence. The same assumption pertaining to adults is contradicted by hundreds of thousands of reports on the Web of withdrawal syndrome lasting many months or years.
I am wondering about the dopamine supersensitivity hypothesis.
What we are seeing when people withdraw from SSRIs and SNRIs too precipitously — even when they had no withdrawal symptoms while tapering or for months afterwards — is a recognizable supersensitivity to stress, evidenced by unprecedented symptoms described as anxiety surges, panic attacks, and a harsh sleeplessness over days or weeks.
Anxiety surges in the early morning are a common feature, an exaggeration of the diurnal cortisol peak that normally gets us ready to wake up and start our days.
As SSRIs and SNRIs have only an indirect effect on dopamine, it’s unlikely that dopamine alone is the culprit for these tardive symptoms. Rather, they’re due to a more generalized disruption of autonomic regulatory systems resulting in over-representation of alerting activity.
These psychiatric drug withdrawal symptoms have a lot in common with endocrine withdrawal symptoms, see
“….Interestingly, hormones with completely different physiological effects can produce similar withdrawal syndromes, whereas some of the clinical manifestations that are due to the chronic presence of high hormone levels or withdrawal syndromes are also observed with drugs of abuse. This review postulates that changes of the hypothalamic-pituitary-adrenal (HPA) axis and the central opioid peptide, noradrenergic and dopaminergic systems act as shared features in the pathogenesis of several endocrine withdrawal syndromes…..”
They repeatedly advise slow tapering to avoid such symptoms.
Although the authors are struggling to associate particular symptoms with putative hormonal mechanisms, which I believe is barking up the wrong tree (the right tree being a more generalized autonomic disruption), the overlap of endocrine withdrawal symptoms with what we know of antidepressant withdrawal syndrome is striking (see Figure 2 in the paper http://edrv.endojournals.org/content/24/4/523/F2.large.jpg ).
In terms of autonomic disruption, there may be no real distinction between playing with levels of neurohormones and playing with endocrine hormones.
I suggest that the supersensitivity psychosis seen after even apparently uneventful withdrawal of antipsychotics is parallel to the stress hypersensitivities very frequently seen in SSRI and SNRI post-withdrawal syndromes, but expressed as “psychotic” symptoms reflecting the particular neurological variability of those who came in hearing voices, etc.
Sandy, I’d be interested to see what you think of the new article by Martin Harrow and Thomas Jobe http://www.madinamerica.com/2013/03/do-antipsychotics-worsen-long-term-schizophrenia-outcomes-martin-harrow-explores-the-question/
As quoted by Bob Whitaker, Harrow and Jobe say: “The discontinuation effect includes the potential of medication-generated buildup, prior to discontinuation, of supersensitive dopamine receptors, or the buildup of excess dopamine receptors, or supersensitive psychosis….” which would suggest some “relapse” is a withdrawal effect.
Those elevations in inflammatory markers seen in the “treatment refractory” (if they exist) may be the result of repeated insult by serial medications.
Has anyone considered not meddling in brain chemistry of these people for a while to see if such markers decrease?
I agree there’s a lot of value in alternative medicine. A true healer is hard to find in any modality.
How excellent that Martin Harrow revisits his own study and elaborates on his interpretation of his own findings!
You bet, some “relapse” is withdrawal syndrome, as Harrow and Jobe say: “The discontinuation effect includes the potential of medication-generated buildup, prior to discontinuation, of supersensitive dopamine receptors, or the buildup of excess dopamine receptors, or supersensitive psychosis….”
Hermes, this is an endless discussion, and off-topic attached to Sandy’s blog post, but I would challenge that antidepressants have any magical effect on depression specifically.
Rather, like amphetamines and other psychoactive substances, they are stimulating or cause other neurological noise (such as emotional anesthesia) that some people report as relieving symptoms of “depression” (whatever that is). Others report effects that they feel as adverse, including — quite commonly — overstimulation.
Antidepressants don’t “work” for depression any more than, say, LSD “works” for depression.