Tuesday, September 18, 2018

Comments by Altostrata

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  • 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.

  • 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.

  • 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.

  • 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?

  • 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

  • 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.

  • 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

  • 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.

  • 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.

  • As I commented on Dr. Kelly Brogan’s post regarding medicating pregnant women https://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 https://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?

  • 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.

  • 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 https://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?

  • 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.

  • Very good post. However, Dr. Brogan says “there still isn’t a clear signal of any reproducible, consistent teratogenicity or danger that is definitely not attributable to the underlying illness.”

    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 https://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.

    As for post-natal depression, studies show that mothers who feel isolated are more prone to this. Dr. Brogan, I urge you to add peer support groups for mothers-to-be and new mothers as an intervention to improve the health of mother and baby without resorting to treating with psychiatric drugs.

  • While I share your concern about communicating the dangers of psychiatric drugs, I wouldn’t deny reality to support an argument against them.

    Many people say they do recover completely. If we don’t accept their subjective opinion of recovery, how would we assess recovery?

    The suffering people incur along the way to recovery is enough of a demonstration that these drugs should be prescribed much, much less frequently and that medicine should know much, much more about tapering.

  • I agree that, by and large, taking a supplement is a lot less dangerous than taking a psychiatric drug. (However, I’ve got a couple of cases of people having difficulty withdrawing from SAM-e….hmmmm….)

    I get outraged about any kind of dishonesty in health treatment, alternative or allopathic.

    Some people just don’t have the money to waste on misrepresented treatments. For example, many naturopaths will order urine tests that purport to measure neurotransmitter balance from a company called NeuroScience. The lab reports come complete with recommendations for NeuroScience’s pricey supplements formulated to correct whatever neurotransmitter imbalances are found. How could this possibly be valid?

    I wish now I had the several hundred dollars I wasted on that bogus testing and those supplements when I was much more naive.

    (Many people have adverse reactions to NeuroScience supplements, which contain various neuroactive ingredients.)

    Like TrueHope’s EmpowerPlus, Immunocal is another supplement for which the manufacturer, Immunotec, generated studies and a lot of scientific-sounding blather supporting its use. Immunotec also got Immunocal approved as a prescription “medical food” reimbursable by Medicare. Immunocal is a whey protein isolate. Unlike other whey protein isolates, supplement composition for Immunocal is held secret.

    From what I can glean, Immunocal is roughly equivalent to NOW Whey Protein Isolate, which lists its composition on its label and is available without prescription. The difference: Immunocal is 15 times more expensive. You (or Medicare) pay $85.00-$99.00 for 300 grams of Immunocal; for the same amount of money, you can get 4536 grams of NOW Whey Protein Isolate.

    Beyond cost, there are real dangers in supplement manufacturer misrepresentations. Neurocritic discusses TrueHope’s liabilities in this post http://neurocritic.blogspot.co.uk/2012/07/empowered-to-kill.html , which includes some very interesting transcripts of TrueHope support calls with people desperate for solutions to their health problems.

  • When you say not hearing about this, do you mean from your patients or other physicians?

    (If physicians — no surprise there. Most could not recognize a withdrawal symptom if it jumped up and bit them.)

    If patients, how are they doing after the second 25% reduction?

    We’re seeing people often can get about half-way down before further decreases cause withdrawal symptoms. My guess is because there’s a lot of excess capacity in common dosing levels.

    Also — people with no prior history of “psychotic” symptoms who are reducing antidepressants or benzos sometimes report psychosis-like withdrawal symptoms, such as hallucinations or depersonalization.

    I suggest this is indicative of withdrawal-induced nervous system instability. A person with a history of “psychotic” symptoms whose nervous system has accommodated to a drug may become similarly destabilized upon withdrawal. More gradual tapering would maintain the stability achieved on medication.

    Sleep disturbance during tapering is an indication of destabilization.

    There are many ways to reduce dosage by amounts smaller than the tablets supplied by drug companies. People use the liquid form of the drug, split tablets, weigh fragments with digital scales, open capsules to count out beads, have drugs compounded into liquids and smaller capsules, and make their own liquids with water or the Ora-Plus suspension base. They become expert in the use of oral syringes.

  • I was referring, probably too obliquely, to the Deplin studies.

    Still, that there is a population with folate processing difficulties — or subclinical low B12 — who might display “psychiatric” symptoms suggests we should do a much better job of screening for those conditions before treating with psychiatric drugs, which do absolutely nothing for the vitamin deficiencies.

  • Sandy, in my opinion, a dosage reduction of 25% is going to be too much for some of your people. If you observe them for a month, the most sensitive will become apparent — and they will be suffering a lot.

    However, for a middle group, withdrawal symptoms sometimes don’t show up for months. If by the second month you’ve decreased by another 25% or 50%, you’re putting those people in jeopardy of withdrawal symptoms after the final dose.

    To minimize withdrawal symptoms, I suggest a reduction of 10% the first month and another 10% for a second month. With 2 months’ observation, you will be able to tell who can reduce faster, by 10% every 2-3 weeks, and most of those who need to reduce slower.

    If this seems like a pain in the *ss, well, yeah, it is. That’s what the physical dependency incurred by these drugs does — puts those who are more neurologically vulnerable at risk for withdrawal symptoms.

  • Doesn’t it seem odd to you that people who have low B12 and folic acid are being diagnosed with psychiatric disorders and treated with psychiatric drugs instead of B12 and folate?

    That’s what those studies are finding — a fairly significant rate of misdiagnosis of relatively simple B12 and folate deficiencies.

    Psychiatry should be apologizing to those people instead of recommending “adjunct” treatment with B12 and folate!!!

    Bonnie Kaplan has, unfortunately, sullied her reputation by her association with the TrueHope company and their supplement EmpowerPlus, which is nothing but an overpriced ordinary multivitamin for which its manufacturer makes excessive claims.

    (TrueHope’s activities are of great concern to me because it also gives out bad information about tapering off psychiatric drugs — with the help of its supplements, of course.

    This is not to say that nutrients and the lack thereof cannot be involved in producing “psychiatric” symptoms and supplementation may relieve those symptoms.)

    In 2006, I wrote to Bonnie Kaplan, whose research is what TrueHope uses to back up its claims. Here is her response:

    Date: Thu, 16 Feb 2006 12:16:24 -0700
    From: “Bonnie Kaplan”
    Subject: [altostrata]
    To: [altostrata]
    Hello [altostrata],
    I’m glad you are checking on ingredients, because the supplement has
    changed since the list in the 2001 publication. The company was able to
    change the processing to provide a much finer particle size for the
    minerals, which seems to enhance the absorption of the minerals (makes
    sense), and so the quantities of some were reduced by a third. The
    current adult full dose = 15 capsules/day (not 32, as it was in 2001).

    You asked about two ingredients in particular. I believe the current
    level of inositol is just 180 mg (very tiny compared to the literature
    on inositol using it in isolation), and the phenylalanine is 360 mg. You
    could check with the company on their website (truehope.com), or phone
    them.

    I’m not affiliated with the company, and in fact I will paste below a
    prepared message that I use when responding to email queries. There may
    be other information in it that is relevant to you.

    Best of luck to you,
    Bonnie Kaplan

    ————————————————-
    Thank you for inquiring about the University of Calgary research on
    micronutrient supplementation in the treatment of bipolar disorder. The
    supplement we are currently studying is available commercially as
    Empowerplus (a slight modification from its name prior to 2003, which
    was E.M.Power+). Our first peer-reviewed article was published in the
    December 2001 issue of the Journal of Clinical Psychiatry, along with
    an excellent commentary by Dr. Charles Popper from Harvard Medical School and McLean Hospital. A second article has been published in the Journal of Child and Adolescent Psychopharmacology. Additional confirmation of our results has been published in a Letter to the Editor of the Journal of Clinical Psychiatry, by Dr. Miles Simmons, of Maine. Another
    manuscript containing an open label case series in children was
    published in April 2004 in the Journal of Child and Adolescent
    Psychopharmacology.

    A formal placebo-controlled clinical trial has recently begun in
    Calgary, Alberta, Canada: it involves adults with bipolar disorder who live in the Calgary area. It is using the newer version of Empowerplus (as opposed to the one employed in all previous publications). You can read about the current study on its website: http://www.MoodStudy.com. If you would like to be on our mailing list to receive reprints of this and future articles,
    please send me your mailing address.

    The following are some additional facts that may interest you:
    The ingredients of this supplement are mostly ordinary minerals and
    vitamins. They are certainly not unusual or exotic: a normal everyday
    diet includes 34 of the 36 components, though not in such high amounts.
    A full daily dose initially consists of 5 capsules three times/day (=
    15/day). [Note: our publications thus far employed an earlier version,
    containing many more capsules.] Most people decrease that to a maintenance dose after a few months, usually at about 4 capsules twice/day (=8/day). The ingredients are not a secret: they are listed on every bottle, at the Truehope website mentioned below, and in our published articles.

    If you are a physician considering using this supplement for patients
    who are currently taking psychiatric medications, I urge you to read Dr.
    Popper’s commentary carefully.

    To purchase this supplement, the distributor can be reached at the
    toll-free number on the website (www.truehope.com), which is
    1-888-truehope (1-888-878-3467). That is also the phone number to call
    if you just have general questions about the supplement. The Truehope
    people are not medical researchers or even health professionals, and
    you will see that the website is written for the general public. The
    Truehope people have a system in place for talking with you and the relevant physicians about the use of the product. Although they do not have health professionals available to provide guidance, this “friends
    helping friends” system will be able to provide information that might be
    helpful.

    None of the academic researchers benefit financially from the sale of
    this product. None of us ever receives any money from the Truehope
    people.

    Thank you for your interest in our work. If you have any further
    questions about the academic research, feel free to write directly to
    me.

    Bonnie Kaplan


    Bonnie J. Kaplan, PhD
    Professor, Dept of Pediatrics
    Univ of Calgary, Alberta Children’s Hospital
    Phone: 403-943-7363 FAX: 403-543-9100

  • I am quite sure the rate of relapse after discontinuation of any psychiatric drug is inflated by the almost universal misdiagnosis of withdrawal symptoms as relapse.

    There are virtually no guidelines for tapering; we can be sure some of those who were observed to be relapsed in studies were discontinued too fast for their individual tolerances.

    In addition, of all the hundreds of clinical trials that involved observation (lasting only weeks) after discontinuation, I’ve seen exactly one that included a protocol to distinguish withdrawal symptoms from relapse. All the others — 99%+ of studies — use psychopathology scales for assessment. Any symptomology at all is going to be reported as a psychiatric condition rather than withdrawal symptom.

    The statistics for relapse are likely all incorrect. I would like to see some reporting based on slow discontinuation and careful observation of withdrawal symptoms during the process, and observation for at least 6 months post-discontinuation.

  • ScottW wrote: “I think we will be able to identify some discrete entities or at least categories which are similar enough to be meaningful. I can’t prove it yet, that is just what I think.”

    Yes, this is a matter of belief. Jay Joseph’s articles explain how history has proved this is unfounded. However, given the collapse of the “chemical imbalance” theory, psychiatry needs a scientific rationale, and millions of dollars are now being poured into genetic research and brain scans in psychiatry — all on the basis of belief, which becomes quasi-religious and impervious to evidence.

    If you look at the vagaries of diagnosis in psychiatry, you will see why “discrete entities” are unlikely to be found. That high-tech research is being done on heterogenous populations because disorders are so sloppily defined. The results of the research are, therefore, chimerical — dependent of the biases of the researchers.

  • To say that so-called psychiatric disorders have a biological basis because they occur in the brain, nervous system, and body — as all thoughts, feelings, senses, etc. do — is reductionism of the worst kind.

    Yes, there must be a physiological basis for thoughts, feelings, senses, etc. But that does not mean there is a physiological disorder or disease underlying specific thoughts, feelings, senses, etc.

    In fact, the “brain circuitry” proponents in psychiatry propose that disorder or disease underlies only those thoughts, feelings, senses, etc. of which they disapprove and have designated as “abnormal,” when they may not be abnormal at all.

  • Interesting. In my experience with (unfortunately) multiple psychiatrists and non-psychiatrists, they did not trouble to find out whether stress was a factor in my complaints.

    All of my doctors were chosen for their excellent (and, as I found out, undeserved) reputations.

    I was told on many occasions that my issue was a “chemical imbalance.” Prescriptions seemed reflexive and quite arbitrary — one internist told me “pick one, SSRIs are all the same.”

    My conclusion is that no one should even attempt to discuss emotional problems with an M.D. They’re not selected or trained to be particularly empathetic. Feelings make them uncomfortable. Their fingers get itchy for their prescription pads no matter what. They hear you whining and — boom — you’re on meds for life.

    ScottW, I disagree strongly that distinguishing genetic vs. environmental causes is not relevant to treatment.

    Historically, emotional states aka “psychiatric symptoms” caused by environmental factors tend to resolve spontaneously within a short amount of time. They do not require invasive treatment such as psychiatric medication, with its many added risks.

    One might say emotional distress is nature’s way of telling us to change our circumstances, not to take a pill.

    You seem to have profound faith in the medical profession and psychiatry research, although the latter has been shown to have been distorted by commercial interests for the last 30 years. It’s not nearly in the same league as neurology research into Alzheimer’s. Have you read Robert Whitaker’s Anatomy of an Epidemic?

  • Yes, exactly.

    A harsh withdrawal from antidepressants or benzos can also include symptoms mistaken for “psychosis.”

    The symptoms are not related to the drug but to the nervous system destabilization that follows from going off the drugs too fast.

  • Many commentators here are addressing relapse or treatment of “mental illness.” Some non-drug treatments are indeed effective.

    But it is crucial to differentiate between the iatrogenic condition induced by psychiatric drug withdrawal and natural neurological variation.

    For the most part, the symptoms of psychiatric drug withdrawal syndromes are caused by autonomic dysfunction of a type that is not seen in nature — except in cases of chronic exposure to toxins.

    The autonomic nervous system is as complex and mysterious as it is important, as it runs all the “automatic” functions of your body, such as heartbeat, blood pressure, digestion, etc. through a poorly understood web of feedback mechanisms. Dysautonomia can have an intense effect on cognition and emotion as well.

    Even cardiologists and neurologists only very, very carefully attempt treating the autonomic nervous system. When you “adjust” one area, it tends to cause disruption in another.

    You cannot treat psychiatric drug withdrawal syndrome as a psychiatric illness. It is not an emotional state, it is dysautonomia. This is why careful tapering to the tolerance of the individual is key to going off psychiatric drugs. Once autonomic dysfunction takes hold, recovery can take a very long time.

    There are no silver bullets for dysautonomia. For the most part, you have to adopt healthy habits that are gentle on your nervous system and wait for it to heal.

    I urge anyone who is concerned about getting people safely off psychiatric drugs to look at many, many case histories to see what’s involved.

    Don’t try to guess what people need from one case or a handful of cases, or from a theory of what might work. See what people who are trying to go off psychiatric drugs actually need by reading their stories.

    There are a couple dozen peer-run Web sites for psych drug tapering and about the same number of Facebook groups. Search by the name of the drugs, for example: “Seroquel withdrawal”, “Effexor withdrawal”, “Ritalin withdrawal”, “Xanax withdrawal”. You’ll see hundreds of thousands of posts from people who are going through withdrawal.

    To be sure, the ones who never had any problems going off their drugs are not posting on the Web. But if you’re planning a withdrawal program or are otherwise interested in the subject, you would be best prepared to understand the worst that could happen.

  • Daniel, “horrible” is an understatement!

    Please note that I posted the above on behalf of a correspondent. Personally, I don’t condemn occasional benzo use to deal with withdrawal symptoms post-discontinuation.

    Tapering should incur almost no withdrawal symptoms. Withdrawal insomnia indicates you’re tapering too fast.

    Rather than relying on benzos during a taper, if withdrawal symptoms occur, the safer thing to to is to slow the taper — hold on the taper or updose slightly, stabilize, and then reduce by smaller amounts.

    If withdrawal symptoms start, they’re probably going to continue through further reductions. Here’s where there’s a risk of depending on a benzo: You’ll be tempted to take them frequently.

    From my perspective, the danger of occasional benzos to deal with post-discontinuation withdrawal syndrome is that usually the person’s nervous system is sensitized to neuroactive substances (including supplements, alcohol, and marijuana) by withdrawal. Benzos can have a paradoxical effect and if this happens, it can make withdrawal syndrome worse.

  • Jonah, it appears we are in the realm of the hypothetical again.

    It’s a lot easier being an armchair philosopher speculating about what might be good for other people than it is to connect with them one-to-one and try to help them.

    There are many people suffering from post-discontinuation withdrawal syndrome on my site. If you think it would help them, you are invited to counsel them in your 12-step approach and see what kind of reception you get.

    Otherwise, no, I’m not going to recommend it to the people who come to my site. It doesn’t seem appropriate to me for the purpose of supporting recovery from psychiatric drug withdrawal.

  • Jonah, some people do find benefit in 12-step programs and some do not. The AA approach is quite controversial.

    Your own experience is entirely valid but may not be generalizable.

    I have experience with this population, many hundreds of people, and I have put forth my opinions above based on that experience.

    From what I’ve seen, pondering and rectifying one’s faults in the 12-step manner would only to the stress of withdrawal syndrome.

    Oh, yes, withdrawal does have adverse neurological effects. If you haven’t experienced the harsh emotions emanating from a nervous system destabilized by withdrawal, you are fortunate.

    If you’ve changed your mind and you’d like to provide support to people suffering from withdrawal syndrome and thus gain insight into what others are going through, please let me know.

  • A correspondent from a benzo withdrawal group on Facebook, a person “who survived benzo withdrawal and 6 years later, began to feel better,” asked me to post the following.

    This person wants to caution against regular use of benzos to counter withdrawal symptoms; benzos themselves incur physical dependency and can be difficult to taper off of.

    “I am beyond horrified that [Daniel Mackler] would mention taking benzos to “help” [withdrawal], for obvious reasons. While in post-benzo withdrawal myself for a few years, I was lucky if I could get out of bed.

    “I’m concerned for those reading his article that might think 1) taking benzos is ok, and 2) that they will feel more despair, shame, and guilt than they already do in drug w/d if they can’t “get moving” any faster than they are able.”

  • If there ever is such a thing as an inpatient withdrawal facility permitting tapering as long as it takes, I’d like to see it modeled on a health spa, complete with healthy spa food.

    As for the 12 steps, I don’t see why people who have suffered iatrogenic harm have to in any way blame themselves, try to purify themselves of evil, or focus on their shortcomings.

    What I’ve seen is that some people suffering in withdrawal try to figure out why the universe is punishing them — this must be an atavistic belief system in humans — and feel terribly guilty for every little error they’ve ever committed.

    (There also seems to be part of withdrawal syndrome, there’s something going on neurologically that unearths every painful memory you’ve ever had.)

    What I tell them in these situations is to forgive yourself and focus on taking care of yourself. Being pushed to this out of necessity often is a revelation and a spur to spiritual growth. Distressed people often seem to have self-neglect at the root of their troubles, and cherishing their own well-being opens them up.

    There is a punitive or moralistic aspect to 12-step programs and other addiction interventions that I do not believe is at all appropriate for people having difficulty in going off psychiatric drugs.

  • In response to Nijinsky’s post on February 28, 2013 at 8:41 pm:

    Yes, some people can fairly quickly go off drugs with few problems, but others have massive problems. It’s the luck of the draw. It can’t be predicted.

    It’s likely you heard from the lucky ones because the unlucky ones….well, they might not be getting out much….

    Withdrawal syndrome is not a matter of psychological dependency, it’s a neurophysiological vulnerability. Implying withdrawal is “all in your mind” is as cruel as dismissing any complaint of an adverse effect from a psychiatric drug.

    Tapering is a way to reduce the risk of withdrawal syndrome. Cold turkey is a way to dare the fates. Lose the bet and you can be suffering badly for a very, very long time.

  • Ran out of Reply buttons.

    In response to Daniel Mackler on February 28, 2013 at 7:02 pm:

    Daniel, I’m glad you’re thinking about this subject. Overmedication is so prevalent, affecting tens of millions, the problem of getting people off drugs without further damage to their nervous systems is huge.

    But we have to get beyond the hypothetical. (There’s a great deal of the hypothetical on MIA.) What can be done to help the many people who need this assistance now?

    First, I contend conceptualizing the solution as inpatient programs is going in the wrong direction. By its nature, gradual tapering takes too long to be an inpatient process.

    Funding such inpatient facilities all over the world would be an impossibility. The services need to be decentralized.

    The best way to get people off drugs is with localized resources: Educated doctors along with psychotherapeutic support.

    You need prescribers to write the prescriptions for tapering. These prescribers should coordinate with therapists supporting the person’s re-entry into non-medicated life.

    Educated prescribers are the scarcest resource in this scheme. How can we find them? If we have to train them, how can we reach them and train them?

  • Actually, people often end up medicated to the gills for no good reason.

    90% of those on psychiatric drugs in the US are on antidepressants.

    My hypothesis — which I believe would be confirmed by a study of systematic tapering — is the horror stories you hear of relapse are severe withdrawal syndrome from too-fast tapering. Those symptoms can include symptoms mistaken for psychosis.

    However, with all due respect to psychotherapists, there are many people going off their drugs without need for psychotherapeutic support.

    Many therapists, believing psychiatric drugs are essential to treatment, will discourage the person’s plan to go off.

    Going off drugs without tapering is risky, but going off drugs without a therapist is very doable.

    That said, supportive therapy is a very good thing to have while tapering, if only to work through the distrust for doctors the process engenders and the realization that one has wasted many years in a drugged haze.

  • Yes, it’s clear to me you assumed tapering was a given, and that’s why I’m so exercised about your post.

    Your assumption that “tapering is a given” is incorrect, and that you can simply get a psychiatrist on staff who knows how to do it — problem solved.

    The ignorance of the medical profession about tapering is why so many people are terrified about going off their drugs. They’ve heard stories of bad tapers, they might have had such experiences themselves, their fears are well-founded.

    Now, about one of the points you put forward above: “Gather detailed information from those who have tried coming off.”

    I’ve given you hundreds of case histories http://tinyurl.com/3o4k3j5 , scientific literature http://tinyurl.com/aqg3bjo , and even tips about tapering specific drugs http://tinyurl.com/42ewlrl

    It’s all tied up in a neat package for you. What are you and your colleagues going to do about it?

  • If by “systematically” you mean studies by medicine, you are correct.

    If we wait for some authoritative study to come out of psychiatry about the proper rate of taper, we will be waiting a very, very long time. The problem of withdrawal syndrome is widely denied by medicine.

    In the meantime, millions of people — I am not exaggerating — are at risk of improper tapering and developing long-term withdrawal syndrome.

    (Thus, peer support sites like mine offer the only tapering coaching available to many people. There are about a dozen or so such sites.)

    If we want any studies, we will have to do them ourselves. That is why I collect case histories here http://tinyurl.com/3o4k3j5 It behooves the MadinAmerica community to respect the knowledge of peer counselors like myself in this area.

    Allow me to explain why tapering, and not support, should be the focus of a withdrawal program. If the person develops withdrawal syndrome, a psychotherapist will be supporting someone with a chronic medical condition, not someone with a clear horizon for personal growth.

    I must stress — the major risk in psychiatric drug withdrawal is not relapse but withdrawal syndrome.

    Psychiatric drug withdrawal programs are misconceptualized as inpatient programs. You will not be able to get most people off psychiatric drugs in a few weeks or even a few months of inpatient care. The rate of taper should be tailored to individual tolerance, not to an arbitrary schedule set by an inpatient program (and insurance coverage).

    The addiction medicine model does not apply to psychiatric drug withdrawal. People do not have to be retained as inpatients to make sure they are going off psychiatric drugs. Usually, they are all to willing.

    Psychiatric drug withdrawal should be conceptualized as an OUTPATIENT service (with informed inpatient services available to the minority with extreme negative reactions to dosage changes; this is NOT available now). Clearly, it needs to be decentralized to serve the millions who need it. Who should do it? Individual physicians.

    How can psychotherapists assist in getting clients the medical help they need in tapering? First, educate yourself about the tapering process. Joseph Glenmullen’s The Antidepressant Solution is probably the best book on this subject (although I disagree with his rate of taper).

    Once you educate yourself about the process, you will be able to talk to physicians about it. Any physician you ask will claim to understand tapering; you will need to ask questions to find out how much the person actually knows.

    One red flag is a reliance on skipping doses to taper. If a doctor does this, he or she knows nothing about tapering.

    Find out from the physicians you have contact with who gets the concept of tapering. Share this information by putting these doctors on a central list that patients, therapists, and other physicians can see.

    Speak in your local and regional organizations about the need for careful, individualized tapering to get off psychiatric drugs safely.

    I’m sorry to be so grouchy about this, but I’m quite frustrated by the insistence that nothing is known about tapering because the doctors you know don’t know squat, and the genuflection to psychiatric mythology.

    Something is definitely known about tapering, and that is: Slower is better, withdrawal symptoms should be all but absent.

  • Jay Joseph, how would you interpret this latest study http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/37584

    Primary source: Lancet
    Source reference:
    Smoller JW, et al “Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis” Lancet 2013; DOI: 10.1016/S0140-6736(12)62129-1.

    Additional source: Lancet
    Source reference:
    Alessandro Serretti, Chiara Fabbri “Shared genetics among major psychiatric disorders” Lancet 2013; DOI: 10.1016/S0140-6736(13)60223-8.

  • Daniel Mackler, thank you for bringing up this very important issue again. The difficulty of getting off psychiatric drugs shadows every discussion of non-drug alternatives.

    But — if I hadn’t been beating my head against the wall for years trying to educate about psychiatric withdrawal, I wouldn’t have believed you could leave out the MOST IMPORTANT aspect of safe psychiatric drug withdrawal.

    This should have been the first item on your list: Understanding what TAPERING means.

    As in your article, there is a lot of emphasis out there from psychologists on “support” for the person withdrawing, as if the only issue was the emotional distress of dealing with a changed situation or maybe relapse.

    But prescribers all over the world, including the vast majority of psychiatrists, are actively injuring people by not understanding even the basics of TAPERING.

    It’s a lie that withdrawal syndrome is mild and lasts only a few weeks. It can be very severe and last for years. It amounts to iatrogenic neurological dysfunction. The risk of withdrawal syndrome can be reduced by TAPERING.

    TAPERING means a gradual, progressive, systematic reduction in dosage. The consensus among peer support sites is that 10% is a rate of dosage reduction that minimizes withdrawal symptoms.

    People who are sensitive to dosage reductions may need to taper as slowly as 10% per MONTH, calculated on the last dosage (the amount of decrease gets continually smaller). People who are very sensitive may be able to reduce by only a fraction of a milligram per month or longer.

    Does this seem onerous? Psychiatric drugs are tremendously powerful. Read case histories here http://tinyurl.com/3o4k3j5

    If a person does not have the self-discipline to taper at 10%, even reductions of 10% per week are safer than decreases of 25% or more at any interval.

    (NEVER skip doses to taper — this is an old wive’s tale going around among doctors. It’s second only to cold turkey in eliciting terrible withdrawal symptoms.)

    Cutting up tablets, using liquid preparations, and customized prescriptions from a compounding pharmacy are a few ways you can accomplish gradual tapering.

    You say “helping people withdraw from neuroleptics in a systematic way is largely unexplored territory.” Excuse me???? I’ve got hundreds of pages of information about tapering here http://tinyurl.com/42ewlrl and symptoms here http://tinyurl.com/3hq949z Journal articles are here http://tinyurl.com/aqg3bjo

    I spend hours every day giving people tips about tapering.

    Let’s stop pretending that neuroleptic withdrawal is a black box. There is actually a great deal known about it. There are some big lies — that withdrawal syndrome is trivial and lasts only a few weeks is the biggest. I’m glad ChuckSigler mentioned “post acute withdrawal” syndrome — many people who believe they’ve relapsed after withdrawal are actually suffering from this.

    Prolonged withdrawal syndrome from psychiatric drugs is largely denied by psychiatry. David Healy is one of the very few authorities who have warned about it.

    There is no information about success and failure rates, as you mention above, because proper systematic TAPERING is so infrequent.

    As far as leaving TAPERING to the “good psychiatrist” you’ll have on board — try to find one. Very few psychiatrists know how to taper. I wish I were exaggerating. This is the only list of such resources that exists http://tinyurl.com/7cp8l8v and it was incredibly difficult to find them. (If you know of a doctor knowledgeable about tapering, please write me at survivingads at comcast * net)

    Here’s what patient advocates need to do to provide a safe avenue off psychiatric drugs: Educate themselves and doctors about TAPERING.

  • “The study will use new technology from CNS Response Inc., which will allow military researchers to track electrical activity in the brains of 2,000 troops and civilians suffering from depression. They’ll compare the results with thousands of others in the firm’s online registries, allowing experts to develop new treatment approaches.”

    Don’t count on this study showing anything about anything. It sounds like they’re going to get brain scans.