Monday, September 24, 2018

Comments by Shipko Stuart

Showing 33 of 33 comments.

  • The informed consent before starting a SSRI needs to include that “you may not be able to stop this drug, even if you have only taken it a short time and even if you have unpleasant side effects.”

    There is a growing problem with akathisia in people taking SSRIs for long periods of time, even if they are not tapering. My impression is that the akathisia is most often labeled “treatment resistant” depression. This article indicates that there is going to be a lot more akathisia as time goes on.

    This article, and others, support the notion that the SSRIs are not easy to stop for a large percentage of people who take them. The desperation of a person who is suffering because of a SSRI, and then suffers worse when they try to stop is heartbreaking.

  • I really liked this article for its broad analysis of the factors leading to suicide. On a slightly tangential note, my understanding is that the primary issue leading to DFW’s suicide was that after he stopped taking Nardil he had a severe withdrawal reaction that did not respond to anything – including the ECT. Is this accurate?

  • Addyi is a SSRI which did not get FDA approval. In reviewing the data originally submitted for antidepressant approval, the drug was noted to have the typical adverse effects on sexual functioning that the other SSRIs show. When data was resubmitted for the female Viagra, there were no adverse effects on sexual functioning. One would expect that a substantial number of women prescribed this drug will show sexual dysfunction and other typical adverse SSRI effects.

  • Thank you for this thoughtful review. While those entrenched in Pharma will find reasons to dismiss this article, there are many more who will be educated and enlightened. My sense is that there is increasing awareness of the dangers of antidepressants, and this article is going to foster even greater awareness. One would think that the insurance industry would take an interest in this article as well.

    Comments have been largely about how the medical model encourages suicide, and indeed it does. I would like to underscore that the powerful direct effects that serotonin based antidepressants have in causing suicidal thought and intention. While akathisia is the most commonly discussed mechanism of suicide, my observation is that they cause suicidal thoughts in other ways as well. Even in the absence of akathisia or severe depression SSRIs can induce a strong sense that suicide (and also death of loved ones) will be relaxing and pleasant. People sometimes develop an obsessive suicidal preoccupation, constantly considering all of the ways that they might kill themselves.

  • Here is the email reply:

    Dear Dr. Stuart Shipko,

    It seems to me that withdrawal symptoms are (by definition) unlikely if people start experiencing the symptoms you describe months after they tapered their antidepressant. The most likely explanation would then be relapse, but perhaps there are long term effects of (long term) antidepressant use we do not know enough about yet.

    I think that this issue is important and should be investigated. However,our study was focussed on the taper itself (which was enough work to get it right) and we do therefore not know how people fared after they finished their taper. Hopefully we will be able to follow up people for much longer times in the future.
    with kind regards,
    Peter Groot

    Dr. P.C. Groot
    User Research Centre
    Maastricht Universitair Medical Centre

  • It does seem surprisingly, fast. I sent Cinderella Therapeutics an email to ask if they have any 3 month or 6 month follow up data, particularly as it relates to tardive akathisia.

    Despite the points that can be criticized, there is a lot to love in this article. The data they present addresses the enormous scope of the antidepressant withdrawal problems.

  • One is labeled an antipsychiatrist when stating that there is no such thing as ADHD. But lets face it. The whole condition of ADHD is a marketing strategy. All anyone ever knew was that there were children who were incorrigible in class and became calm on amphetamine products.

    Judging by all the amphetamine seeking people who call my office, the stimulant epidemic is already here. The Netflix documentary ‘Take Your Pills’ does a good job at explaining that stimulants have become acceptable performance enhancers in an increasingly competitive society.

  • I suspect that most psychiatrists and medical prescribers, if they have the opportunity to read this, will dismiss it as antipsychiatry rhetoric. On the other hand, I have been meeting some young psychiatrists who are surprisingly aware of the real literature and who are highly skeptical of the drugs. These doctors will embrace a well written article like this. For myself, I find that articles like these allow me to cite statistics as to why starting with antidepressants is not such a good idea. The days when everyone wanted Prozac are past, and most patients are more interested in good information than a quick prescription. Now if only the doctors could get on board… Articles like this one are not going to revolutionize psychiatric prescribing overnight, but they do have an impact.

    Thanks Bob.

  • This is a great review. It points out how profound venomagnosia can be. Imagine writing a whole book about these drugs and having no sense of the downside. “He is giving an account of a mythical treatment, as far removed from real medicine as an inflatable sexual partner is from the real thing.” (I love this quote).

    I agree that the effect that the drugs have is to cause emotional numbing. Medicine is filled with hard decisions. At times some emotional numbing can be merciful.

  • “…she thought it was the only thing that could help me feel better in my circumstances.”

    When patients call me for an evaluation because their therapist says this, I usually comment that it sounds like their therapist doesn’t know what to do, and that they should consider working with a different therapist.

  • I’m glad that the information in my blog was helpful to you. The whole point of writing the blog was not to discourage people from trying to stop taking SSRIs, but to have some informed consent concerning possible severe and long lasting consequences from stopping SSRIs. Having the information allows a person to make a decision about whether they are willing to risk possible severe and disabling neurotoxic damage. I think that I am pretty clear that the frequency of this sort of damage is unknown. Still, even if the risk is small, I would want to know about this possibility before deciding to stop a SSRI.

    I hope that you continue to improve.

  • Flibanserin was initially proposed as an antidepressant. In the disclosed side effects this as an antidepressant to the FDA from Boehringer (6/18/10), it is noted that flibanserin caused a decrease in libido (read that as DECREASE, found on page 205 of 248 pages) as a side effect, but there was no INCREASE in libido as a side effect. In the information submitted to the FDA as a sexual enhancement, somehow decreased libido was not a noted adverse effect.

    Boehringer writes that In the Phase IIa depression trials, in which flibanserin failed to show efficacy on the primary
    endpoint, virtually no sexual dysfunction was noted. This is not quite true. Between 0.6% and 1.4%, depending on the dose, of subjects showed reduced libido.

    Reduced libido is a very serious side effect of a drug that offers such minimal proof of improving libido.

  • Thank you so much for this somewhat uplifting comment. While you describe tragic losses because of Effexor induced mania, your story is also a success story. Given the destructive nature of his mania and the tendency of SSRI induced mania to worsen over time, it is really understandable that you would want him off Effexor as fast as possible. CT is a little extreme, but you gambled and you won. Good to know someone can survive CT after seven years :). Actually, there is little scientific information about the difference between what happens when stopping quickly or stopping slowly.

    It is wonderful that he has made it off the Effexor and off the Xanax as well. I agree that if a person is on a BDZ and a SSRI, one must stop the SSRI first. While there is a lot of debate about this in Internet forums, my personal opinion is that outside of BDZs there is not an effective treatment for SRI withdrawal akathisia and that risking the perils of BDZ tapering later probably outweighs the more immediate risk of suicide in serious akathisia.

    I really appreciate your comment and the information you have to share, and I have some questions that might help me to treat other patients in the future. How old is your husband? What dose of Effexor was he on when he stopped. What is the Xanax dosage he was on when he stopped Effexor. I would be interested in why you feel that the Xanax was key to tolerating the withdrawal. What did you do with the Xanax dosage when he stopped Effexor? How long did he take Xanax alone before tapering, and what sort of tapering schedule did he follow?

  • Dr. Urato provides invaluable information concerning antidepressants and pregnancy. It is obvious that these drugs damage the fetus and that the arguments that untreated depression is more damaging are spurious. They started out saying that Prozac was completely safe. Later the standard was that Paxil, clearly the most toxic SSRI, was the safe drug for pregnancy. The ten ton gorilla in the kitchen is that a high percentage of women who get pregnant on antidepressants have been on them for so many years that tapering and stopping the drugs is going to be very difficult. There may not be time to slowly taper the drugs during pregnancy – which requires about a month for every year on the drug. Dr. Urato is cautious, scientific and understated about the risks of SSRIs during pregnancy, and his efforts at educating the public are praiseworthy.

  • It is upsetting to read the many posts such as yours. Your post is well written and thought provoking. It seems that when a person gets to the point that you are at, that the only option is to go off drugs entirely. Your situation is not hopeless so much as one that has not been systematically explored at all. You can take heart in knowing that over time the nervous system seems to recover from most neurotoxic substances, and that while it might take a while, you can expect meaningful improvement.

    The damage from psychiatric drugs is an extreme example of the damaging actions of the pharmaceuticals. Gotzsche’s book, ‘Deadly Medicines and Organized Crime’ outlines how this is not at all limited to just psychiatric medications.

    Be patient, things will get better.

  • The “light” on SSRI antidepressants was shed in the mid 90’s. I had a website on panic disorder that was very popular called ‘The Panic Disorders Institute.” Around that time the SSRIs came out and were promoted heavily for panic disorder. I saw a lot of patients who were prescribed SSRIs for panic disorder who then had the most severe panic attacks ever. Doctors were telling them that ‘this can’t happen.’ When people realized that I acknowledged that it does happen, I was flooded with hundreds of people c from all over the country who had all sorts of adverse effects of SSRIs. They couldn’t find a doctor who would even listen to their story. Of course, I had no treatments – I hadn’t even heard of most of what people were complaining about. But patients couldn’t (and to this day still have a problem with this) find a doctor willing to acknowledge that the adverse symptoms that started after initiating the drugs were likely side effects. I trained a long time ago, back when if you started a new drug and then had a new symptom, it was a side effect – whether or not the doctor had ever heard of it before.

    About the BDZs. I have much more experience helping people to stop taking BDZs than I do with the SSRIs. I have read benzobuddies, thank you, as well as other BDZ boards for years. In Xanax Withdrawal http://xanaxwithdrawalbook.com/ I address the issue of protracted BDZ withdrawal and explain my reasoning and opinions.

    I’m OK with people disagreeing with me, and I am not going to defend my clinical experience and understanding here. Read Xanax Withdrawal and then write me a private email and we can dialogue.

    I realized that even writing about using the BDZs for tardive akathisia would rub some people the wrong way, but these drugs can be very helpful and for many the benefits outweigh the risks.

  • The 90 mg dose of Valium was established over a two week period of time. Dropping it to 60 mg at two weeks would typically be a pretty safe dosage change, and is not analogous to tapering from 90 mg after a longer period of time. Could the Valium itself be the cause of the suicide? No way to know, however, they were profoundly suicidal with a constant sitter prior to the 90 mg, and committed suicide within 24 hours of the dose change. My opinion is that it was my desire to avoid complications from the Valium that was the primary problem.

  • Hi Richard:
    Your questions are thoughtful and ones that I have considered. First off, you need to know that I don’t prescribe medications all that often to anyone in my practice, and that patients coming to see me for withdrawal problems are mostly people coming to see me because they have already had a bad experience.
    *Some of the patients smoke pot, but none are drinking or using other recreational drugs.
    *Generally I do not prescribe any medications for people while they withdraw or who have had problems stopping – except if suffering is extreme (and sometimes it is very extreme). The severely ill are not people who are capable of exercising or meditating. On the other hand, when I am supervising a new withdrawal, exercise and diet are part of the program. I teach meditation but it is not so popular. Acupuncture is surprisingly helpful. I have not found that there is a particular association between prior traumatic life experiences and difficulty with withdrawal. The major issue seems to be duration of cumulative exposure to SSRIs and therapy. It is possible that the drug has reduced frustration tolerance and coping skills and leaves the person more vulnerable to stress. This could use more exploration.
    *I disagree with you about benzodiazepine withdrawal frequently being protracted. I write about this in more detail in ‘Xanax Withdrawal.’ Again, I need to emphasize that the use of Xanax is reserved for the most serious situations. The case I describe is not an extreme exception.
    *In my experience Neurontin has not been of much benefit except for its sedative properties.

  • I agree completely. Most people coming for help have understandable emotional distress and feel that this distress means that they are somehow defective. When the mental health professional makes a diagnosis, the person not only has the emotional distress, they also are defective in some way. I have seen patients who know that they are appropriately distressed related to life circumstances, but they are coming for evaluation to find out if this distress represents a chemical imbalance, a mental disorder. When this happens, I answer their question and let them know that their emotions are appropriate. Despite a desire to help the person I do not set another appointment; how can their emotions be normal if they need ‘treatment?’ They are grateful to have their own perceptions validated. Still, the fact that they came in for an evaluation underscores how powerful the media has been in convincing people that normal emotions are a disorder.

  • It isn’t going to happen in my lifetime, but I like the idea of just ending psychiatry. We don’t need psychiatrists to evaluate for physical causes of mental status change as this can be done by internists, neurologists and other medical specialists. Fundamentally, psychiatry is an assembly line for giving people drugs willy nilly, with no meaningful guidelines or informed consent. The world is a complex place, and one cannot say that some people’s lives are not actually improved because of their prescribed drugs. Still, looking at the big picture, the world would be a better place if psychiatry as it is practiced today did not exist at all.

  • I so agree with Dr. Levine. It is always somewhat sad when a person shows up in the office with obvious life difficulties just as Levine describes, and the person is mostly focused on what sort of DSM diagnosis they might have and concern that their emotional distress is a ‘serotonin deficiency’ and not acknowledging the expected human reaction to these difficulties. Its bad enough that people suffer in their lives, and even worse that they have to deal with concern that the suffering is really a ‘chemical imbalance’ and somehow not legitimate.

  • Peter Gøtzsche, MD has pretty much nailed the mistaken assumptions that misguide the public and physicians alike. I wish that I didn’t agree, but his point about doctors being unable to properly work with psychotropic medications is spot on. Dr. Gotzshe is also quite correct that psychiatrists are afraid to acknowledge their own observations for fear that their career will suffer. If physicians would only acknowledge these misconceptions, then the mentally ill would stand a fighting chance to get better.

  • Hi Alto:

    The term ‘citizen scientist’ was actually a compliment and not a derogatory term. The best, and perhaps only, information on withdrawal is coming from the patients themselves.

    I am not frustrated or angry and have not given up on helping patients to withdraw. I do want to make a major effort to keep people away from these drugs if their problems are modest and not worth the risk. Also, the potential tragedy that I see when long term patients on SSRIs try to stop should be something that patients consider before stopping.

    As far as tapering, the BDZs and the SSRIs are quite different, and I definitely agree that the drugs should be tapered slowly. What I find, however, is that even with slow tapering this does not ameliorate the longer term problems. I write this because a lot of patients seem to blame themselves for tapering too fast, when this self blame is unfounded. They may have tapered very slowly, yet when longer term withdrawal related symptoms occur, they feel that if only they had tapered more slowly things would be OK.

    I am by no means giving up on helping people who want to get off of SSRIs, and the autonomic nervous system is certainly implicated as part of the damage that the drugs do, but the withdrawal emergent effects are so variable that at this point I’m reluctant to experiment on patients without a better database.

    This is not an end point for my work in the area so much as a call to arms on a very difficult problem

  • Hi Monica;
    I am a big fan of ‘Beyond Meds.’ We are not so far apart in our opinions. It is not so much that I believe that patients stopping their SSRIs are never going to get better. The issue is that people need to be aware that they run the risk of becoming disabled and that even with reinstatement of the medication they may not return to their baseline for years or possibly indefinitely.

    As a physician, my mandate is to first do no harm. In this spirit, I cannot be casual about what may happen to a person who has been on SSRIs for a long time who wants to stop the drug. You wrote that you were bedridden for two years. What if the person who wants to stop the drugs is the family breadwinner and with two years of inability to work, the family will lose their home and savings? This is what I need to consider as a physician.

    Not at all an attitude of not caring, this is a realistic assessment of what I am seeing. Even with this level of informed consent there are long term SSRI users who still want off of the meds. Some do surprisingly well, and some don’t. If they do not do well, I do not experiment on what drug might help anymore, after observing that additional drugs are generally tolerated poorly. Of course, I encourage all aspects of a healthy lifestyle, but do not find that there is any meaningful antidote. I hope that everyone who stops a SSRI will return to at least baseline, but there is simply no way to know whether or not that is going to happen. How can I tell a patient that if they wait long enough everything will be OK?

    I am not saying that everyone should give up, or stay on the drugs, but that this should be part of the information given before taking them, and also part of the information regarding going off them; it may be harder than people think.

  • The book is literally the information I give to patients in the office for informed consent. It isn’t just a summary of side effects. Written in a folksy doctor voice, I give the drugs their due share. Despite the statistical lack of effect, every psychiatrist has seen patients who are suffering an anguishing degree of depression or anxiety who gets enormous relief with a SSRI antidepressant. The book never tells you not to take the drugs.

    I have actually used the book with a few of my own patients who were considering starting a SSRI, and they found it informative and helpful. One patient acknowledged all of the downside and said that they felt that they still might want to try a SSRI. It would seem that nobody would ever take a SSRI if they had reasonable knowledge about their effects and side effects, but some patients still feel a potential upside is worth the risk.

    Remarkably, the book does not seem to scare patients, and seems to open up a more in depth discussion of the illness itself, and not just whether or not to take a pill.

  • Believe me, I thought long and hard before writing this blog posting and before writing ‘Informed Consent.’ Hope is so important to anyone who is suffering and I did not want to take that away. Nobody really knows what is going to happen in the long term. Still, people who are considering stopping SSRIs need to have warnings about what might happen to them – particularly people like yourself who have taken drugs for a long time.

    It is certainly a situation of the frying pan or the fire. A person does not want to keep taking neurotoxic drugs, yet, what happens when the drugs are stopped can be so uncomfortable and disabling.

  • Your point is well taken. In the book itself I clarify several times that my patient population represents people who have had the most difficult time with stopping SSRIs. These are largely the patients having the most difficult time with the withdrawal experience who have already tried unsuccessfully to stop taking the drug. So, I am looking at the tail end of a bell shaped curve. Given how many people take these drugs, I suspect that the serious problems are not so common – but when they occur they are serious indeed!

  • Research is desperately needed not only for strategies to stop taking the drugs, but to delineate exactly what occurs when people stop taking the drugs. Why do some people do well for weeks or months and then have the fairly abrupt onset of neuropsychiatric symptoms. What exactly is the clinical description and time course of what happens to patients who stop the drugs – at 2 years – at 5 years – at 10 years? Why is it that some patients do so poorly with reinstatement. As it stands there is no meaningful scientific study of the neurotoxicity unmasked when the drugs are stopped. Before figuring out what to do about the problem, the scope of the problem needs to be elucidated.

  • I found the location for the hunger strike in Pasadena. One of the local churches had a separate house that they were looking to use for events. Finding a place for the strike was not easy, as most were hesitant to rent space for such an event. I knew some good people at a local church who had a separate house for events. My office address was used as the mailing address for correspondence to the APA.

    At night people gave talks, including myself. Before the strike, all the people I met were online. Suddenly I met everyone at once. It was one of Loren Mosher’s last public appearances.

    I had some fear that if anything went wrong medically as a result of the strike that I was going to have a lot of trouble on my hands. Despite my background in emergency medicine, my malpractice insurance only covered psychiatry. I was sorry that I had to formally decline helping out with the strike related health care, but a single problem and my career was in jeopardy.

    The outcome of the strike is very profound for me. I have referred to the strike when providing expert testimony in order to support that there is no such thing as a chemical imbalance. Hunger strikes with scientific panels are very pursuasive. That the APA was unable to offer any credible evidence for a chemical imbalance to the hunger strikers is more powerful than a double blind study.

    The hunger strikers had to do all of their own contact work with media and the APA etc., even as they were getting weak from hunger. The effort was extraordinary.

    I visited the strike almost every day. Partially to keep an eye on everything from a medical perspective and partially because it was a surprisingly pleasant and upbeat place to spend a little time.

    It was a special event.

  • It is so difficult for a psychiatrist to make sense of the conflicting information about what drugs are supposed to do and what we see them do. Medicine is basically a team sport, and any time a doctor disagrees with the ‘standard of care’ then it is an uphill and often career trashing experience.

    I want to praise Dr. Steingard for having the motivation and energy to express her individual opinions, which run counter to the way that psychiatry is practiced. The big problem is that the antipsychotics do clearly help some people, so taking a total antidrug position is simplistic. Unfortunately when a psychiatrist opens up an honest dialogue about antipsychotics, they are quickly marginalized and labelled an antipsychiatrist. Absent a meaningful scientific literature on the risks and benefits of the drugs, there is probably no better source of information than an honest clinician who can draw their own conclusions. I look forward to reading the next two installments.