Thank you...thank you...thank you! I just finished one of Breggins books and have recently started tapering my meds myself after not finding anyone who would help other than my therapist. I was misdiagnosed as bipolar a little over a year ago and thankfully have only wasted that short amount of time on these horrible drugs. I have tried the majority of them out there and not a single one could fix the "bipolar" in me.

Research into withdrawal needs to be done but I believe that big Pharma is afraid to do it. They don't want people to find out just how sick these meds can make you. They don't want the hell of withdrawals to be public and in plain view for everyone to see. If it were, people might think twice before starting on their drugs.

Philip, please understand that what I am about to say is not meant as a comparison to Gianna, Her situation is a million times worse than mine.

But what sucks for me is that in spite of tapering the right way (I tapered 5% after waiting 4.5 weeks and tapered 5% the previous cut), I am suffering horrible withdrawal symptoms at around 2.5mg of Remeron. I made mistakes at work that normally I wouldn't make. I also had to use alot of self talk to not get upset at little things.

What is scary is if I had done it the way I am sure my psychiatrist wanted me to do it, I would probably be in Gianna's position.

I am dammed angry that doctors are clueless on this issue. I think before they put you on these meds, they should be required to explain how they would taper you off of it when the time came. Yeah right and George Bush is a a democrat.

Anyway, I will get off these meds as I will not let them destroy my life. So bleep all of you drug companies who push this bleeping poison. I will be free of your meds and I will do my best to make sure that other people are too.

Sorry for the rant but I am so sick and tired of feeling like crap. I can't imagine what Gianna is feeling if I am feeling the way I am feeling. I hope she gets well soon.

AA

Right on, and if all you adults are suffering through this hell, can we just stop and think for a minute what it must be like for a child to endure this without having a clue what's going on and through no choice of their own? That's exactly why I wrote 1500 words (instead of 250) about the "Bipolar Puzzle" in the NYTimes.

Withdrawals are so real, and I wish Gianna the best in her recovery and I do know she will reach her goal. She is a real inspiration.

What I cannot handle personally from taking these meds, is how we cannot just remove them or stop them w/out such severe PHYSICAL symptoms.

I've been sick while coming off of Seroquel and Xanax, and find it incredible we can't just stop the drugs when we want to---I was thankful that my psychiatrist listened and took notes to help others.

I kinda doubt my situation is a million times worse than yours AA. I come in and out of feeling really shitty...just like most of us on this journey.

I've encountered hundreds of people having a hard time withdrawing and the suffering involved is always similar and a mistake people make is to assume their suffering is worse than everyone else's or alternatively that someone else has it so much worse...

it doesn't work that way. withdrawal hell takes on hundreds of shades of gray and we've all got it bad when we're in the throws of it.

also, up until a month or so ago, I followed a very slow withdrawal similar to you own and got sick anyway...I'm not convinced there is a right way to do this...there are ways of being cautious, but no guarantee even with caution that one will get through the process unscathed.

and then there are people who very easily let go of all of it and laugh in our faces...oh well.

I'm not sure if I have some serious goddamn illness or it's Zyprexa withdrawal. I have an awful cold last week with sore throat but no fever then weird body temperature fluctuations, waking up sweating, my feet and hands cold and clammy all day. Unable to sleep. It's fucking awful and I assume it's the Zyprexa and hope it's not something more serious.

I was fine the first week or two after I stopped but now I just feel WEIRD all the time.

The only relief is exercise, meditation, and the EFT tapping technique.

DtH,
flu like symptoms are common and are often linked to having withdrawn too fast...

I don't know your whole story, but if it hasn't been long since your withdrawal and if it was done rapidly keep a keen eye on you emotional stability. If you withdrew to fast it can be dangerous to stability.

Pharma companies, who as far as I can tell are motivated by nothing but greed, don't want any information to come out that might tarnish the image of their wonder-drugs. And when people get stuck, and have to keep getting prescriptions for drugs that they don't want to be taking, I'm sure the pharma suits weep about as hard as the tobacco execs do when they think of all those poor addicted smokers.

Additionally, most psychiatrists and NAMI-parent-types claim that it is a disservice to sick people to raise any doubts, no matter how well-founded, that might lead the mentally-ill to be reluctant to take the drugs. (At least that's what I infer when they call me a murderer.) Just like the religious zealots who claim that the very worst heresy is to sow doubt in the minds of the faithful.

So I say, props and felicitations for Ms. Kali and everyone else who's shared the story of their struggles, that others may be likewise inspired.

In your July 26, 2007 posting about Lamictal Withdrawal, I pointed out back on July 1, 2008, one method to attempt tapering which I learned in residency that seems to work for about 70% of patients who are READY to withdraw. For those of you who are truly interested in treatment interventions, at least read the whole thing and come to your own conclusions if it makes sense or not.

Responsible doctors know and apply techniques how to taper meds, and this is not just about psychiatric medications, but most meds that are titrated up to the effective dose. It doesn't need to be studied, it needs to be reiterated to doctors, and for that matter patients, who are usually impatient and quick to demand or expect changes when things don't go as expected. Like you are changing soft drink choices.

Any drug that is sold as one dose fits all is a fraud, ie Prozac, Cymbalta, Ambien, Lexapro, and now this new joke called Pristique, the clone of Effexor. So, if any of these meds are offered to you, especially by non-psychiatrists, you get what you pay for in utilizing people with no expertise with these medications.

Now, let us read the jackals circle this comment.

My psych drug history started with high doses of Zyprexa, which resulted in huge weight gain, apathy, cloudy thinking and severe anxiety - looking back on it it seems like 2 years of my life have been wasted, then seroquel for a few months - switched over in the space of a couple of weeks after which I became VERY psychotic, moreso than I have been before ever being on any meds. Let's just say I'm still coming to terms with it three years and no "relapses" later. I was then put on Risperdal consta, highest "officially safe dose" for a while, until I decided to change to the tablet form of the drug (which provoked an angry rant from the psychiatrist). One thing though, once the psychosis had run its course, years of paranoia which had been affecting my life in a myriad of ways fell away. The upshot being that I felt I no longer needed the medication and stopped taking the 8 daily mg for 3 days. The withdrawal was totally different to the psychosis, the most unpleasant trauma I have ever experienced. I did this without medical supervision, my excuse would be that If I had known what it was going to be like there is no way I would have done it. That was two years ago. Having read up on the subject of tapering off meds I began to withdraw from the risperdal gradually, 0.5mg every month or so with good results. Even at this miniscule reduction I felt very weird at times, sometimes entertaining suicidal thoughts, sometimes just not feeling myself, amplified emotions, including anger, but nothing that registered as worrying in my friends', family's or the mental health professional's radar as worrying. I started a new job a few months ago and gradually became a little delusional at times, which ebbed and flowed as the tide, interspersed with insight. The doc wanted to increase the meds as I hadn't been sleeping very well, but as in a lot of cases I felt it was the change in routine brought on by the job which was affecting me mentally, and decided to hold on tighter to the rollercoaster and stay on the same dosage. 25 days ago I stopped taking the 2mg risperdal I was on and strangely, have had no withdrawal effects worth mentioning, apart from the odd weird moment, and they have decreased exponentially with time. I could write about this experience until the proverbial cows come home, and hopefully you are still reading at this stage. I feel that my new job has made me more mentally resiliant, and since it requires high degrees of concentration and snappy thinking, the meds just seemed out of place in my life. For any of those who have given up smoking using the Allen Carr Book, I think that my experience was similar to the epiphany that Mr Carr describes, the point was reaced where I felt okay to stop, a combination of will power, confidence, and the firm belief that i was cured. I consider myself very lucky to have had a smooth ride and I wish to offer all takers of psychiatric meds a glimmer of hope. I have been on 20g Abilify for the past 2 years also and am still taking that dosage, and plan to reduce it in the future - probably another month once the risperdal has left my system. I would strongly discourage anyone from going cold turkey however as there is nothing to describe the uncomfortable levels the mind can get to with this method.

it's always easier to come off a neuroleptic while still on a neuroleptic. hence my easy time coming off seroquel as I was on plenty of risperdal to cut the edge...

the neuroleptics get tough when you come off the end of the last one...

good luck taper and I recommend taking it exceedingly carefully if you choose to stop the abilify too. you will then be neuroleptic free...the final months can be the hardest.

therapyfirst...
25% of a drug is very often way too much to taper at once...

I've found that sometimes (and this is not just my experience but the experience of many people coming off psych meds) that no more than 5 - 10% of CURRENT dose should be tapered at one time...

most of the people who come to sites seeking advice on withdrawal are the ones for which the psych docs have not known how to advise...so we see the 30% that you don't treat successfully, if that 70% number you give is accurate.

Some people even have to cut down by 2% and often whether it's 2%, 5% or 10% a waiting period of anywhere from 2 to 4 weeks is advised. Withdrawal symptoms can and do show up a good month after a taper sometimes.

I have no beef with you therapyfirst, no desire to argue...

I just want to point out that the people you see in your practice and the desperate people I see in withdrawal groups are not the same people.

On another note to anyone who is interested---my husband just read this post and thread and suggested a class action lawsuit with the intent being that withdrawal need be researched if a drug is going to be unleashed on us...anyone got any ideas about the viability of such a lawsuit?

We might consider it like the requirement for crash testing for new cars---if something is shown to be badly designed then there is a recall.

Good idea, Gianna. I would suggest getting people who care to contact Senator Charles Grassley, head of the Senate Finance Committee, who actually berates the FDA and Pharma. There is currently a letter-writing campaign to him to get a bill going to start up Soteria Houses (one is starting up now in Alaska). I suspect that Senator Grassley doesn't know about this horrible problem so he will need educating. Here's an email for access: Brian_Downey@finance=rep.senate.gov or you can call the number on his website. The top guy in the House to approach is Congressman Henry Waxman. Both these gentlemen are very powerful, and they both care.

So saying, I have a daughter who tried on her own to get off an MAOI, parnate, and immediately had hallucinations. So she is going to wait awhile, as she has just, finally, begun to feel better. We're talking a four year battle, with almost death events multiple times.

DtH, I looked at your website and I'm glad you're trying to get off drugs. You seem like a cool guy but I'm with Gianna in urging you to be careful. You don't know how lucky you are you found this website and I trust you'll look at hers too. Get all the help you can and just know withdrawal can last a long time after the drugs are out of your bloodstream because the effects on the brain (and the body) last a lot longer. Be careful but I wish you the best of luck.

Ugh. I hate class action law suits. They line the pockets of attorneys, inflate malpractice insurance, clog the courts or encourage unfair settlement, and do very little for the people who may have been actually injured by the product.

They also encourage people who have suffered no ill effects to ride the injured parties' coattails in hope of collecting the jackpot for nothing. Meanwhile the settlement is usually little more than a slap on the wrist to the civil respondent.

The one class action suit I participated in, involving a car recall, paid out a measly $50 coupon to each plaintiff.

If you want to go off a med, consult the treating doctor on how to do this safely. Don't just quit on your own, like many of us do (I'm guilty of going cold turkey off a lot of meds, and really paying for it, with the exception of Abilify, which, for some reason was easy to kick).

Food for thought: meds do work for some of us. I take Effexor, Wellbutrin and Klonopin and rarely have breakthrough episodes. When I do, a temporary dose icrease brings my mood up quickly.

YMMV

Pregnancy is another reason for coming off meds or at least reducing the dose. I only discovered your blog a couple of days ago and until I read this entry I didn't know there was little or no research into med withdrawl. No wonder I can't find anybody to help me get off Efexor!

When I was pregnant this year I encountered some very crappy and ignorant attitudes to my antidepressant use. The midwives wanted me off them and the doctors wanted me to stay on them. Neither group had any actual knowledge of Efexor, the side effects, withdrawal symptoms or how to manage changing the dose.

I cannot be sure but I think Efexor was responsible for my daughter being born five weeks premature. The stress of also trying to deal with this issue with different medical professionals who think they know more than me but who are actually 100% ignorant probably had an impact too.

Every p-doc I have ever had has always told me to go off a med COLD TURKEY. None of them had ever heard of tapering.

This is for 35 plus meds in 23 years. One might have been substituted for another one, (ie: Paxil was substituted for Prozac, which then was substituted for Zoloft), but I never questioned.

The other thing is with the exception of Lamictal, and lithium, every drug was given to me at high dosages, never small amounts to get my body adjusted.

I would question, but my several in my immediate family worked for Big Pharma, and I was brought up they knew best. Don't question, unless of course on Lamictal when I got the rash.

In my case it took a near death ( flatline) experience with a drug this spring to make me tell them I need to question everything any doc writes a script for, even Tylenol. My family still believes that Big Pharma/ docs know best, and my experience was a fluke. I am old enough to realize I cannot change their minds, so I have to do what's best for me.

Gianna was wonderful and inspirational to me when I was going cold turkey off Cymbalta. I read her blog daily, and am inspired by her story.I then wrote in my blog about this experience, inspired by her.

I know she will get to her goal, she is a remarkable woman and her blog deserves to be in everyone's RSS feeds.

I'm somewhat lacking in patience so I tend to quit drugs cold turkey, too. It can be a hellish few days but I prefer just to get it over with. The worst ones to withdraw from are the SSRIs, in my opinion.

Recently, I was discharged on lithium and Seroquel. I gave up the lithium right away as I'm concerned about my kidney function. Seroquel was prescribed "as needed" up to 800 mg. Now that I'm off that crap, I occasionally pop a Seroquel for sleep. It's amazing. 100 mg now completely konks me out while I didn't even feel that amount when I was inside.

Our bodies do adjust to the drugs. The more you take, the less impact they have. I like to have them available for emergencies but I'll never take maintenance meds again. One problem with them is that when you're doped up it's hard to pay attention to what's working/not working in your life. Psychotropics kind of remove you from your own senses.

I wanted to report that I am feeling much better this morning so hopefully, that is a good sign.


Anyway, I agree with Gianna about 25% being too fast for alot of people as it certainly would have been too fast for me with Remeron since that has one of the shortest half lives.


TF, forgive me if I am making an invalid assumption but I am assuming you're suggesting the 25% cut due to the practicality of cutting pills which I totally understand. Let me expand further on how to implement smaller cuts


1. SSRI meds such as Paxil, Prozac, Luvox, Zoloft, and Celexa can be prescribed in liquid form. A syringe and something else? will be needed to measure the cuts which can be done by 10%.


2. If not an SSRI med, if it can be crushed like the Remeron I am crushing, buy a digital scale (.001g) on E-bay. Then buy some gelatin capsules.


Crush an original size pill and put it in a capsule and weigh it so you know the starting measurement you are dealing with.


3. Ask your psychiatrist/doctor to write a prescription for a compound pharmacy that will make meds in doses that can't be obtained at your local CVS. I did this with Wellbutrin XL and it worked very well. The downside is this method can be expensive but the person I used was very reasonable.


Obviously, the methods I am suggesting have their advantages and disadvantages and don't cover all situations. But hopefully, this helps someone as I wanted to give practical information instead of just discussing rhetoric.

I think it's important to distinguish physicians' ignorance about the withdrawal effects of abrupt discontinuation of psychotropic medications, and there being an absence of research on the subject.

In 2006, the Journal of Clinical Psychiatry published a supplemental issue (67: Supplement 4) on "Antidepressant Discontinuation Syndrome:
Current Perspectives and Consensus Recommendations for Management". There are several great articles there, with references to many more, on the subject that is public and available to anyone who wants to read it. There is no conspiracy to hide this information from the public.

However, you are correct regarding many -- if not most -- physicians' ignorance about these effects. I am currently training in psychiatry, and I have very rarely heard my supervisors warn patients about withdrawal effects. This should certainly be improved, and more public awareness -- as occurs on this website -- with properly information is needed.

anti-depressants are the most studied drug regarding withdrawal dguller...see if you can come up with anything well researched on anything else???

At least SOME doctors actually know about AD withdrawal, certainly not as many as they should, but when you get to other drugs, it's not just the psychiatrists who are ignorant it's the whole pharma and research industry...I've combed everything that's out there...and have as much of it as possible on my blog...it's a paucity of information...but it's a start...

Benzos might be the exception with Heather Ashton's work, but her work too is only appropriate for some, not all benzo sufferers.

Thanks for the advice on tapering meds people, I will review my medical regime. Back to the subject of carrying out research on the effects of withdrawal from meds. I believe research should be done on this on a huge scale, at least as much as research goes into the initial effects of these drugs. People who take meds are rarely educated as to the long term effects and the hellish withdrawal which usually follows. These patterns are not helped by the general stigma which surrounds mental health issues, preventing open discourse, or even admission of the problem to friends so people can't be blamed for not understanding what they are getting themselves in for. I'm no expert on the pharmaceutical industry, however when I see the massive profits that are made on the drugs, and then look at how many patients were used to test the drugs before they were made legal, I can see a disproportionate amount spent on promoting the drugs and little on how they affect the person long term. Most clinical trials only last a few weeks, yet the amount of time people are usually advised to take them is typically a measured in years. Back to withdrawal - yes research should be done, probably the best organisations to carry this out are the governments of the world.

I have a lot to say about withdrawal.
But I'm avoiding stress and I don't want to go to the memory lane.
I became a psychiatry patient because of withdrawal.
I was given clonazepam when it started to be used off-label to treat anxiety.
I don't know why all of a sudden diazepam was no longer "strong enough".
The first time I came across with withdrawal was when I spent three days without taking clonazepam.
I sat on the floor paralyzed and in panic.
I've started to call everybody... blah blah blah... a friend of mine brought me the drug and I felt fine.
The withdrawal from clonazepam is terrible, now I know but haven't a clue that time and either did the psychiatrist I went to help me withdraw.
He put me in Tofranil, the first antidepressant...
terrible side effects + withdrawal symptom= diagnosing withdrawal symptoms as mental diseases by another psychiatrist.
I was diagnosed many diseases and took all drugs on the market for a short period of time or long.

If I knew I had to withdraw clonazepam v-e-r-y s-l-o-w-l-y I would not be here.
Now taking:
200 mg Seroquel
150 mg Effexor (spent 18 months withdrawing and after 3 months off I had to take it again)
and...
2 mg clonazepam...
lol
Ironic!

PS:
About the Effexor withdrawal: It was hell. I was taking 225 mg.
For 18 months I've tapered off. When I got rid of the first pill I felt fine and the second even better before the body finally found it's balance.
But the last 35 mg were more difficult and only at this dose I felt the brain zaps. I felt all the other withdrawal symptoms including suicidal ideation but not the brain zaps.
Perhaps if I've spend more time on 35 mg, perhaps even for 6 months or more I would not have felt so terrible in the 3 months after off Effexor.
Life was impossible the way I was feeling.
Of course I was diagnosed depressed - I DID NOT felt depressed!
I felt "chemical despair" and lots of physical symptoms - ("-it's depression!", "-Yes Doctor, it's depression!" -
I woke up three time at night wet as if I had just taken a bath.
So... I had to go back to the drug.

I'm telling this because it can help other people.
One day I will write about well explained.
the story is in Socialaudit because it was there where I found support during the withdrawal process.
But the discussion board is closed.

Me again:
Gianna,
I wish you all the best in your withdrawal.
I don't go to often to your site because I still have problems dealing with all this failures of withdrawal.
Research?
I believe they cannot research on something they claim that doesn't exist:
These drugs are not addictive!

Ana said, "The first time I came across with withdrawal was when I spent three days without taking clonazepam."

I just went three days without clonazepam because the pharmacy didn't think I had a refill on file and wouldn't fill the script last Friday. Had to wait all weekend so they could call the pdoc Monday, but by then they had miraculously discovered there was a refill on file after all. I'll bet they could have found it Friday if they'd tried a little harder. Anyway, you're right; the withdrawal feels miserable, and it screws with your sleep, too.

But I have to say, the worst experience I've had was coming off Paxil. No problem during the taper, but when I quit completely, I had flu-like symptoms for over a month. Never again.

Ana,
I'm not failing...I'm making it!

I've come off 11 mg of Risperdal, 50 to 100 mg Seroquel, 375 mg of Lamictal, 72 mg of Concerta, 200 mg Zoloft...

I've got 3 mg of Klonopin and 25 mg of Lamictal to go....

I see no failure there...a long tough journey yes, but I see victory!!

My blog celebrates both the highs and lows and it's not all about withdrawal only...

come visit please!

Dguller, it gives me hope that someone training in psychiatry cares enough to visit this blog. Thank you.

I googled the citation you listed. Obviously, an abstract doesn't tell the whole story but I am concerned that the tapering schedule might still be too fast.

Also, I am bothered by the suggestion of using Prozac to taper an antidepressant with a short half live like Paxil or Effexor. The problem is that someone might react to Prozac and then you have two drugs to worry about getting off of.

Also, just because Prozac is long acting doesn't mean it will be easier to taper from

Is there more to the story that I am missing as I am really curious?

Finally, if you really want to get more of a taste of what withdrawal sufferers go though, you might want to visit http://www.paxilprogress.org. Don't be fooled by the name as it is for anybody going through withdrawal from antidepressants

In case you're not familiar with it, it is run by an RN whose son became psychotic when reducing Paxil from 50mg to 39mg thanks to an MD tapering schedule. He was completely fine once he got off Paxil and continues to do well athough he still has a few lingering physical problems from the drug.

Again, thanks for visiting

First of all, I would like to thank aa for his comments and suggestions re other techniques to tapering meds. My only question is do people have the ability to practice some pharmaceutical compounding? I would offer re Effexor that I know of some people who have opened the capsule and counted out the individual spheres to taper down a bit more evenly once below 37.5 . Beware though, some capsules contain powder and the bioavailability of the med is ruined once out of the protective capsule. Extended release tabs CANNOT be split or this disrupts bioavail. too.

I'm not going to retype what I wrote back in July, but I would like to highlight the first suggestion so the whole comment is heard, and not just the pieces:

" A basic formula (NOT ABSOLUTE, BUT A GENERAL DIRECTION): for every 3 months on a med, expect at least two to three weeks to get off of it via tapering by NO MORE THAN 25% of the dose on at the time. So..."

I go on to use Lamictal at 150mg and show how you can decrease in 8 tapers that should take about 12 to 16 weeks if one was on it for 2 years prior. That is a taper schedule I have successfully used for antiseizure meds (like Lamictal), benzo's, and some ssri's (but not as long for the most part); However, in suggestion 2, I clearly say: "you really shouldn't consider decreasing or discontinuing meds in the middle, or anticipating of pending stressor(s) as THE STRESS OF WORRY OF GOING OFF MEDS ONLY INCREASES THE CONCERN WITH THE ACCOMPANYING STRESS AT HAND. Biggest mistake I have seen is people who are fairly stable get overconfident or complacent and want off meds while they are dealing with serious psychosocial stressors.

I once knew a person who wanted off Zoloft before the person got married, and after I advised not right now, went off it anyway; I got a call 10 days before the wedding and the person was experiencing similar symptoms that initiated the med, so Zoloft was restarted and after back from the honeymoon and settled, THEN we d/c'd it and things seemed to go well thereon.

Lastly, a correction about the end of that posting: the line was to say
If you want to get better, then take a pill, but if you want to get it right, FACE the truth (not fact, sorry for the typo).

This is a quote on my wall, and some patients not only comment about it, but some use it for motivation.

I do practice what I preach.

Hope this is of value to readers. In the end though, have the physician involved with the meds help with the tapering plans. Do it without professional guidance, you only have yourself to blame if things get out of hand. And, if the doc refuses to work with you to taper and you strongly feel it is needed, and the right time, get a second opinion. I've been the second doc, and I will work with someone if they are showing sense and responsibility.

Read suggestion 3 about being on a high dose. That is a black and white matter to me.

And now, a new practice I will do at the end of most of my comments, a sendoff:

3 words you never want to hear in a dark room:
ready, aim, fire!

Therapy First, I am a female:)) But since I made the same mistake with you previously, I guess we're even:))


My meds are easy to practice self compounding as I am tapering Remeron and Doxepin. Thankfully, I am not tapering Effexor as you make some excellent points about it.


Here is a link if you want to locate a compound pharmacist:


http://tinyurl.com/2qu5yn


I think you have to register which is a pain in the neck but it might be worth it if you want to go this route.


The only downside is that many insurance companies will not reimburse you up front as you have to file a claim.

Gianna,

I don't have time to do a thorough literature review, but a quick search on Pubmed found the following articles on Lithium withdrawal:

-- Br J Psychiatry. 1993 Oct;163:514-8.
-- Compr Psychiatry. 1988 May-Jun;29(3):330-4.
-- Eur Arch Psychiatry Clin Neurosci. 2003 Jun;253(3):120-5.

What other medications were you looking for information about their withdrawal syndromes? Maybe I could help you locate some articles?

AA:

First, which abstract are you referring to? I referenced a supplemental volume of the Journal of Clinical Psychiatry that contained five articles. Which one did you find an abstract for?

Second, the tapering schedule varies depending on how long a patient has been on a medication and how high their dosage is. Usually, a physician should decrease the dose by a specified amount every week or so. Most patients who do experience a withdrawal syndrome will have a mild one that resolves within two weeks. Those who have severe symptoms should be tapered much slower than the recommended dose reductions. A small minority will have severe enough withdrawal that would require several months of tapering, which is extremely unfortunate.

Third, the reason for the recommendation regarding Prozac is that there were several studies that compared severity of withdrawal reactions between SSRI's, and they found that Paxil was the worst offender, and Prozac was far less likely to cause a discontinuation syndrome. It was assumed that this was due to its long half-life.

Fourth, there is a good review article on antidepressant withdrawal from the American Family Physician journal: Am Fam Physician. 2006 Aug 1;74(3):449-56. It is available for free, and I'd recommend it to people. Again, this is more reason to blame ignorant physicians and not devious pharmaceutical companies -- who are devious is many other ways!

"Finding health," in all senses of the word, should be all of our goals -- and I wish Gianna the best in continuing her long quest.

But if I may file a minority report ...

Some of us don't WANT to withdraw from our meds. I want to be an informed consumer (which is why I am here) and pick the best meds at the right doses marketed and tested in the most scrupulous ways -- but I am perfectly willing, unlike many, to accept the idea I will be on meds for the rest of my life.

The side effects from my meds, severe though they sometimes can be, pale in comparison to the side effect of staying sane.

I appreciate your doing a search dguller...I can tell you those abstracts bear little resemblance to lived experience of people I've "watched" through the internet come off of lithium...

I don't deny withdrawal has never been looked at...but it has not been looked at closely enough or carefully enough...

a good paper on neuroleptic withdrawal is by Joanne Moncrieff. She has a wonderful book too. Everything she does is brilliant and sensitive...but most research I think approaches the whole problem with far too much aggression and not enough understanding of addiction and problems that arise after long-term use.

One paper by Moncrieff is here:

psychrights.org/articles/Moncrieffe2006medhypdrugred.pdf

it's by no means definitive and gives no real guidance on how to do a withdrawal safely, but it understands how dangerous withdrawal is and makes it clear that "underlying illness" may very often have nothing to do with problems that are encountered.

She's also written a brilliant book recently that I think would be good reading for a psychiatric intern...

The Myth of the Chemical Cure...

I highly recommend it. She is a serious scientist.

and article from the Guardian spotlighting her:

http://www.guardian.co.uk/commentisfree/2008/mar/02/mythoftheantipsychotic

Gianna:

First, you are certainly right that better research is needed to better elucidate this problem, and there are certainly many people who experience very severe discontinuation syndromes when attempting to get off their psychotropic medications. However, I would caution taking a small unrepresentative sample of severe cases and attempting to use their suffering to generalize to others.

Most studies that I've looked at have found a 20-60% of discontinuation symtpoms, but most of them have been mild. If you look at the tens of millions of people on antidepressants, then even a low rate of 1% will mean that there are hundreds of thousands of people having severe withdrawal reactions. The majority who experience no or mild symptoms will not be vocal and agitating on the Internet, but the distressed minority will be. That is why I would caution you overestimating the problem.

All medications have cases of severe adverse effects, but the risk is taken because the benefits are demonstrated. I suppose the best course of action would be to ensure that patients who are offered antidepressants are educated on the possibility of withdrawal symptoms, the importance of strict compliance with their medications, and the need for a supervised and slow taper to discontinue the medication.

Second, I read the article, and it was very interesting and informative. Thank you.

Third, I will certainly look into her book when I have the time, but after reading its description on Amazon.com, it appears that it is a critique of the notion that mental illness is a brain disease due to chemical imbalance. This is hardly groundbreaking stuff as most researchers have stopped looking at it in that way for the past few decades. It is no longer viewed through the lens of chemical imbalance and more in line with neurotransmitter dysfunction in various brain circuits important for cognition, emotion and motivation. This change was made possible by sophisticated brain imaging techniques that have been very informative, but still have a long way to go.

There is no doubt that this debate between biological psychiatry and its opponents is very emotionally laden and people tend to circle the wagons. I personally have no stake in either side, and will use whatever the evidence says is effective for my patients.

Currently, there is sufficient evidence for medications and psychotherapy, and I will continue to use them until they are conclusively shown to be ineffective and another alternative is presented.

aa: sorry. And, dguller, thanks for the inputs.

and so I suppose no one should give a shit about the tens of thousands of people who have nasty discontinuation problems, since they are a minority?

this is the eternal problem...if you don't fall within the norm too bad...

that is the doctors typical stance and not only that they often don't even believe you when you are suffering...because they haven't seen it before...leaving us much better educated then them...yeah I dare to say it...I'm better educated than most docs on this one...and I dare to include you, oh mighty intern. I
too have seen many people come off drugs with no problem...I've seen the wide scope of possibility. I was a social worker in mental health for years.

The difference is I care about the individual...

I'm in groups, email groups with thousands of members all suffering profoundly from withdrawal, ...millions of people are on psych meds... it's not hard to do the math, albeit we don't have the entire formula and figure this "minority" is no small number of folks.

i don't believe it's such a small sample...
and even if it is, who gives a shit...we deserve good medical care too.

oh..another point to consider...withdrawal syndromes get mistaken as relapse all the time...hence would not even be included in literature most likely...

docs see withdrawal and rush their patients back on the meds...

I say it's more common than your precious studies suggest as studies often don't know what the fuck to look for.

When it comes to psychiatry science is a joke.

Gianna:

Wow. I think you need to take a breath and calm down. I have been nothing but respectful to you on this blog, and have never insulted your professionalism or your empathy.

All I have tried to do is share my own understanding, based upon my readings, my training and my contact with my patients who I assure you I care very much about. If you are going to respond to my future posts with uncontrolled tirades against my character, then I would appreciate you do not address me in the future.

Now, regarding my comments about the low incidence of severe withdrawal effects. I never meant to belittle the suffering of those undergoing severe discontinuation reactions, but rather to try to keep things in perspective. In 2006, 42,642 people were killed in traffic accidents. Each and every one of those deaths is an infinite loss to humanity in general and to their families and friends in particular. However, I do not hear many people calling for a ban on automobiles.

What is the mortality for the antidepressant discontinuation syndrome? Zero, as far as I know, but I'd be happy to see some data. Again, this is not to belittle them, but to keep things in perspective. We accept that life is a series of trade-offs between risk and benefit. We accept having automobiles knowing that there is a baseline mortality associated with it. Similarly, when using medical care, we accept that there are risks associated with it. Please, explain why this attitude is incorrect.

Also, who ever said that patients having severe withdrawal effects do not deserve medical care? They should be closely monitored and have their medications titrated down as slowly as possible to minimize their discomfort as much as possible.

Finally, you may be right that withdrawal symptoms may be confused with relapse of illness, but this is unlikely to be very significant, because withdrawal symptoms resolve within one month for the vast majority of patients, whereas a relapse continues to build in intensity and lasts several months at a time. Also, withdrawal effects occur within a few days of discontinuing medication whereas relapse takes weeks to build up to significant strength, and both have characteristics in terms of their somatic symptoms that are distinct. There are clear differences between the two.

Psychiatry still has a long way to go before it can be considered a rigorous science, but that is the lot of much of modern medicine. However, there is sufficient evidence to support many of its treatments and they should be continued, but with ongoing research for the sake of future improvements.

Thank you for your time.

dguller:

With some in this crowd, you are seen as 'shaking the nest', so I advise you either have a 'swatter' on hand, or be ready to run.

By the way, I think you are correct. It's so rare the doctor is insensitive to minority reactions, they just can't proceed like every patient is going to have an obscure, unanticipated problem.

Dismiss the analogy, but I'm offering it anyway:
If you go to an auto repair shop and you tell him your brakes are not working right, would you expect him to examine the transmission first? 80%+ of the time, symptoms are related to specific organ systems, so you look for horses figuratively, not zebras. Once you eliminated there is no horse, then start looking for stripes. I can't taper ever patient by 5% at a time because 10% may struggle with a larger taper schedule. If a 20-25% cut back causes problems, then you go back and decrease the taper amounts. Sorry, minority experiences aren't going to be ignored, but also will not dictate the process. That is the reality here.

For me, another validation.

Today's offering: "I'd offer a placebo, but I wouldn't want to waste valuable resources."

okay..I stopped reading at "take a breath and calm down." I won't be disrespected AGAIN by another know it all doctor who imagines I have no reason to be angry...so yeah..I'll go take a breath now...elsewhere, where I don't have to read what is most likely drivel following disrespectful shit suggesting I have no reason to say the things I've said.

And I'll grant you I'm hyper-sensitive right now...you know why?? Because my CNS is fried by drugs---drugs that people like you gave me for no good reason...maybe if I wasn't so fried I'd be able to find the will to read whatever follows your disrespectful statement...but for now...know I read nothing you wrote.

If you want to be a sensitive psychiatrist you need to be able to hear people like me...there are good psychiatrists out there...but you are not promising to become one.

later.

Woops, dguller, I think you do have a lot to learn. Don't get me wrong I'm glad you're on this site and reading FS but if you think the mortality from antidepressant discontinuation syndrome is zero then one thing you might want to do is check out some of the stories on www.ssristories.com labelled "Antidepressant Withdrawal." As for withdrawal symptoms resolving within a month -- I'd like to see your evidence for that! Persistent withdrawal symptoms can go on for years, if not forever, after coming off a course of psychiatric drugs. It's called brain and body damage that might well be irreversible. If you are in medical school you are being brainwashed left, right and center, so just beware. Start reading some uncensored stories of patients. They're out there. You might want to start with Peter Breggin's new book Medication Madness.

To find the "Antidepressant Withdrawal" stories on the site www.ssristories.com, go to the index and click on the red heading "Drug" and the column will resort alphabetically -- then you can scroll down to Antidepressant Withdrawal, Paxil Withdrawal, Prozac Withdrawal, Zoloft Withdrawal etc. Read a number of them -- the repetition of themes and circumstances should give you pause. Very nasty things go on when people withdraw without having a clue what they're doing and when they haven't had the slightest warning.

Dguller, as an FYI, I had the same reaction as Gianna.


When doctors say we are in the minority regarding any situation, that comes across even though that wasn't your intention of minimizing our issues. Also, how many times in medical history were patients told their problem was rare only to find that wasn't true?


You ask Gianna for data but I would like to see data run by researchers not connected with drug companies that show that discontinuation syndrome resolves in two weeks. People on Paxil Progress board who CTs or tapered quickly are not reporting those experiences as their withdrawal symptoms are lasting for months. The key tipoff is that alot of them weren't put on the drug due to psychiatric reasons and are suffering from psychiatric withdrawal symptoms. Also, they are dealing with alot of physical symptoms that aren't typically seen as part of psychiatric disorders..


I really think your data is not accurate. After all, if I am suffering withdrawal symptoms for a week on a 5% cut, there is no way that if people are being tapered faster than that, can just have symptoms for two weeks. No way.


If you really want to be enlightened, I suggest you contact Laurie Yorke, the RN who runs the Paxil Progress Boards which gets 3 million hits per month. She is the one whose sone became psychotic thanks to reducing Paxil from 50mg to 39mg per MD instruction. He is fine now that he is off Paxil. Anyway, she has done alot of activism on this issue but does not believe in militancy. I think you would find her to be reasonable.


If you're interested, I will ask her and we can work out the arrangements so that confidentially is not broken.

Dguller, one more thing. If psychiatrists tell patients that antidepressants can take up to 12 weeks to take effect, how is it possible that discontinuation syndrome only lasts 2 weeks?


What your profession is saying just doesn't make sense since the brain needs time to adapt to there being less of the drug in the body. This isn't a case of reducing tylenol as psych meds make changes throughout the whole body.

TF, you said:


"I can't taper ever patient by 5% at a time because 10% may struggle with a larger taper schedule. If a 20-25% cut back causes problems, then you go back and decrease the taper amounts. Sorry, minority experiences aren't going to be ignored, but also will not dictate the process. That is the reality here."


Fair point. But most psychiatrists are unfamiliar with the methods I listed for making smaller cuts and if god forbid, the patients suggest them, they are crucified. In all fairness, my psychiatrist has become very supportive after that rocky beginning but sadly, I think my experience is in the minority.



And by the way, Prozac can't be substituted for something like Remeron withdrawal since usually, it is taken for sleep.

Sarah:

When I referred to a zero mortality rate, I meant a direct medical consequence of the medication's withdrawal. For example, some patients die following the withdrawal of alcohol if they had been chronic alcoholics due to a condition called delirium tremens. I exclude suicide from mortality, but that may have been too narrow a medical definition.

If we broaden the definition it include ANY death following withdrawal due to the cognitive, emotional and perceptual disturbances that can follow, then there certainty have been too many tragic deaths in that regard.

That speaks to the deep need to educate patients about these possible effects and to monitor them closely for them for their safety and the safety of others. These consequences are certainly real and it is a crime for physicians not to be aware of them and to put others in danger in such a way.

Regarding the duration of discontinuation symptoms, I said that MOST people will have them last up to two weeks. That implies that there are SOME people who will not. Most people will have minor reactions that last under two weeks, but there will be some who have severe reactions that can take many months to discontinue the medications safely. If you would like references for that data, then please refer to the article in the journal American Family Physician and the supplemental volume of the Journal of Clinical Psychiatry that I referenced above.

Thank you for your time.

Dguller, not to beat a dead horse but if antidepressant take up to 12 weeks to build up to therapeutic levels in a patient's body, having discontinuation symptoms that just last up to two weeks is impossible. What is the explanation for the inconsistency? The article doesn't really address that unless I am missing something.


Anyway, here is the link and thank you for posting the reference


http://tinyurl.com/3l3ccm


If someone else could read it and provide a critique, I would appreciate it. I wanted to give it a C but due to be tired from lack of sleep that I can't blame on psych med withdrawal, I want to read it again tomorrow when I am more refreshed. I can't say I was impressed but maybe I am just in one of those moods.

aa:

I think it is important to keep in mind that simply adding up the number of adverse experiences in a large group of people who may share one condition in common (i.e. using antidepressants) without controlling for other differences (e.g. their age, sex, medical conditions, other medications, and so on) will inevitably bias the sample and make the conclusions drawn from it unreliable. How many of those people had other medical conditions or were taking other medications that could have contributed to their symptoms?

I suppose that is the root of my opposition here. It is easy to blame the medications for the horrific behavioral consequences in some people's lives, but without rigorous study, that will simply be a hypothesis that becomes more contentious, because of the heightened emotions involved. There are so many confounding variables to control for before we can make a definitive assessment about this matter.

This does not mean that I believe that SSRI's/SNRI's absolutely do not cause adverse effects on patients, because I believe that they do for a significant minority. This is a serious matter that requires proper medical attention to alleviate their distress to the best of our abilities. However, I think that we should have the right understanding of the causes and extent of the problem in order to research better solutions.

Demonization of psychotropic medications and psychiatrists in general will only stand in the way of an objective and rational understanding of the matter.

Thank you for your time.

DGuller, please don't use what I call are smokescreen issues which is what you are doing when you claim that people demonize psychotropic meds and psychiatrists. Not once in my responses, have I trashed psychiatrists or meds so I would appreciate the same respect. And many other people on this board have not done that.


You might want to study medical history in which similar issues have come up. The one that comes to mind is when patients were claiming that SSRIS were causing weight gain and were told that couldn't possibly be true. Now, I don't think there are too many psychiatrists who would deny that. God, I hope not.


Regarding the book, Medication Madness, that I think Sara suggested that you read, the author, Peter Breggin, left out any examples in which he felt there were other causes. Doing a study really isn't that hard to do if you really make it happen.


Here is a great example, as Jeff Riordan, former major league baseball pitcher who is set financially for life, holds up a store with a toy gun while on 5 antidepressants. What other controlling factors could there be? Like I said, it isn't that hard to come up with people like this.


Finally, I will leave you with a personal example. I was told that Remeron couldn't possibly be the cause of my hearing loss even though there was no doubt in my mind that it was. And hearing loss is listed as a Remeron side effect


One day this year, I screwed up my dose and ended taking more than I should have. My hearing got worse after it had improved as I lowered the dose.


Of course, this does not meet any scientific study but if I report that Remeron is a great drug, that is taken as scientific proof that it works. But any negative reports are deemed not credible. Hmm.

aa:

I believe that the answer is that the time it takes to reach a therapeutic level depends upon a variety of factors including half-life, individual metabolism, compliance, drug-drug interactions, and other variables.

So, if you take Prozac for example with a half-life of several weeks, then it will take about 5-6 weeks to reach steady-state levels at a current dose, and it can take longer depending upon if the person is a slow or fast metabolizer and on how they respond to the drug (i.e. do they need to increase in their dose or not).

All of those variables are also involved in discontinuing a medication, and it typically takes about 5 days over 95% of the drug to be eliminated from the body. That sudden decease is what causes the various side effects.

Now, getting to your point that if it takes X weeks for therapeutic effect to occur, then it should take X weeks once the medication is withdrawn for a discontinuation syndrome to occur, because the brain will take the same amount of time to adjust.

I really do not have the answer to this. We are still in an infant stage in terms of understanding the brain. All I can tell you is what the data actually shows. We do many things in medicine that we have little understanding of the underlying mechanisms involved.

Just to get a little bit of perspective, the duration of time for X to occur does not necessarily have to equal the duration of time for X to be undone. It takes a fraction of a second to break a bone, but it takes many months for it to heal. It takes a moment of sexual abuse to traumatize a person, but it takes years of treatment to correct that problem. And so on.

All I can tell is what my own clinical experience and the medical literature have found. However, this is certainly an area that deserves much more study.

Thank you for your time.

I read the article in the American Family Physician Journal & it really didn't tell much. It references other studies but it doesn't ever tell the reader what dosages the patients were taking of a particular drug or how long the patients were studied, etc. The authors tell the sample size & the name of the drug & that's about it. You would have to pull up the individual studies to know info on dosage& other relevant info. For example, if a study examines patients experiencing abrupt withdrawal from 75 mg of Effexor that cannot be generalized to patients experiencing an abrupt withdrawal from 375 mg of Effexor, and so on. Since the authors never mention the dose in the studies I don't know if we're looking at people on low doses of an antidepressant or those on high doses. Kind of interesting that they didn't think that was important info to include.

One study it referenced was a chart review - the data in the charts depend on the doctors recording the data - if he/she already has the mindset that discontinuation of antidepressants is typically a mild experience then they may be tempted to attribute the patient's condition to other factors. There's not a single mention of my experience withdrawing from meds in my medical record - and I suspect I'm not alone in that. What is it they say in the medical field, if it's not recorded it didn't happen?

Another study was sponsored by Pharma (which the authors of this article do admit) & not surprising that study found patients had a mild withdrawal.

dguller, you make an important point about patients being on multiple meds. I don't see any studies looking at discontinuation syndrome experienced by people on multiple psych drugs. Therefore, these studies will have no relevance to those patients & what their experience may be like during withdrawals. Might be a good idea to study what withdrawals look like in those patients before others are put on them.

When I get a chance I'll read the other source that was referenced.

aa:

I don't think any physician would be following evidence-based medicine to rely on case reports as conclusive evidence whether for or against a treatment. Case reports are the beginning of scientific knowledge and require larger, randomized, double-blinded trials to reduce the background noise of underlying biases and get clear information.

For example, there were many case reports on the website I was refered to of patients committing suicide while on antidepressants, and the implication is that the medications are what triggered the suicidal behaviour. That is certainly possible, given the low probability of SSRI-induced akathasia and manic induction in vulnerable individuals.

However, if you look at several recent studies that looked at large groups of people, there have been some interesting findings. For example, a recent study in the American Journal of Psychiatry (2007; 164:1044-1049), which looked at 226,866 veterans who received a diagnosis of depression in 2003 or 2004 and looked at the frequency of suicidal behavior in those who received antidepressants versus those who did not. They found a statistically significant difference between the antidepressants versus those untreated in terms of suicidal behaviour. In short, antidepressants reduced suicides across all age groups.

So, some patients DO suffer adverse effects that could increase suicidal behavior, but the important point is that MOST do not, and the medications actually decrease suicide rates in general.

As a clinician, what I take away from this is that IN GENERAL antidepressants are helpful, but that SOMETIMES they can be harmful and I should keep my patients aware of the risks and benefits and to inform me of any adverse outcome. At that point, I would have to try to determine if the adverse effect was due to the medication or some other cause. I wouldn't disregard my patient's distress irrespective of the statistical evidence, but would look at it as a case-by-case basis.

Thanks for your time.

Lisa:

Great points. Thanks for the feedback.

I do not believe that medications actually decrease suicide rates in general. The supposed proof for this is based on epidemiological studies that really are very flimsy. It's very hard to correlate the use of one class of medication with a behavior as complex as suicide in a population wide study. Of much more significance are clinical studies that show a marked increase in suicidality in those taking antidepressants over placebo. Even the FDA has admitted causality between antidepressants and suicidality and honestly those who try to say suicidality and suicide don't move along parallel lines are pretty illogical in their arguments.

Also I would never say that in general antidepressants are helpful but sometimes harmful. In general I would say it's just the opposite. Most of the time they are harmful. Very occasionally, at low doses for a short period of time, they might appear to be helpful. Those who believe they are helpful are usually chemically dependent on them and can't get off and mistake adverse drug or withdrawal reactions for their disease. I know those within the establishment groan at the mention of Peter Breggin but frankly his new book Brain-Disabling Psychiatric Treatments is really an outstanding review of the literature on the ways in which the drugs harm those taking them.

Sara:

Let's look at the FDA issue:

First, the FDA's conclusion was based upon antidepressant use in children and adolescents, and thus has no bearing on adult use.

Second, although the rate of suicidality -- a vague term -- was 4% with antidepressants and 2% with placebo, there were no completed suicides in any of the 4,562 patients involved in the 24 studies. It is also interesting to note that the statistical power of the review was too low for any firm conclusions to be derived from it, given the sample size.

Third, the criteria by the FDA review of what counted as a suicidal thought, behaviour and attempt were not strict and rigorous. For example, one female hit herself in the head, and it was counted as a suicide attempt. Actually, a new study that uses a more rigorous criteria -- that the FDA agrees is "robust and reproducible" -- found that although there were slightly more suicidal events, there were 50% less suicide attempts than previously reported in the trials (American Journal of Psychiatry, 2007; 164:1035-1043). This implies that the suicide rate in the FDA meta-analysis was over-estimated.

Fourth, although inconclusive, it is suggestive that multiple retrospective studies involving hundreds of thousands of patients have shown that with increased antidepressant use, there has been a decrease in the suicide rate, and vice versa. You can think that such studies are useless, but they pointed the way towards the link between smoking and cancer many decades ago, and thus shouldn't be dismissed out of hand. However, you are right that placebo-controlled trials are better.

What I feel is reasonable conclusion is that although most adolescents taking antidepressants would tolerate them well without any increase in suicidality, there is a minority that is very sensitive to them and can have short-term agitation and activation in keeping with akathasia within the first two weeks, and thus all patients should be closely monitored during the early period of drug introduction and dose increase.

Now, regarding your claim that psychotropic medications are effective only at small doses and for short period of time, but that is only because those people have become "chemically dependent" upon them. Wow. I would love to know your evidence for that assertion.

Thanks for your time.

aa:

I actually read up on Jeff Reardan.

You failed to mention the fact that he was depressed and suicidal for almost two years prior to starting his antidepressants due to the death of his only son by an overdose in February 2004. He was admitted to a psychiatric facility in December 2005 for a week and prescribed six psychotropic medications, including multiple antidepressants.

He had surgery soon after and was prescribed more medications, including Levaquin, which can lead to paranoia, depression and anxiety. He was on a dozen medications.

He robbed the store the day after Christmas 2005 due to a delirium.

So, this puts a new flavour to your story, because it appears that he (a) was already depressed and suicidal before treatment for almost two years, (b) there is a family history of a suicide attempt, (c) was overprescribed psychotropic medications, and (d) was overprescribed other medications, which was a dangerous combination of factors. However, that's the point, because it was a combination of things, and not a single isolated part that you chose to highlight, i.e. his multiple antidepressants. I can't tell you the number of drug-drug combinations that can lead people into a delirious state, but I can assure you, it's huge.

I truly hope that this anecdote isn't representative of your evidence against antidepressants, because it is truly flimsy, and it actually underscores the need for unbiased studies that can isolate the actual causal mechanisms involved in disease and treatment.

Oh, and by the way, he actually improved with ECT when readmitted to the psychiatric hospital.

Funny how you excluded that fact, too.

Thanks for your time.

Now, regarding your claim that psychotropic medications are effective only at small doses and for short period of time, but that is only because those people have become "chemically dependent" upon them. Wow. I would love to know your evidence for that assertion. No, not the people who were only on them for a short time. Rather the people who after years of being on them still claim they are "helpful" -- those are the ones who are chemically dependent and don't realize that the drug and withdrawal effects they experience are not their "disease." They think their meds are life-saving only because they are unaware that they are addicted.

dguller, you clearly read a lot of the literature. I have read many of these articles too and have even written up quite a few medical journal reports showing how flawed and conflicted they are. Among other things withdrawal events are often categorized as placebo events thus making placebo look "worse" and active drugs look better. A lot of the time the articles aren't even written by the lead authors but by firms paid by pharmaceutical companies to write them. The authors are added after the fact. I take it you are still a young doctor and I hope that you will open your eyes to the confounding effect of psychopharmacology on underlying mood and emotional problems. Few doctors really think about this. There is a lot of evidence out there that these drugs are neurotoxic. The "power [of drugs] to harm" is enormous and, for that reason, alone I do not think they should be given to adolescents, much less children. They have no real understanding of what they are agreeing to and just look to their primary caregivers to decide for them. At least an adult might have a chance of making an informed decision. A child really doesn't and taking the medications can be a life altering experience, usually for the worse . You are already well on your way to becoming a practitioner of the standard treatment protocols that are out there and I think it's too bad. All I can say is I hope you extend your reading well beyond the AJP and other journals like it. And for now I'll stop debating. You are only serving to reaffirm my views and I don't want to be doing the same for you.

No one is asserting that medication is the only cause in some of these bizarre acts of behavior - not sufficient on its own, but necessary, because without it, the act would not happen. That's an important point. Sure the stage is set in some ways by life circumstances and maybe genetics, but without the petrol to light the fire, it wouldn't happen. That is how I see the role of these medications in a lot of these "stories." It provides the agitation and the loss of impulse control that enables something awful to happen that would not otherwise occur.

Sara:

There are fairly reliable ways of distinguishing SSRI discontinuation symptoms versus depression relapse, including the rapidity of onset, the duration, and the types of symptoms involved. You are probably right that many clinicians are unaware of them and this has led to poor medical practice.

If you are arguing that the vast majority of what studies report are relapse of depression following SSRI discontinuation are actually withdrawal symptoms, then I would love to see your evidence for that assertion.

You said: "Most of the time they are harmful. Very occasionally, at low doses for a short period of time, they might appear to be helpful." I wanted some evidence for this assertion, and you provided none.

Furthermore, could you please cite the journal articles that you have published where you have critiqued the clinical evidence? I would love to read them for myself. Also, which studies miscategorized their data? Could you cite them and tell me where that information is located?

I would also love to know what journals I should be reading instead of the standard ones in my profession? Could you please tell me which ones you would recommend?

I hope that we can continue this discussion.

Thank you for your time.

Sara:

Regarding the neurotoxicity of psychotropic medications:

Which medications did you have in mind when you asserted this? What studies can you cite to support it?

What about the studies that have shown that antidepressants inhibit the stress-induced reduction in hippocampal volume associated with major depression? A good article is in The Neuroscientist (2008; 14(4):326-338), which reviews the evidence for this hypothesis.

Please share your thoughts.

Thank you for your time.

Dguller, why the sarcasm when I have treated you with total respect?


By the way, I didn't include the examples you mentioned because I was being devious. I relayed the story because that is the way I remembered it.


If you want respect, you have to give it yourself. I was so angry and upset by your post that I was tempted to say, you're just like all the other psychiatrists. But then you would accuse me of demonizing psychiatrists and it probably isn't a fair statement. At least I recognize it for what it is which is far more than what you have done in recognizing your mean spirited behavior.


Like Sara and Ana, I am done debating with you.

Sara:

I see.

So psychotropic medications are not inherently problematic, but rather in SOME situations involving a COMBINATION of factors (e.g. stressful life events, genetics, other medical conditions, other medications, etc.) CAN lead to harmful behaviour.

I suppose that a good standard of practice would be to be alert to those vulnerability-inducing conditions by doing a thorough history, physican examination and labwork, and be cautious when prescribing medications in that context with close monitoring and follow-up. Oh wait. Those ARE the guidelines!

Or are you saying that most people have those underlying vulnerabilities and the risk of adverse outcome outweighs the benefits? What is your evidence for this?

Also, many treatments have certain adverse outcome rates associated with them. What would be an acceptable rate for you before you would agree to the validity of a treatment?

Sara:

Also, you wrote: "No one is asserting that medication is the only cause in some of these bizarre acts of behavior" (@2:14 pm).

Um, aa wrote regarding Jeff Reardon: "What other controlling factors could there be? Like I said, it isn't that hard to come up with people like this" (@3:31 am).

I didn't pull that example out of thin air. I was directly responding to aa's anecdote.

It seems that you disagree with him that there ARE "other controlling factors" involved in that case. Namely, the qualities that you mentioned that make certain people vulnerable to adverse effects of psychotropic medications.

Glad to hear we agree. :)

aa:

I am sorry if I made my point too forcefully. I suppose I projected some of my frustration with other individuals on you, and I truly apologize.

However, I think you just made my point. We need more rigorous standards for our evidence. Reporting a vaguely recalled anecdote as evidence against medications is insufficient. Granted you supported your position with other information, but why include an inflammatory example without properly vetting it before putting it in the public domain. Before I cite an article, I make sure to pull it up and read it to ensure that I'm quoting it properly.

Perhaps if we set some ground rules that when citing a piece of evidence then it should be reported faithfully and with a citation where to find more information?

Again, sorry about any insult I may have caused.

Thank you for your time.

I almost agree with your above dguller. But before you dismiss what you find here you could consider the context in which these anecdotes and databases are created. The research isn't being done by the universities. Which is the suck. To ask concerned citizens and bloggers to adhere to the scientific method when they don't have the training isn't fair. You can dismiss the findings or take them for what they are --- inklings, raw beginnings, screams into the void. The relevant question is not about the rigor in which they're compiled but why aren't these horror stories investigated and funded by the research establishment? How do non-dominant views get into the discourse? DIY is necessary, and the grassroots are always messy, but that's generally where it has to start.

Maybe it's best to know what we're talking about and make sure we don't take something to be something else. I hope no one is saying SSRI Stories are proof of anything, much less the final word. Because they're not, by a long shot. But when you look at the sheer volume of case studies collected, and their overall similarity don't you wonder why the blackout? Medical guidelines are founded on case studies. These are case studies. Where's the scientific inquiry?

Flawedplan:

I absolutely agree with you that it is a travesty that drug companies and government-funded organizations are not investigating the adverse effects of medications, and I certainly appreciate the frustration of individuals who have suffered as a result of those pills.

Everyone who is involved in collecting the data and pressuring the aforementioned institutions to investigate these matters fully should be commended for their efforts. I hope that all your efforts will not only continue, but ultimately find success in improving both transparency and accuracy in drug companies.

My only point was that people here seemed to imply that their efforts thus far were the final word on the matter, and that anyone who questions their evidence is brainwashed or otherwise in the pocket of Big Pharma. My position was that there are standards of evidence that must be adhered to in order to avoid biases. One well designed study will overrule hundreds of poorly designed studies, because you cannot infer much from the latter due to their flaws.

Multiple case reports are on the bottom rung of the evidential ladder, because there are no ways of controlling all the biases involved. That is not to say that they do not matter, because they are always the START of the scientific process. My point was that it is a huge mistake to assume that they are also the END of the process, as many people seem to believe here.

In other words, there is an attitude that all research studies are inherently unreliable due to drug company funding or other biases, and so all that is left is the thousands of case reports, which must be accepted as the gospel truth.

I think that we should all have higher standards of evidence, because until those case reports are retrospective analysed to eliminate confounding variables and other biases, they are highly unreliable in this matter.

Perhaps if everyone involved could donate money to hire a research program to investigate the matter, then that may help?

Any other thoughts on how to scientifically analyze the corpus of case reports that your community has accumulated?

Thank you for your time.

Flawedplan:

Oh, and one more thing. Medical guidelines are never founded on case studies. They are based upon the best evidence available, i.e. double-blinded randomized controlled trials if they are available, and if not, then they go down the evidentiary ladder. It is very rare that a treatment would be included in any guidelines that was only based on case reports.

Thanks!

Thank you flawedplan for stating those points. SSRI Stories is not being presented as rigorous science. It's a lay person's effort to do a little epidemiological review because no one else is doing it. What we are trying to demonstrate is that there is something seriously amiss in clinical practice if all these "treated" patients can go on to commit these bizarre acts, especially of violence. If 50 school shootings and countless other rampage events are linked to antidepressants it surely means there needs to be more investigation if nothing else. We would like nothing more than for coroners and other officials to take this on.

Here is an article describing how washout and discontinuation events are categorized as placebo events. Again, this is done largely because of a failure to understand withdrawal and believing it's over in two weeks which is not the case. Having the medication out of the bloodstream is far different from the brain and body being healed from its effects.

BMJ 2006;333;92-95
Did regulators fail over selective serotonin reuptake inhibitors?

As for my "write-ups" they have been "published" on list serves both here in the U.S. and in Canada, to which many distinguished academicians, medical professionals, journalists and others belong. My correspondence with the editor of the AJP is on line including his arrogant reply.

Patients do not share with their doctors many of the adverse effects in part because they are ashamed of them and because they don't understand that medications can have such powerful effects on behavior. Doctors often come across as arrogant and intimidating too.

I do not believe that there is a deliberate conspiracy going on between psychiatry and big pharma but I certainly believe that there has been an insidious corruption of values over time that have taken over the practice of ethically driven research. There are many well meaning people out there who have just lost sight of plain common sense.

Two journals that may be out of the mainstream: Ethical Human Psychology and Psychiatry and PLoS

Finally you can dismiss Bregging's books but until you've read the two he's published this year from cover to cover I suggest you refrain from criticizing him.

And here are some others:
Rethinking Psychiatric Drugs: A Guide for Informed Consent, by Grace Jackson
The Myth of the Chemical Cure, by Joanna Moncrieff
Schizophrenia: A Scientific Delusion?, by Mary Boyle
Medicine out of control? Antidepressants and the Conspiracy of Goodwill, by Charles Medawar and Anita Hardon
Prozac Backlash and The Antidepressant Solution, by Joseph Glenmullen
Let Them Eat Prozac, by David Healy

And how could I forget Mad in America by Robert Whitaker, the real story behind the approval of atypical antipsychotics.

Sara,
Isn't it amazing that people still don't know these highly important bibliography?

There it goes some books I have on a list:

Medawar C, Hardon A: "Medicines out of Control? – Antidepressants and the Conspiracy of Goodwill" (Amsterdam: Aksant Academic Publishers, 2004). ISBN 90 5260 134 8.

David Healy. "Let them eat prozac: The unhealthy relationship between the pharmaceutical companies and depression." New York: New York University. 351 p.

Peter Bregguin - "The Antidepressant Fact Book" (2001)
"Talking Back to Prozac" (1994)
"Brain Disabling Treatments in Psychiatry" (1997).
"Your Drug May Be Your Problem: How and Why to Stop Taking Psychiatric Medications" by Peter Breggin M.D. and David Cohen Ph.D.

2007 updated paperback edition.
Hardback published 1999 by Perseus Books, Reading, MA.

Joseph Glenmullen. "Prozac Backlash", 2000.
"The Antidepressant Solution"

Robert Whitaker. "Mad in America," 2002

Bruce E. Levine." Commonsense Rebellion Taking Back Your Life from Drugs, Shrinks, Corporations and a World Gone Crazy"

Elliot Valenstein, Ph.D., "Blaming the Brain: The Truth about Drugs and Mental Health". 1998

Edward Shorter, "A History of Psychiatry: From the Era of the Asylums to the Age of Prozac" 1997

Blake, Ann. "Prozac: Panacea or Pandora? - Our Serotonin Nightamre," Cassia Publications Salt Lake City,Utah, EUA, 1994. 424pp.

Edited by Peter Haddad, Serdar Dursun, and Bill Deakin. "Adverse Syndromes and Psychiatric Drugs A clinical guide" ISBN-13: 978-0-19-852748-0
Publication date: 27 May 2004 336 pages, 6 black & white photographs and 3 colour plates, 234x156 mm
http://www.oup.com/uk/catalogue/?ci=9780198527480

Sydney Walker III. "A Dose of Sanity".John Wiley & Sons, New York, NY, EUA, 1996, 260 p
(neuropsychiatry and neurosurgeon makes an analysis of wrong diagnostics based on DSM)

Phillip Day. Credence, Tombridge. "The Mind Game". Kent, Inglaterra, 2002, 462 p

Lynne McTaggart. "WHAT DOCTORS DON'T TELL YOU The truth about the dangers of modern medicine" Thorsons, London, Inglaterra, 2005, 2ª ed, 410 p

Ronald Diamond, "Instant Psychopharmacolgy" Ronald Diamond, published by W.W. Norton
Peter Breggin "Toxic Psychiatry", St. Martin's Press
Eva Edelman, "Natural Healing for Schizophrenia, Borage Books. Eugene Oregon
Mary Ellen Copeland, "Living Without Depression & Manic Depression" . New Harbinger

Lynn Payer, Disease-Mongers: How Doctors, Drug Companies, and Insurers are Making You Feel Sick, Nova York, John Wiley & Sons, 2002.

Vince Parry, “The art of branding a condition ”, Medical Marketing & Media, Londres, maio de 2003.

Jörg Blech, Les inventeurs de maladies. Manœuvres et manipulations de l’industrie pharmaceutique, Arles, Actes Sud, 2005.

Harry Marks, La médecine des preuves: Histoire et anthropologie des essais cliniques (1900-1990), Institut Synthélabo, col. “Les empêcheurs de penser en rond”, Paris, 1999.

There are others French authors and numerous work that are not on the list.

Sara:

Thank you for the references, especially the 2006 BMJ article, which was especially enlightening, particularly about the particular SSRI studies that he cited that played foul with the suicidality in the placebo group.

I wonder what the effect of that would be compared to another study that looked at FDA studies with more rigorous criteria to determine which events counted as suicidal ideation, behaviour and genuine attempts, and found that there would have been 50% fewer suicide attempts (see American Journal of Psychiatry, 2007; 164:1035-1043).

Also, there are other studies that have looked at the data in different ways, and have found either that the suicidality has been exaggerated or mainly exists marginally in people under the age of 25.

Please see:
-- European Archives of Psychiatry and Clinical Neuroscience (2008) 258, Suppl 3:3-23.
-- British Medical Journal (2005) 330(7488):385.
-- JAMA (2007) 297:1683-96.

I can cite others if you like.

The main problem is that given the small increase in suicidality with antidepressants, the studies cited in the meta-analysis are too small to make meaningful conclusions possible. One would have to perform studies with hundreds of thousands of patients, which is not possible.

The only other alternative is to do retrospective analysis of epidemiological data, such as was done when a study looked at 226,866 veterans and their use of antidepressants compared with suicide rates, and found no correlation (American Journal of Psychiatry (2007) 164:1044-1049). However, those studies introduce biases of their own.

Given this inherent uncertainty, it appears reasonable to conclude that the risk of suicide is minimal, if it does exist, and if it does, then it is only in certain vulnerable individuals. It also appears to occur in the early stages of treatment, particular by inducing akathasia or dysphoric states indicating a possible underlying bipolar disorder.

Regardless, the answers are not fully clear.

Drug-induced suicidal ideation is already recognized by the UK Parliament as well as other problems:

5.Problems with Seroxat and other SSRIs
Prozac and Seroxat are the best-known examples of SSRI and related antidepressants, but others are widely used.The introduction of SSRIs led to a threefold increase in antidepressant prescriptions between 1990 and 2000. Prescriptions for antidepressants now match those of the benzodiazepine tranquillisers at their peak, 25 years ago. Almost from the outset, there was concern about two main problems with SSRIs. First, there was suspicion (initially centred on Prozac) that these drugs could induce suicidal and violent behaviour – infrequently, but independently of the suicidal thoughts that are linked to depression itself. There was also concern (centred on Seroxat) about a risk of dependence; some users found it impossible to stop taking SSRIs because of severe withdrawal symptoms. The MCA/CSM formally reviewed these problems on several occasions.The suicidality problem was first investigated in 1990/1; withdrawal reactions were investigated in 1993, 1996 and 1998.In 2002,the MCA organised a further intensive review of both problems. This review was abandoned in April 2003, following criticism about conflicts of interest involving key figures on the review team." p. 87

"The Influence of Pharmaceutical Industry" - March 2005

http://www.publications.parliament.uk/pa/cm200405/cmselect/cmhealth/42/42.pdf

If the suicide of Traci Johnson, a healthy 19 years old girl who had no mental disease, on Elli=Lilly's facilities during Cymbalta's clinical tests as well as the suicide of 4 other volunteers during this test is not enough evidence i believe I have better stop trying to raise awareness.
I will not even talk about my experience while tapering Effexor with drug-induced suicidal ideation.
If FDA, which has already many evidences on this site alone, that is much more concerned with pharmaceutical profits than promoting health, will keep on denying and giving contradictory studies on drug-induced suicidal ideation it will be harder and harder to raise awareness on this tiny little problem.
If ssristories is not being taken seriously...
if..
if...

Oh Gosh! It's hard!
Sometimes I ask myself why keep on trying to raise awareness if what is in the mainstream media and what is said on articles that are part of the consortium that only cares about selling drugs is what is taken as truth.
Anyway.
I need a break.
I'm tired.
I'm tired of seeing my experience as well as other people testimonies not being taken into consideration.
I will take a break on mental health because i'm really tired.
I'll be back, of course. But I need a break.

Sara:

One more thing that I'd like your help with, please.

What exactly is Peter Breggin's position about how to treat people with mental illness?

Is he against all use of medications for any conditions, because they are dangerous and useless?

Does that mean that he believes that all mental illnesses should only be treated with psychotherapy?

Or does he disbelieve in the existence of mental illness in general?

Is he for the use of medications, but only for conditions that they are approved for?

Is he for the use of medications, but only if their adverse effects are not minimized by physicians and patients are entitled to all information before they can make an informed decision?

Thank you for your time.

P.S. I have read the Glenmullen book, The Antidepressant Solution. Great read. :)

DGuller, thank you for your apology.


Regarding BP disorder being diagnosed on the basis of a med reaction, here is what Dr. Joseph Glenmullen says in his book, “The Antidepressant Withdrawal Solution.” He is not antimeds by the way.


"Bipolar disorder is a diagnosis made on the basis of the patient's behavior and mental state. If a patient who is not on any drugs becomes manic, than one can reasonably conclude that the patient has bipolar disorder. But, if the manic-like state is caused by an antidepressant, this is a drug induced state, which although it may mimic bipolar disorder, is not actually bipolar disorder, as explicitly stated by the DSM, psychiatry's official diagnostic manual.


Another way of looking at it – Birth control pills can cause depression but yet, I don’t think there are too many doctors (I hope not) who would look into a woman’s psychiatric history to see if she was depressed prior to taking this drug. It is simply accepted as a known side effect.


It just seems that psychiatry in general (not everyone) thinks it is acceptable to diagnose psychiatric conditions based on med reactions when that wouldn’t be done in any other area of medicine.


Even though I was responding to your thread about Antidepressants and Suicidality, I want to mention a study about Antidepressants being effective since you had raised that point previously.


http://www.peh-med.com/content/3/1/14


Effectiveness of antidepressants: an evidence myth constructed from a thousand randomized trials?


The author makes an excellent point than any study on effectiveness is limited because there are not long term trials


Anyway, this is the perception I have of your responses and I don't mean this to be inflammatory. When we give you what seem like very credible citations, you poke holes in them and say that nothing can really be determined. Then you go back to the citations you studied and claim they are the correct interpretation.


Speaking of these studies, it would help if you listed the names of the researchers. Of course, we can look it up but by having the names immediately available, people can immediately research them to make sure there are no financial conflicts. Not that taking money from drug companies is a disqualifying factor but people who see these citations have a right to know this information.


One limit of any study is that if it isn’t set up correctly, the results are going to be deceptive. For example, the a study on St. Johns Wort around 2001 claimed that it didn’t relieve major depression. Well, most SJW experts did not make the claim that it did as they kept saying it helped for minor to moderate depression. But yet, the mainstream medical community was spinning the fact that SJW didn’t work for depression period when the design of the study was faulty to begin with.
To use your argument, someone considering St. Johns Wort for minor to moderate depression would see that study and be falsely persuaded that it wouldn’t work. Deception occurs on both sides my friend.


Those are my thoughts for today.

Sara:

Just to clarify one more thing.

Saying that the risk of suicide is minimal does not mean that physicians shouldn't vigorously monitor their patients on these medications, and involve their families if possible, in order to keep them safe. That is especially true in vulnerable individuals who should be followed even more closely.

Sorry for the possible confusion.

Thanks!

duller, "underlying bipolar disorder" is a crock of shit. Patients who have never experienced mania and then do after psychotropic drugs are blamed as being latent bipolars. This is typical psychiatric mythology. It's far more likely that the drugs CAUSED the mania. It happened to me. It's happened to thousands of others. When will psychiatry take responsibility for the destruction that they sow?

duller, "underlying bipolar disorder" is a crock of shit. Patients who have never experienced mania and then do after psychotropic drugs are blamed as being latent bipolars. This is typical psychiatric mythology. It's far more likely that the drugs CAUSED the mania. It happened to me. It's happened to thousands of others. When will psychiatry take responsibility for the destruction that they sow?

DGuller, fair questions about Peter Breggin. But by the same token, here are my questions to you:


1. Do you believe that people can completely recover from disorders like BP disorder and schiziphrenia and do it without meds?


2. Do you believe that once diagnosed, never undiagnosed, as Philip's psychiatrist said to him about BP disorder?


3. Do you believe that meds are the only treatment for severe depression or that people can recover using CBT?


4. Do you believe the people can commit crimes due to meds when nothing in their history would indicate that was a possibility?


5. Do you believe that psych meds can cause long term damage?


6. Do you believe than any class of psych med is neuroprotective?


7. What is your position on fish oil capsules being used to treat various psychiatric disorders?

aa:

I never meant to imply that anyone and everyone who has a manic or dysphoric reaction following antidepressant use must be diagnosed with bipolar disorder. Actually, according to the DSM-IV, bipolar disorder requires the mood states to occur independent of any kind of medication or substance use. So, that's just a moot issue.

However, studies have shown that those who DO have such reactions are MORE LIKELY to have bipolar disorder diagnosed in the future, and that there are a variety of risk factors associated with it, including family history of bipolar disorder, rapid onset depressive episode that resolves within 2-4 months, and so on.

Again, even if someone has an antidepressant-induced manic or dysphoric state, and has a family history of bipolar disorder, and has a depressive episode with all the characteristic features of bipolar depression, then you still cannot conclusively diagnose them with bipolar disorder. It just becomes a diagnostic possibility that should be kept in view. Only time will tell if it is valid or not.

If a patient has presented with the above combination of symptoms, then I would tell them that there is a possibility of underlying bipolar disorder and discuss with them whether they would want a trial of a mood stabilizer rather than an antidepressant. After presenting the rationale for the various options available, the patient would have to decide for themselves what they wanted.

The fact that many physicians rush to diagnose people with bipolar disorder after minimal evidence for it in specific patients is certainly to be opposed. It is not what the evidence says should be done, and it is not what the DSM-IV says either.

Thanks!

aa:

Here are my answers to your questions:

1. Do you believe that people can completely recover from disorders like BP disorder and schiziphrenia and do it without meds?

-- I believe that there are certainly a small minority of people who can do so, but that the vast majority struggle very much without their medications. For example, there are many solid studies that demonstrate that patients with schizophrenia who go off their medications or are switched to placebo have a 2-4 times increased risk for relapse into psychosis than those who stay on their medications. As many faults as they have, the antipsychotics are the most effective treatments we have at this time, and hopefully newer medications and treatments will be developed in the future.

2. Do you believe that once diagnosed, never undiagnosed, as Philip's psychiatrist said to him about BP disorder?

-- I disagree. I try never to accept diagnoses of other clinicians without doing my own assessment. There have been far too many misdiagnosed for me to be complacent.

3. Do you believe that meds are the only treatment for severe depression or that people can recover using CBT?

-- I believe that people with mild depression can recover without medication, people with moderate depression can recover with either medication or psychotherapy, and that people with severe depression require medications and can further benefit from psychotherapy.

4. Do you believe the people can commit crimes due to meds when nothing in their history would indicate that was a possibility?

-- Yes.

5. Do you believe that psych meds can cause long term damage?

-- Yes, as evidenced by the decrease in brain size of patients using atypical antipsychotics in the upcoming Andreason study. However, I think that, in general, this question is simply not studied enough to have conclusive answers, but it is definitely a possibility. It is also important to keep in mind that many essential medications, such as corticosteroids, birth control pills, cardiac medications, puffs, and others can cause long-term problems, too.

6. Do you believe than any class of psych med is neuroprotective?

-- There is evidence that SSRI's can be neuroprotective against hippocampal volume reduction in major depression. I have not looked into the other medications and other conditions.

7. What is your position on fish oil capsules being used to treat various psychiatric disorders?

-- I believe that there is some evidence for their use in depressive disorders, and none for schizophrenia. However, this is all preliminary work and much needs to be done to clarify the doses, the types of depression, their interactions with medications, and so on before they should be regularly included in the management plan.

Now, I'd like to read your answers to my questions above.

Thanks!

Sara:

Thank for the the article that you cited. I read it with great interest, and it made many good points.

I suppose that I have as much of a confirmatory bias as anyone else, and view evidence against my position with much more scrutiny than those that agree with mine. I have rejected some teachings by my staff supervisors after reading the literature on my own, so I am certainly not closed minded, but I will try to be as harsh with my evidence as with yours. That is only fair, as you pointed out. :)

You are right that there are not enough long-term studies, but there are some that are suggestive.

A review in the Canadian Medical Association Journal (2008; 178(10):1293-301) discussed two types of long-term trials.

The first looked at studies that took a group of subjects who responded to antidepressant medications, and then randomized them either to continue the treatment or to be switched to a placebo. It is called a discontinuation trial, and is the common way to analyse relapse rates.

A recent analysis of those studies (Lancet 2003;361:653-61) found that "a subgroup of patients who experienced recovery while taking medications, long-term therapy with selective serotonin reuptake inhibitors reduced the chances of relapse by up to 70% for up to 36 months, relative to patients whose therapy was discontinued earlier". In other words, those who recovered from depression on antidepressants had a 70% higher chance of relapse when the medications are discontinued for up to 36 months.

The other type of studies, which are far rarer, are when one group of people is randomized to receive medication and another to receive placebo, and they are followed long-term. The CMAJ article analyzed six studies that followed subjects for an average of 6-8 months, but none over a year. They found that the medications had a signifcant difference compared to the placebo group in terms of response, but not remission and acceptability.

Both of these reviews support current guidelines that patients who remit on medications should continue them for 6-12 months. However, there is still much research that needs to be done, and I wholeheartedly agree with you on that score.

Thanks!

DGuller, I finally found the reference to this study:


"Relationship Between Antidepressants and Suicide Attempts: An Analysis of the Veterans Health Administration Data Sets"


http://tinyurl.com/4l5r6a


Without access to the full article, we are really limited in our discussions. But I can make some points about 3 of the researchers that would call into question whether the study was bias free or not. In fairness, you have made the point about the study having biases although I am not sure you were referring to the researchers. By the way, I realize that this might have been mentioned in the full text article but people who don’t have access to it have the right to know this information


1. Robert D. Gibbons, Ph.D. – According to http://www.cspinet.org/cgi-bin/integrity.cgi,


Served as an expert witness for Wyeth Pharmaceuticals. ("Early Evidence on the Effects of Regulators' Suicidality Warnings on SSRI Prescriptions and Suicide in Children and Adolescents," Am J Psychiatry. 2007;164:9:1356-63.)Owns the following statistical software packages under the Robert D. Gibbons Ltd. trademark: DUMPStat and CARStat, both of which are licensed to and distributed by Discerning Systems Inc.


Also, you might want to read this blog entry http://clinpsyc.blogspot.com/search?q=Gibbons in which he is referring to study Gibbons did in September on the same issue. It looks like a different study but I can’t say that I am 100% sure. Anyway, he says:

“It is important to note that the authors of the paper did not have data from 2005, but there is nothing from the 2003-2004 U.S. SSRI prescription data cited in their paper that even suggests a relationship between decreased SSRI use in youth and an increased suicide rate, as the decrease in prescriptions was minimal. Pay close attention: The authors ran a total of zero statistical analyses to examine the relationship between SSRI prescription rates and suicide rates in the United States. That’s right, zero. So they put up a couple of figures without a single shred of statistical evidence, then claim that declining SSRI prescriptions are associated with an increase in suicide rates”


Obviously, the guy running this blog isn’t totally bias free but I saw criticisms of the same study on other sites.


2. J. John Mann - http://www.cspinet.org/cgi-bin/integrity.cgi

Received research support from GlaxoSmithKline; served as an adviser to Eli Lilly and Lundbeck. ("Early Evidence on the Effects of Regulators’ Suicidality Warnings on SSRI Prescriptions and Suicide in Children and Adolescents," Am J Psychiatry 2007; 164:1356–1363.) Attended a 2002 GlaxoSmithKline advisory meeting on lamotrigine. (Preliminary Report of the Task Force on SSRIs and Suicidal Behavior in Youth, American College of Neuropsychopharmacology, January 21, 2004, p.16; On file with CSPI) Consultant and expert witness for Pfizer for the drug Zoloft (sertraline), submitting a deposition for the company in 2000. Expert witness for SmithKline Beecham (now GlaxoSmithKline). In 1990, received funding from Eli Lilly for a study on the safety and biological mechanisms of action of norepinephrine and serotonin reuptake inhibitor antidepressants. (http://www.healyprozac.com/Trials/Tobin/Transcripts/5-31%20Suhaney-Mann.txt, pg. 1622; accessed 01/19/04) Research involving all suicide victims in a region of Hungary received three years of funding from Janssen Pharmaceutica, Inc. (http://www.hu.afsp.org/english/fr_hun_eng.htm; accessed 01/19/03)


You might want to read about John Mann’s involvement in the controversy regarding the suppression of Paxil Data and suicide that Joseph Glenmullen bought to light:


http://clinpsyc.blogspot.com/search?q=John+Mann


3. C. Hendricks Brown - http://www.cspinet.org/cgi-bin/integrity.cgi


C. Hendricks Brown, Professor, Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa. Directs a suicide prevention program that is funded by JDS Pharmaceuticals. ("Early Evidence on the Effects of Regulators’ Suicidality Warnings on SSRI Prescriptions and Suicide in Children and Adolescents," Am J Psychiatry 2007; 164:1356–1363.)


I just feel that when any study is referenced by you, people have the right to know if there are any financial conflicts by the authors.

DGullen, thanks for your responses

Here are my answers to the questions about Peter Breggin. Let me qualify this by stating I am guessing and am not 100% sure of what he has really said:


1. Is he against all use of medications for any conditions, because they are dangerous and useless?
Probably most of the time. However he provides alot of citations to support his position. I haven't yet seen you critique any of them.


2. Does that mean that he believes that all mental illnesses should only be treated with psychotherapy?


I would say yes. But Robert Whitakker, who wrote the book, "Mad In American" and who started out believing in the miracle of these meds makes similar types of points about schizophrenia.


3. Or does he disbelieve in the existence of mental illness in general?


I don't know what he has said specifically but I think it is safe to assume he feels it is way overdiagnosed.


4. Is he for the use of medications, but only for conditions that they are approved for?
Is he for the use of medications, but only if their adverse effects are not minimized by physicians and patients are entitled to all information before they can make an informed decision


I think in general, he is usually against meds period.


Again, I am not 100% sure of these responses so please, if I am wrong, correct me gently.

AA:

Thank you for the information on the authors. The study only makes note of Dr. Mann's connections with GSK, but stated that the other authors did not have conflicts of interest. I don't believe that the background information you provided necessarily implies that the other two are unreliable, but it is certainly important to know.

The study that I referenced is different from the one that the blog you cited criticized, and it is available for free online:

http://ajp.psychiatryonline.org/cgi/content/full/164/7/1044

Please have a look at it and let me know what you think.

One potential flaw that I identified with it is that the study excluded lethal suicides, because the VHA database that they were using did not record specific causes of death, and so it was impossible for them to know if subjects who had been hospitalized for suicide attempts subsequently died or if they died in other settings, but did not contact the VA system. So, they focused only on suicidal thoughts and attempts. This means that their study has no bearing on whether antidepressants affect completed suicides.

Other than that, it's a pretty solid study. Again, please have a look and let me know what you think.

Thanks!

aa:

Thank you for answering the questions. A few comments:

First, I haven't critiqued his citations, because I haven't been presented with them. Or maybe I missed them in a previous post?

Second, he believes in treating schizophrenia with only psychotherapy?

What time does he promote? Cognitive-behavioral therapy? Psychodynamic psychotherapy? Psychoanalytic psychotherapy? Humanistic psychotherapy? Gestalt therapy? Attachment-based psychotherapy? Interpersonal psychotherapy? And what evidence does he cite that these therapies work?

I have worked with people with schizophrenia. When someone is agitated and psychotic, what does he recommend? Chatting with them? Are injections of antipsychotics to calm them down less humane than strapping them down to a bed?

Anyone who has worked with these suffering individuals to any extent knows that the medications -- with all their problems -- do a great deal of good for their hallucinations and delusions.

Their major drawbacks are their side effects and their lack of efficacy in treating the cognitive and negative symptoms of schizophrenia. However, they are all we have, and to suggest returning to the days of psychotherapy for these patients is very unproductive.

Thank you for your time.

My take on Peter Breggin in response to your questions. He is against all medications because he believes they are harmful (toxic) to the brain and body and ultimately worsen mental illness and general health over the long term. He certainly believes in mental illness but believes the most important triggers are life circumstances and how you frame your story to yourself. (We react to stress differently and that is probably genetic.) I think he believes in a model like the Soteria House and/or different forms of psychotherapy as well as community and family support if possible and available. He also believes in the possibility of healing for even virulent cases of mania and psychosis for instance, that these do not have to be "life long" conditions. They are more likely to be life long if one is chronically medicated than if one isn't because of brain alterations caused by the medication. I am just restating his views as I understand them and not expressing my own here, although in general I am supportive of his views. As I said try reading his latest books. You can always put them down if you can't "take it."
Thanks for recommending The Shock Doctrine. I think it looks intriguing.

Sara:

Thank you for presenting Mr. Breggins' views. They certainly sound very appealing. After all, we are often struck my stories in which love and empathy can transform the lives of people, and this is certainly possible in people with chronic mental illness.

Personally, I believe in aiding patients in understanding their emotions, cognitions and underlying schema in the context of their life histories in conjunction with medication when necessary. My attitude is that medications are not the end of treatment, but rather help certain patients with significant deficits reach a point when they can do the hard work of piecing their lives back together by interweaving threads that had been torn asunder.

I personally implement cognitive-behavioral therapy, psychodynamic psychotherapy, schema therapy and emotionally focused therapy, depending on the patient. I certainly do not believe that medications will solve all a person's problems, especially when their problems are build upon a lifetime of thinking, feeling and acting in ways that repeat dysfunctional patterns.

However, if someone is too depressed, too anxious, too disorganized, too psychotic, and unable to gain sufficient insight to do psychotherapy, then medication is absolutely essential.

I still believe that fault lies both with those who deify medications as a panacea to all psychological distress and those who demonize them as ineffective toxic substances that uniformly damage the brain. They are tools that are useful in certain situations for which there is sufficient evidence, but they have to be carefully monitored and regularly reviewed.

At least that is how I practice psychiatry.

Furthermore, I believe that mental illness is certainly a brain disease. We are understanding more and more about both cognitive and affective neuroscience through sophisticated brain imaging that is giving us insights both into the neurochemistry and neurocircuitry involved in psychiatric disorders. For those who doubt that it is ultimately biological in origin, then they must answer the question of precisely where our mental states come from if not from underlying brain states.

Thanks!

P.S. Has Mr. Breggin published any studies that show that his approach is more effective than the standard approaches to treating mental illness? I would be very interested to read it for myself.

Breggin (and by the way -- it's Dr. Breggin -- he's a psychiatrist) has a lot of his published articles on his website (link is on Philip's link column). Also his book Brain-Disabling Psychiatric Treatments (catchy title isn't it?) is thoroughly footnoted. And the ICSPP conference is next weekend in Tampa Florida. I've been to 3 out of the last 4 and admit to finding them inspiring and educational.

I don't know exactly what Breggin thinks but besides psychotherappy and all the other things required to rectify a world gone crazy that drives people crazy, I think there are lots of lifestyle issues like nutrition and "sleep hygiene," to name only two, that usually are required in the "healing" of mood disorders. Mindfulness is another big thing.

As for brain "disease" I'm not sure that can be defined. Of course moods and crappy patterns of thinking are based on neurochemistry. Every thought we have is based on neurochemistry and proceeds in turn to alter neurochemistry; the brain is in a constant state of flux, always working to maintain some allostasis, homeostasis, whatever it is (I don't pretend to know), and not always succeeding. Some of us learn and probably are born with better stress coping skills better than others. Is that "organic"? Well maybe but what does that mean? And that's the point we really do not understand the brain; imaging etc. can lead people down some fanciful roads that are based on a lot of assumptions which isn't to say it shouldn't be used but if one is going to use it as a basis for treatment then watch out.

Well, dguller, you've drawn me into quite a lengthy conversation that I never intended to engage in. I would kind of like to draw this thread to a close to be honest. Here's hoping your experience on FS makes you a better doctor.

Sara:

Okaly dokaly.

Thanks for sharing your thoughts.

Take care.

Sara:

Sorry, just one more thing.

I've been trying to search online for any studies done by Dr. Breggin comparing his form of therapy to no treatment, placebo, standard medications, and/or other psychotherapies, but I've been unable to do so.

Could you please direct me to where I can find them? All I could find were some general articles outlining his ideas on his website, but there were no research studies to back up their efficacy cited. If they are cited in his books, then could you please post them?

Thanks, and sorry to be such a pest!

Maybe there aren't any -- or maybe he didn't do them. I guess I base my beliefs on real live human beings I've seen get better off meds, including psychotic individuals. I guess you don't call that science but I call it life. It doesn't help you in school but it might help you in practice. Anyway good luck finding some evidence. I hope you do.

All I know is what I feel when withdrawing from psych meds: like shit.

I've withdrawn from Seroquel, Xanax and Prozac and my body reacted severely. Beyond flu-like symptoms, it was violent physical illness, fatigue that is indescribable, diahrea that causes a person not to leave the house. Symptoms that are so predictable to my body's reaction to losing the chemical in the system (like a junkie)that tapering is a dreaded process.

I value patient anecdotal stories, and wish it was easy to find a psychiatrist who DID understand people have sensitivity to chemicals (drugs)and tapering is VERY individualized and not often acknowledged.

This is not a rant against any psychiatrist or professional, it's my own story. My pysch fortunately admitted to not understand withdrawals, and has listened intently and has taken notes on my experience, so he can watch for it with other patients.

I WISH I didn't have to go through what I do when withdrawing a psych med, it amazes me that I have to. THIS is the problem. We go on psych meds without a clue that removing them is a whole other world, and in my case, it was worse than the reason I went on the med, hands down.

I was given Prozac and Xanax and Seroquel by a PCP for "anxiety" and this happens far too often: people go to PCP's and they come out with psych meds, and are not monitored and don't know they need to be. Then go off the med into sheer hell is what happened to me, I leared what hell is coming off of Prozac, and tapered it slowly by pouring the powder into juice or into jelly/jam.

It was 9 months of basic junkie symptoms, the shakes, brain zaps, zaps from fingers, headache, fatigue ,stomach problems, 5 pm stomach pain, sweats, nightmares.

Try going to work like that.

Sara:

I'll keep looking.

Thanks.