Medication Withdrawal
Antidepressant withdrawal symptoms
Neurotransmitters act throughout the body, and you may experience physical as well as mental effects when you stop taking antidepressants or lower the dose too fast.
Common complaints include the following:
Neurotransmitters act throughout the body, and you may experience physical as well as mental effects when you stop taking antidepressants or lower the dose too fast.
Common complaints include the following:
- Digestive. You may have nausea, vomiting, cramps, diarrhea, or loss of appetite.
- Blood vessel control. You may sweat excessively, flush, or find hot weather difficult to tolerate.
- Sleep changes. You may have trouble sleeping and unusual dreams or nightmares.
- Balance. You may become dizzy or lightheaded or feel like you don't quite have your "sea legs" when walking.
- Control of movements. You may experience tremors, restless legs, uneven gait, and difficulty coordinating speech and chewing movements.
- Unwanted feelings. You may have mood swings or feel agitated, anxious, manic, depressed, irritable, or confused — even paranoid or suicidal.
- Strange sensations. You may have pain or numbness; you may become hypersensitive to sound or sense a ringing in your ears; you may experience "brain-zaps" — a feeling that resembles an electric shock to your head — or a sensation that some people describe as "brain shivers."
How to go off antidepressants
From www.health.harvard.edu/diseases-and-conditions/going-off-antidepressants
If you're thinking about stopping antidepressants, you should go step-by-step, and consider the following:
Take your time. You may be tempted to stop taking antidepressants as soon as your symptoms ease, but depression can return if you quit too soon. Clinicians generally recommend staying on the medication for six to nine months before considering going off antidepressants. If you've had three or more recurrences of depression, make that at least two years.
Talk to your clinician about the benefits and risks of antidepressants in your particular situation, and work with her or him in deciding whether (and when) to stop using them. Before discontinuing, you should feel confident that you're functioning well, that your life circumstances are stable, and that you can cope with any negative thoughts that might emerge. Don't try to quit while you're under stress or undergoing a significant change in your life, such as a new job or an illness.
Make a plan. Going off an antidepressant usually involves reducing your dose in increments, allowing two to six weeks between dose reductions. Your clinician can instruct you in tapering your dose and prescribe the appropriate dosage pills for making the change. The schedule will depend on which antidepressant you're taking, how long you've been on it, your current dose, and any symptoms you had during previous medication changes. It's also a good idea to keep a "mood calendar" on which you record your mood (on a scale of one to 10) on a daily basis.
Consider psychotherapy. Fewer than 20% of people on antidepressants undergo psychotherapy, although it's often important in recovering from depression and avoiding recurrence. In a meta-analysis of controlled studies, investigators at Harvard Medical School and other universities found that people who undergo psychotherapy while discontinuing an antidepressant are less likely to have a relapse.
Stay active. Bolster your internal resources with good nutrition, stress-reduction techniques, regular sleep — and especially physical activity. Exercise has a powerful antidepressant effect. It's been shown that people are far less likely to relapse after recovering from depression if they exercise three times a week or more. Exercise makes serotonin more available for binding to receptor sites on nerve cells, so it can compensate for changes in serotonin levels as you taper off SRIs and other medications that target the serotonin system.
Seek support. Stay in touch with your clinician as you go through the process. Let her or him know about any physical or emotional symptoms that could be related to discontinuation. If the symptoms are mild, you'll probably be reassured that they're just temporary, the result of the medication clearing your system. (A short course of a non-antidepressant medication such as an antihistamine, anti-anxiety medication, or sleeping aid can sometimes ease these symptoms.) If symptoms are severe, you might need to go back to a previous dose and reduce the levels more slowly. If you're taking an SRI with a short half-life, switching to a longer-acting drug like fluoxetine may help.
You may want to involve a relative or close friend in your planning. If people around you realize that you're discontinuing antidepressants and may occasionally be irritable or tearful, they'll be less likely to take it personally. A close friend or family member may also be able to recognize signs of recurring depression that you might not perceive.
Complete the taper. By the time you stop taking the medication, your dose will be tiny. (You may already have been cutting your pills in half or using a liquid formula to achieve progressively smaller doses.) Some psychiatrists prescribe a single 20-milligram tablet of fluoxetine the day after the last dose of a shorter-acting antidepressant in order to ease its final washout from the body, although this approach hasn't been tested in a clinical trial.
Check in with your clinician one month after you've stopped the medication altogether. At this follow-up appointment, she or he will check to make sure discontinuation symptoms have eased and there are no signs of returning depression. Ongoing monthly check-ins may be advised.
From www.health.harvard.edu/diseases-and-conditions/going-off-antidepressants
If you're thinking about stopping antidepressants, you should go step-by-step, and consider the following:
Take your time. You may be tempted to stop taking antidepressants as soon as your symptoms ease, but depression can return if you quit too soon. Clinicians generally recommend staying on the medication for six to nine months before considering going off antidepressants. If you've had three or more recurrences of depression, make that at least two years.
Talk to your clinician about the benefits and risks of antidepressants in your particular situation, and work with her or him in deciding whether (and when) to stop using them. Before discontinuing, you should feel confident that you're functioning well, that your life circumstances are stable, and that you can cope with any negative thoughts that might emerge. Don't try to quit while you're under stress or undergoing a significant change in your life, such as a new job or an illness.
Make a plan. Going off an antidepressant usually involves reducing your dose in increments, allowing two to six weeks between dose reductions. Your clinician can instruct you in tapering your dose and prescribe the appropriate dosage pills for making the change. The schedule will depend on which antidepressant you're taking, how long you've been on it, your current dose, and any symptoms you had during previous medication changes. It's also a good idea to keep a "mood calendar" on which you record your mood (on a scale of one to 10) on a daily basis.
Consider psychotherapy. Fewer than 20% of people on antidepressants undergo psychotherapy, although it's often important in recovering from depression and avoiding recurrence. In a meta-analysis of controlled studies, investigators at Harvard Medical School and other universities found that people who undergo psychotherapy while discontinuing an antidepressant are less likely to have a relapse.
Stay active. Bolster your internal resources with good nutrition, stress-reduction techniques, regular sleep — and especially physical activity. Exercise has a powerful antidepressant effect. It's been shown that people are far less likely to relapse after recovering from depression if they exercise three times a week or more. Exercise makes serotonin more available for binding to receptor sites on nerve cells, so it can compensate for changes in serotonin levels as you taper off SRIs and other medications that target the serotonin system.
Seek support. Stay in touch with your clinician as you go through the process. Let her or him know about any physical or emotional symptoms that could be related to discontinuation. If the symptoms are mild, you'll probably be reassured that they're just temporary, the result of the medication clearing your system. (A short course of a non-antidepressant medication such as an antihistamine, anti-anxiety medication, or sleeping aid can sometimes ease these symptoms.) If symptoms are severe, you might need to go back to a previous dose and reduce the levels more slowly. If you're taking an SRI with a short half-life, switching to a longer-acting drug like fluoxetine may help.
You may want to involve a relative or close friend in your planning. If people around you realize that you're discontinuing antidepressants and may occasionally be irritable or tearful, they'll be less likely to take it personally. A close friend or family member may also be able to recognize signs of recurring depression that you might not perceive.
Complete the taper. By the time you stop taking the medication, your dose will be tiny. (You may already have been cutting your pills in half or using a liquid formula to achieve progressively smaller doses.) Some psychiatrists prescribe a single 20-milligram tablet of fluoxetine the day after the last dose of a shorter-acting antidepressant in order to ease its final washout from the body, although this approach hasn't been tested in a clinical trial.
Check in with your clinician one month after you've stopped the medication altogether. At this follow-up appointment, she or he will check to make sure discontinuation symptoms have eased and there are no signs of returning depression. Ongoing monthly check-ins may be advised.
4 Things You Should Know Before Stopping Your Medication
From themighty.com/2018/09/how-to-stop-taking-antidepressants/
Psychiatric medications work differently for everyone because of our unique biological makeup and individual environmental triggers. Which drugs work for you may be useless to someone else. You may have side effects and your best friend on the same medication may not. Accordingly, whether or not to stop taking antidepressants is a decision that only you — with input from a doctor you trust — can make.
1. There’s a Risk of Mental Illness Relapse
One major risk of stopping your medications is a risk of relapse. Some doctors consider the danger of a mental health relapse a greater concern over any hypothetical negative impacts of using antidepressants for years. Mental illnesses like depression or bipolar disorder are prone to recur. Medication may be the best option to prevent future episodes and maintain a higher quality of life.
“Once a person has a second episode, that person will almost always have recurrent episodes,” Seidman told The Mighty. In the case of a condition like bipolar disorder, a manic episode that’s left untreated may turn into a psychotic break. Those with untreated depression or bipolar disorder have a higher risk of suicide.
“It’s a generalization but it really holds true for all the major mental illnesses like schizophrenia, recurrent unipolar major depression [and] bipolar depression,” Miller told The Mighty. “[The] more episodes a person has over the course of their life and the longer they go untreated, the greater the risk they have for future episodes and the harder those future episodes will be to treat.”
2. You May Experience Withdrawal Symptoms
When you stop taking your medication, you may experience withdrawal, or discontinuation, symptoms. These could include “flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal,” said Johnny Williamson, MD, a psychiatrist and medical director at Timberline Knolls in Illinois.
You may also experience “headaches, dizziness, fatigue, electric shock type symptoms (sometimes referred to as zingers) and irritability.” Usually, any withdrawal symptoms start within a few days of lowering the dose of your antidepressants and last one to two weeks. Most symptoms are mild, though that’s not always the case.
3. You Should Do It With the Support of a Medical Professional
Before stopping psychotropic medications, talk to your doctor first. You’ll want to discuss your reasons for discontinuing medication, how the process might work and the potential effects of withdrawal. A doctor — or even a pharmacist — can help decide how fast (or slow) you should go while lowering doses to minimize any potentially dangerous consequences, including side effects or interactions with other drugs you’re taking.
4. You Need to Go Slowly and Taper Off
Clinicians usually suggest waiting at least six months to a year after your mental illness symptoms have subsided before considering quitting your meds. From there, you’ll work with your doctor to create a plan to taper your medications slowly over time, which could mean weeks, months or even a year or more. Slow tapering has two major benefits. First, it reduces the discontinuation symptoms you’re likely to experience.
From themighty.com/2018/09/how-to-stop-taking-antidepressants/
Psychiatric medications work differently for everyone because of our unique biological makeup and individual environmental triggers. Which drugs work for you may be useless to someone else. You may have side effects and your best friend on the same medication may not. Accordingly, whether or not to stop taking antidepressants is a decision that only you — with input from a doctor you trust — can make.
1. There’s a Risk of Mental Illness Relapse
One major risk of stopping your medications is a risk of relapse. Some doctors consider the danger of a mental health relapse a greater concern over any hypothetical negative impacts of using antidepressants for years. Mental illnesses like depression or bipolar disorder are prone to recur. Medication may be the best option to prevent future episodes and maintain a higher quality of life.
“Once a person has a second episode, that person will almost always have recurrent episodes,” Seidman told The Mighty. In the case of a condition like bipolar disorder, a manic episode that’s left untreated may turn into a psychotic break. Those with untreated depression or bipolar disorder have a higher risk of suicide.
“It’s a generalization but it really holds true for all the major mental illnesses like schizophrenia, recurrent unipolar major depression [and] bipolar depression,” Miller told The Mighty. “[The] more episodes a person has over the course of their life and the longer they go untreated, the greater the risk they have for future episodes and the harder those future episodes will be to treat.”
2. You May Experience Withdrawal Symptoms
When you stop taking your medication, you may experience withdrawal, or discontinuation, symptoms. These could include “flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal,” said Johnny Williamson, MD, a psychiatrist and medical director at Timberline Knolls in Illinois.
You may also experience “headaches, dizziness, fatigue, electric shock type symptoms (sometimes referred to as zingers) and irritability.” Usually, any withdrawal symptoms start within a few days of lowering the dose of your antidepressants and last one to two weeks. Most symptoms are mild, though that’s not always the case.
3. You Should Do It With the Support of a Medical Professional
Before stopping psychotropic medications, talk to your doctor first. You’ll want to discuss your reasons for discontinuing medication, how the process might work and the potential effects of withdrawal. A doctor — or even a pharmacist — can help decide how fast (or slow) you should go while lowering doses to minimize any potentially dangerous consequences, including side effects or interactions with other drugs you’re taking.
4. You Need to Go Slowly and Taper Off
Clinicians usually suggest waiting at least six months to a year after your mental illness symptoms have subsided before considering quitting your meds. From there, you’ll work with your doctor to create a plan to taper your medications slowly over time, which could mean weeks, months or even a year or more. Slow tapering has two major benefits. First, it reduces the discontinuation symptoms you’re likely to experience.
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Antidepressant Withdrawal and Patient Safety
A new survey provides vital details and requires urgent action. From www.psychologytoday.com/us/blog/side-effects/201810/antidepressant-withdrawal-and-patient-safety “This has destroyed my life as I knew it and made me incapable of functioning normally or healthily.” “I have lost my capacity to function on a daily basis and exist as a shadow of the person I once was.” “Pure hell. Thought I was going mad.” “Unmitigated hell. The pills have completely ruined my life.” These and many similar remarks form a backdrop to Antidepressant Withdrawal, a comprehensive survey of patients’ experiences released last month by the UK’s All-Party Parliamentary Group for Prescribed Drug Dependence. The outcome of a year-long study involving almost 1,700 respondents, 319 of them users of antidepressant medication, the survey—undertaken with researchers at London-based University of Roehampton—represents one of the largest international surveys of its kind into withdrawal from psychiatric drugs, in this case antidepressants, antipsychotics, and benzodiazepines. The qualitative data was gathered by report authors Dr. James Davies, Dr. Regina Pauli, and Luke Montagu. More than 90 percent of respondents “attributed the symptoms to being caused by withdrawal.” Their answers—summing up the often-incapacitating effect of withdrawal on their health, work, finances, and relationships—describe an intensity to their depressionand anxiety altogether different from that for which the medication was initially prescribed. “On a scale of severity from 0-10 (10 being the most severe withdrawal),” the researchers note, “the mean average was 9 points.” The report gives us data not often recorded in clinical studies. We learn that “around half of the survey participants were told that their original symptoms were caused by a chemical imbalance, a genetic problem, or something wrong with the brain.” The authors extrapolate, “It appears that doctors are continuing to promote the belief that mental health problems are biological diseases, despite the lack of evidence in support of this position.” They cite Joanna Moncrieff’s research-driven study, The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment (2007). Additional references would include Irving Hirsch’s The Emperor's New Drugs: Exploding the Antidepressant Myth (2010) and Robert Whitaker’s Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (2010), both also driven by meta-analyses and other published datasets. Given the persistence of the belief among prescribers that depression and anxiety stem from a “chemical imbalance,” the report points to a gap between patient experience and physician interpretation. Many prescribers are quoted as insisting that their patients' adverse effects are always, necessarily, a return of the original symptoms. Many reject out of hand any correlation between heightened, acute sensitivity to noise, intense mood swings, and sometimes painful head zaps and adjustment in pharmacological treatment, despite the amount of time needed for the drugs to wash out of the brain and central nervous system. In the words of one respondent, “They dismissed any notion of withdrawal and prescribed a number of different medications.” Another writes, “The psychiatrists simply waived my story out of hand as impossible, saying that ‘it was just the old illness coming back,’ even though I’ve never experienced anything even remotely approaching this.” “I used to get this burning sensation deep within my brain, especially towards the end of the day. Even my thoughts started to hurt me,” explains Alyne Duthie from Braemar, Aberdeenshire. Her chronic discontinuation problems were detailed in Scotland's Sunday Herald yesterday, in an article on the numbers countrywide “hooked on antidepressants—and harmed by withdrawal.” “Within days of coming off them,” Duthie continues, “I started having severe tinnitus, the kind that pierces your brain. I started having severe abnormal movements—my head, arms, and legs jerked constantly…. I would get boiling hot then freezing cold the next. I used to go around with cold packs strapped to my chest.” According to the newspaper, “a record 902,168 people in Scotland were prescribed antidepressants last year.” In sharp contrast to this consistent summary of antidepressant withdrawal, well-sourced, empirically guided information on how to discontinue safely appears to be at a premium. That's a mounting problem given the millions of people prescribed psychiatric drugs worldwide. According toAntidepressant Withdrawal, a majority of prescribers “provided no advice regarding withdrawal.” Some 64 percent of respondents claimed “not to have received any information from their doctors on the potential risks/side effects of antidepressants they were prescribed.” And 25 percent were given “no advice at all about how to withdraw,” while 7 percent were told to withdraw “cold turkey.” Just as critical, the symptoms of antidepressant withdrawal described often exceed and outlast current prescribing guidelines, which characterize discontinuation as generally “mild” and “self-limiting” (resolved in one to two weeks). Overall, 47 percent of all respondents experienced withdrawal and related adverse effects for more than a year. “The withdrawals are so severe,” one remarked, “that I cannot function to do simple tasks like make a cup of tea, let alone leave the house to go to work.” In the section assessing the effect of withdrawal on relationships, comments included: “No sex drive (affects marriage).” “Find myself getting angry with partner and kids.” “My withdrawal symptoms include ... aggressive behaviour towards family.” “It has affected my relationship with my partner and children.” And, “withdrawal was the hardest thing I have ever done. It nearly destroyed me and my family.” Given the alarming discrepancy between patient experience and doctors’ frequent dismissal of claims that the cause could be pharmacological, the researchers pull no punches in citing a widespread “failure of those responsible for their [patients'] care to understand and to treat the problem.” “Doctors and psychiatrists do not understand the potential harms of antidepressant withdrawal sufficiently,” they warn, “and a majority are not informing patients about side effects.” As such, the datasets informing the survey not only “make clear the ruinous impact of antidepressant withdrawal on some individuals;” they also expose “a deep deficit in the current understanding of the potential harms of antidepressants by doctors and psychiatrists.” That deficit is a concern for multiple reasons, not least for patient safety. On the one hand, first-line prescribers of psychiatric drugs in the UK (76.4 percent of them GPs, the remaining 23.6 percent psychiatrists) are, in the words of several respondents, “in such complete denial of the harm they have been doing” that they simply cannot see the problem before them. “I was told that ‘discontinuation syndrome’ could only have lasted a few weeks,” one respondent writes, characterizing the objection, “so I didn’t know what I was talking about.”However, according to “A systematic review into the incidence, severity and duration of antidepressant withdrawal effects,” the recently published meta-analysis by John Read and James Davies that is receiving international attention—alongside cognate analyses on the sometimes incapacitating experience of withdrawal from antidepressants—prescribers and physicians in the UK, the US, and beyond are relying on prescribing guidelines greatly at variance with empirically driven research. According to the meta-analysis, more than half (56 percent) of people who attempt to come off antidepressants experience withdrawal effects, and, of those, almost half (46 percent) experience withdrawal effects they describe as severe. Source: American Psychiatric AssociationOn Thursday last week, the American Psychiatric Association appeared to acknowledge the gravity and scale of the problem, tweeting from its official account at 8:01 AM: “Researchers have warned that medical guidelines in the UK and US on antidepressant withdrawal urgently need to be updated to show it is more common and severe than currently stated.” The candor and sense of urgency were noted and broadly appreciated, though neither lasted into the afternoon. Within hours, the tweet had been taken down without comment or replacement, leaving the highly consequential matter of the APA’s position on antidepressant withdrawal altogether unclear. Was the organization now recanting that it considered withdrawal “more common and severe than currently stated”? Did it no longer think medical guidelines “urgently” needed updating? Meanwhile, as patients and psychiatrists wait for clarification—including, in Britain, for the Royal College of Psychiatrists to update its own guidelines—we face the likelihood of ongoing, large-scale prescribing on the basis of empirically faulty data. With prescribing rates continuing to climb, millions of patients are not being given adequate or accurate information about the drugs' adverse effects, much less how to end treatment safely. The scale of the drugs' discontinuation issues requires the following caution: patients concerned about adverse effects are strongly advised NOT to terminate treatment abruptly, but instead to taper (titrate) carefully and gradually by microdoses over a course of several months, always in consultation with their doctor, to ensure their own safety. Peer-reviewed, specialist information on discontinuation issues appears on the website Surviving Antidepressants, with a forum specifically on “Tapering.” Much of the early bibliography on withdrawal is also detailed here, in this 2011 post on “Side Effects.” |
Antidepressant Withdrawal Syndrome
Why SSRI antidepressants often produce a withdrawal syndrome. From www.psychologytoday.com/us/blog/side-effects/201107/antidepressant-withdrawal-syndrome In his "Defense of Antidepressants" in last Sunday's New York Times, Peter Kramer tried to discredit meta-analyses of SSRI antidepressants indicating that most of their efficacy is due to placebo, to the point where the difference between those antidepressants and placebo is "clinically meaningless." As Kramer repeatedly mischaracterized the research he summarized, I found his defense of the drugs unpersuasive. Even so, it was striking that his relatively long op-ed essay had nothing to say about well-documented cases of withdrawal symptoms among those trying to end SSRI treatment. In May 2007, to invoke a quite different perspective on antidepressants in the same newspaper, Bruce Stutz wrote a long and thoughtful piece on his own difficulties ending a treatment of Effexor (Venlafaxine). Stutz also reported some of the clinical literature to-date on the phenomenon. In 1997, he explained, "nearly a decade after the introduction of Prozac, its manufacturer, Eli Lilly, sponsored a research symposium to address the increasing number of reports of patients who had difficult symptoms after going off their antidepressants. By then it had become clear that drug-company estimates that at most a few percent of those who took antidepressants would have a hard time getting off were far too low. Jerrold Rosenbaum and Maurizio Fava, researchers at Massachusetts General Hospital, found that among people getting off antidepressants, anywhere from 20 percent to 80 percent (depending on the drug) suffered what was being called antidepressant withdrawal (but which, after the symposium, was renamed ‘discontinuation syndrome')." (The percentages noted in the study in fact ranged from 22% to 78% of patients discontinuing, with 78% still representing a distressingly high number.) "The symptoms of discontinuation syndrome could be fierce," Stutz added, as he recounted in considerable detail, at varying doses, his own harassing problems with "brain zaps," panic attacks, insomnia, and despair on lower and lower doses of Effexor. Fava, he noted, went on to publish in 2006 a paper citing further withdrawal symptoms, such as "agitation, anxiety, akathesia, panic attacks, irritability, aggressiveness, worsening of mood, dysphoria, crying spells or mood lability, overactivity or hyperactivity, depersonalization, decreased concentration, slowed thinking, confusion and memory/concentration difficulties." To the authors, these symptoms and their widespread recurrence looked increasingly like a drug-related syndrome. After Rosenbaum and Fava drew clinical attention to "discontinuation syndrome," several more studies unearthed comparable difficulties among those trying to end SSRI antidepressant treatment. Sometimes couched as a dependency issue, and sometimes also mistakenly viewed as a form of relapse in which the original depression or anxiety treated is said to recur, withdrawal symptoms from antidepressants have come to be seen among these researchers as a serious pharmacological problem in their own right. The symptoms stem, the researchers argue, from the neurological effects of the drugs' retention of serotonin and the consequent down regulation of neurotransmitters that are once again needed (though in short supply) when treatment ends. article continues after advertisementAs Kramer's silence on the topic last week helps illustrate, however, there has been enormous resistance among advocates of SSRIs (and, naturally, among their manufacturers) to addressing this issue. Only recently have a few researchers tried to isolate for withdrawal syndrome, rather than group such symptoms with adverse effects and with assumptions about relapse. In "Rebound Syndrome: When Drug Treatments Fail," a chapter of my book Shyness: How Normal Behavior Became a Sickness, I focused extensively on GlaxoSmithKline's own "product monograph" for Paxil (Paroxetine hydrochloride), which the drug-maker updated in 2005, following a chorus of complaints about the drug's well-documented side effects. Those bear a rather startling resemblance to the discontinuation syndrome that Rosenbaum and Fava earlier documented. The side effects range, the drug-maker conceded, all the way from "agitation, anxiety, headache, tremor, confusion, diarrhea, nausea, vomiting, and sweating" to "mental status changes that include extreme agitation progressing to delirium and coma" (qtd. p. 142; the manual can be downloaded here). "Recent analyses" of the drug's effect on patients under the age of 18 recognized "behavioral and emotional changes, including an increased risk of suicide ideation," GSK noted with obvious reluctance, following the FDA's decision in August the previous year (2004) to add a black-box warning about the drug-related risks of suicide on teens and young adults prescribed the antidepressant. Since the list of "severe agitation-type adverse events" in teens and adults included "self-harm or harm to others," GSK went on to add, as well as "disinhibition, emotional lability, unpredictable mood swings, hostility, aggression, depersonalization, [and] akathisia," a serious condition marked by extreme motor restlessness, apparently none of the several million people taking the drug could safely be said not to require "rigorous clinical monitoring for suicidal ideation"—an almost unbelievable outcome, voiced by the drug-manufacturer itself, for a company still encouraging the public to take Paxil for anxiety about going to parties and fear of being criticized. As USA Today noted at the time, "20 percent of patients treated with Paxil in worldwide clinical trials in major depressive disorder and 16.1 percent of patients treated with Paxil in worldwide trials in social anxiety disorder ... discontinued treatment due to an adverse event." article continues after advertisementIn the same chapter, I documented further evidence of such "adverse events" by citing the extant literature on discontinuation syndrome and interviewing one member of paxilprogress.org who has continued to track the research on SSRIs and withdrawal syndrome with impressive diligence and care. "Kate," as she's dubbed in the book, following her request for anonymity, described to me at the time how she was given Paxil because she thought she had social anxiety disorder, and how, after initially responding well to the drug, she carefully tapered her dose when she felt better. "I immediately had a whopping reaction," she despaired. "Three months of quasimania ... followed by six months of anxiety, insomnia, periodic brain zaps, and total uninterest in sex." Other drugs, prescribed by "well-meaning psychiatrists," only worsened her anxiety, weepiness, and sense of hopelessness. She said she felt worse, coping with Paxil's aftereffects, than she did before starting treatment. There are clear neurological reasons, Kate explained and follow-up research corroborated, why an SSRI antidepressant like Paxil would generate a withdrawal syndrome. First, while this class of drugs artificially raises the amount of serotonin in the brain, the serotonergic system doesn't ignore the increase, but adjusts to and compensates for it, downregulating the number of 5-HT1A receptors because the drugs, altering serotonin levels, put them in less demand. At the same time, the serotonergic system needs more 5-HT2 receptors to soak up the excess of the messenger, a situation many studies have linked to patients' widespread complaints of sexual dysfunction, because those receptors send saturation signals to the brain. In 2002, in the International Journal of Neuropsychopharmacology, to invoke just one study, Adam Opbroek and his colleagues found that "80% of patients with SSRI-induced sexual dysfunction also describe clinically significant blunting of several emotions" (p. 147). When patients try to end treatment, even stepping down their dose very gradually, many of them (22% to 78%, according to Rosenbaum and Fava) find that the receptors in their serotonergic system—saturated artificially for months, even years—experience the drop to pre-drug levels as starvation. Some patients then find themselves at the mercy of hair-trigger symptoms that register as intense anxiety, aggression, and insomnia. Several receptors—including 5-HT1A—aren't especially malleable, moreover, and take longer to sprout anew after drug treatment ends, delaying the patient's return to neuronal health. Indeed, some studies I consulted found that in certain patients those receptors fail to grow back at all, in effect leaving the patients worse off than before. (See for instance "Dissociation of the Plasticity of 5-HT1A Sites and 5-HT Transporter Sites" in Paxil Research Studies 19.3 [1994], 311-15.) As the proportion of SSRI-takers found to suffer from discontinuation syndrome is, by pharmacological standards, astronomical, and "one in ten Americans"—roughly 30 million people in the U.S. alone—"ingests" the drugs each year, as Peter Kramer noted only last week, it seems incredible that clinical trials have been so slow to recognize, and isolate for, withdrawal syndrome in patients trying to taper and end SSRI treatment. The number of people affected would, in any normal situation, drive a lot more targeted research on the problem. However, while drug-companies have done their best to redefine withdrawal syndrome as relapse, to confuse doctors and patients into thinking the original depression or anxiety had returned, the good news is that research is starting to focus exclusively on the widespread problem of SSRI withdrawal syndrome. Today, in her 7th year of recovery from severe Paxil withdrawal syndrome, "Kate"—also known as "Altostrata"—runs a website called "Surviving Antidepressants" that compiles research and data explicitly on the syndrome. She is still "hypersensitive to neuroactive medications," she reports, and recovering from severe setbacks 33 months after discontinuation, but with the help of a doctor who treats and has studied withdrawal syndrome, she is slowly recovering. In addition to providing peer support for patients struggling to end their SSRI-treatment without massive, harmful problems, "Surviving Antidepressants" notifies readers of research-in-progress, including by Dr. Carlotta Belaise, a colleague of Fava's and a frequent co-author with him of scientific papers challenging the long-term use of antidepressants. While Dr. Fava's research recently has been publicized on sites such as The Daily Beast, Dr. Belaise, a research fellow in the Affective Disorders Program of the department of psychology at the University of Bologna, Italy, is collecting data on antidepressant withdrawal syndrome, "which," she writes, "we strongly believe is a very important, common and delicate clinical problem." (Update, October 19, 2012: the published results are summarized here.) Precisely because of that delicacy, patients concerned about the drugs' adverse effects should NOT terminate their treatment abruptly, but should instead taper their dose very carefully and gradually, over a course of several months, always in consultation with their doctor, to ensure their own safety. |
