Monday, September 24, 2012

What does it mean to say that antidepressants are not addictive?

The Royal College of Psychiatrists has published a leaflet with the results of a survey about coming off antidepressants, which I mentioned in a previous post. Generally, I think this is a helpful leaflet. However, it ends with a throw-away remark, "We would like to reassure readers that despite some people having symptoms of withdrawal when stopping antidepressants, antidepressants are not addictive".

I think what is meant is that there is no evidence that the body gets addicted with antidepressants. However, people can get psychologically addicted and it seems confusing to restrict the use of the term 'addiction' to physical addiction. GlaxoSmithKline, the makers of paroxetine, eventually dropped its insistence that paroxetine is not addictive, I think at least partly because of this confusion (see Guardian article).

Helpfully, the survey confirms that the primary symptom of antidepressant discontinuation is anxiety. This would fit with my argument that antidepressant discontinuation problems are due to psychological dependence (see my Antidepressant discontinuation reactions webpage and my book chapter Why were doctors so slow to recognise antidepressant discontinuation problems?)

38 comments:

Altostrata said...

Your current theory that antidepressant discontinuation problems are due to psychological dependence is dead wrong, Dr. Double.

I cannot express vehemently enough that withdrawal symptoms are mostly physiological. For the most part, they represent autonomic dysfunction, resulting in a wide range of symptomology.

"Brain zaps," for example, a variety of Lhermitte's sign, are seen only in psychiatric drug discontinuation and, by the way, are not benign as they indicate disrupted electrical functioning in the nervous system.

Anxiety is the primary symptom of withdrawal because lack of feedback by the downregulated serotonin system results in disinhibition of the alerting system (Harvey, 2003).

While it's true some people may become psychologically attached to the idea their drugs are a dam against a flood of distress and may be fearful of discontinuing them, hundreds of thousands of patient reports of severe withdrawal symptoms following the autonomic dysfunction model (not to mention thousands of published case reports) demonstrate difficulty in discontinuation is NOT due to psychological factors.

It's probably a small minority who worry themselves into "withdrawal symptoms." You may have observed patients reporting withdrawal symptoms when they accidentally forget a dose -- no anticipatory anxiety involved.

There is real reason to taper slowly to avoid withdrawal symptoms.

Antidepressants cause physical dependence. Whether or not you call this addiction is a question of semantics.

I am deeply appalled that you are in the camp of blaming the patient for antidepressant withdrawal symptoms. This kind of rationalization cause vast patient harm, as physicians discount their reports of withdrawal difficulties and further obscure a very definite drawback of antidepressants.

Duncan Double said...

As I've said before, Allostrata, I'm not blaming patients for antidepressant withdrawal symptoms. I think I was one of the first to recognise them in a letter to the BMJ in 1997.

Here's what I wrote then and I haven't changed my views since:-

Robert G Priest and colleagues advocate educating patients that discontinuing antidepressant treatment will not be a problem but remarkably do not cite any evidence to support their recommendation.1 They also complain that many lay people regard antidepressants as addictive. They suggest that people may be extrapolating from what they have heard about benzodiazopines. This may be, but it is also common sense to believe that discontinuing taking a drug that is thought to improve mood may be difficult. I think that the general public understands this issue better than the Royal Colleges of Psychiatrists and General Practitioners, which are responsible for the Defeat Depression Campaign.

Of course what Priest and colleagues mean is that there is little evidence of physical dependence caused by antidepressants, but this is not what they say. There are, however, case reports of a withdrawal syndrome.2 Clinical experience is that it can be difficult to withdraw treatment with antidepressants for various reasons. The general public might reasonably expect psychiatrists specialising in disorders of the mind to recognise psychological dependence, base their advice on clinical experience, and use their common sense.

Randomised controlled trials of discontinuation of antidepressant treatment have a relapse rate varying from 92%3 to 36%4 in the placebo group. Relapse rate is significantly reduced by continuing antidepressant treatment. Some patients therefore do maintain their therapeutic gains when antidepressants are withdrawn, but the relapse rate is not insubstantial and seems to support the general public's commonsense view rather than the Defeat Depression Campaign's purist scientific statement. Perhaps the public needs to be suspicious of the motives of a campaign that encourages them to seek medical treatment and also tries to help doctors recognise depression. Patronising misinformation is not constructive.

References
1.Priest RG,et al Lay people's attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch. BMJ 1996;313:858#9. (5 October.)
2.Charney DS,et al Abrupt discontinuation of tricyclic antidepressant: evidence for noradrenergic hyperactivity. Br J Psychiatry 1982;141:377-86.
3. Prien RF et al.Lithium prophylaxis in recurrent affective illness. Am J Psychiatry 1974;131:198-203.
4.Klerman GL et al Treatment of depression by drugs and psychotherapy. Am J Psychiatry 1974;131:186-91.

Altostrata said...

Dr. Double, are you saying the patients have psychological reactions beyond their control, in addition to neurophysiological withdrawal reactions?

If that is your position, it needs clarification, but we can agree.

One very, very common and distressing psychological reaction is that patients discover how little their doctors know about these drugs or their adverse effects. The betrayal of trust is experienced deeply and emotionally.

Getting back to your initial article, let us look at the use of the term "anxiety" as reported to the Royal College of Psychiatrists in its withdrawal survey.

Patients are often at a loss to describe withdrawal symptoms. "Anxiety" may be as close as they can come to that unprecedented, unimaginable bone-shaking inner tension that is withdrawal anxiety.

There is, of course, a range of severity of this reaction. At one end, you have "anxiety" that might be mistaken for normal anxiety -- except it comes in waves, out of the blue, stays for a while, and vanishes, like storm clouds blowing away, leaving blue sky.

At the other end, you have akathisia. Patients don't know this term, and may describe their feelings to the doctor as intense anxiety, fear, terror, inner vibrations, unbearable restlessness, etc., any of which the doctor may interpret as anxiety.

Beyond akathisia, there is uncontrollable extreme anger, rage, or fear, or depression. In ths state, patients may kill themselves or others.

(Simply having these bizarre symptoms will cause a patient to become quite understandably distressed, which might be understood as a garden-variety psychological reaction.)

Survey instruments simply do not have enough choices to describe withdrawal anxiety, or any withdrawal symptom that might be mistaken for an emotion.

Withdrawal syndrome sufferers have coined a term, "neuro-emotion," to describe those quasi-psychological symptoms magnified by neurological dysfunction, see http://tinyurl.com/8hunn2u

It's quite likely that the "anxiety" found by the Royal College of Psychiatrists refers to all of this and more.

A nervous system deranged by withdrawal produces symptoms that are far beyond any known range. You have to look into the literature on Cushing's syndrome and traumatic brain injury to grasp them.

This is what comes of trying to fit the round pegs of withdrawal symptoms into the square holes of standard psychiatric parlance.

Altostrata said...

The RC Psychiatry survey instrument is still visible at http://www.surveymonkey.com/s/5MVZ7SQ , and a blunt instrument it is, too.

Of the 30 or 40 symptoms recorded for antidepressant withdrawal, the survey chose to provide checkboxes for these six:
- Stomach upsets
- Flu-like symptoms
- Anxiety
- Dizziness
- Vivid dreams or nightmares
- Sensations in the body that feel like electric shocks

And a text box in which the user may specify Other.

This guarantees that reporting will be skewed towards the listed withdrawal effects provided with checkboxes.

The survey provides a duration and severity scale for each of the six listed symptoms.

- Mild (uncomfortable, but no big deal)
- Moderate (annoying, but did not significantly affect my daily life)
- Severe (intolerable and affected my ability to function as usual)


This is how the leaflet presents the information garnered from the symptom frequency-severity scale:

"Of the common symptoms reported, the one rated severe by most people was anxiety. The symptoms that were rated moderate by most people were stomach upsets, flu-like symptoms, dizziness, vivid dreams and electric shocks/brain zaps. The less common symptoms were reported as severe: returning depression, headache, suicidal thoughts, insomnia, fatigue and nausea."

I would have liked to know how many people reported being severely affected by each of these symptoms.

Note that "severe" means "intolerable," and apparently a good chunk of those reporting "anxiety" reported it as "severe" -- not your garden-variety kind of anxiety.

One significant finding noted by the leaflet: "People in our survey report that the symptoms generally lasted for up to 6 weeks. A small percentage of symptoms lasted longer than this. A quarter of our group reported anxiety lasting more than 12 weeks."

To me, this indicates the received wisdom that withdrawal syndrome lasts only a few weeks is absolutely wrong. And, in fact, prolonged withdrawal syndrome of months or even years is much, much more common than medicine has so far confessed. (Ask Peter Haddad about this.)

As for the "relapse" reported in the leaflet after quitting ("63% of people in our survey said they had experienced withdrawal or a return of depression."), I suggest that this survey, as well as almost every paper written about antidepressant discontinuation, is contaminated with misdiagnosis of attenuated withdrawal symptoms as garden-variety "depression" or "relapse." Very few studies include protocols to distinguish between withdrawal-induced depression ("neuro-depression") and normal depression, utilizing survey instruments almost as dumb as this one.

Duncan Double said...

I think where we're agreed, Altostratus, is that antidepressant discontinuation problems are real and can be prolonged.

Altostrata said...

Dr. Double, perhaps I've misunderstood your statement in your recent blog post: "antidepressant discontinuation problems are due to psychological dependence" [rather than physical dependence]. Could you please explain it?

There is plenty of evidence that antidepressants cause physical dependence. The reason they are not considered "addictive" is that in the 1987 DSM-III revision, the American Psychiatric Association deliberately redefined "substance dependence" so that it did not apply to antidepressants.

The exemption of antidepressants from addictiveness is carefully described in NICE guidelines CG90 Depression in adults: full guidance 28 October 2009 http://guidance.nice.org.uk/CG90/Guidance/pdf/English

This semantic distinction has been enshrined in every reference to antidepressant withdrawal symptoms, and it is to this I believe the RCP leaflet refers.

However, see Nielsen, 2011 What is the difference between dependence and withdrawal reactions? for a counter-argument.

Duncan Double said...

Perhaps we need to debate what the evidence is for physical withdrawal - you don't say what it is.

Altostrata said...

Are you looking for visual evidence of nerve damage? Is it your contention that all symptoms have a psychological rather than neurological origin?

How do you account for the fact of downregulation? Do you think the receptors immediately bounce back?

See Harvey, 2003 rodent studies.

There are thousands of papers on psychiatric drug withdrawal syndromes. In PubMed:

http://www.ncbi.nlm.nih.gov/pubmed?term=ssri%20withdrawal%20syndrome
http://www.ncbi.nlm.nih.gov/pubmed?term=ssri%20discontinuation%20syndrome
http://www.ncbi.nlm.nih.gov/pubmed?term=antidepressant%20discontinuation%20syndrome
http://www.ncbi.nlm.nih.gov/pubmed?term=antidepressant%20withdrawal%20syndrome

and so forth, also search for "paroxetine withdrawal syndrome," "venlafaxine discontinuation syndrome," "quetiapine withdrawal syndrome," etc.

I've got a collection of papers here http://survivingantidepressants.org/index.php?/forum/16-from-journals-and-scientific-sources/ , with highlights here: http://survivingantidepressants.org/index.php?/topic/317-important-topics-in-journals-and-scientific-sources/

Here's a clinical guide to Adverse Syndromes and Psychiatric Drugs by Peter Haddad, a major psychiatric researcher in withdrawal syndrome: http://books.google.com/books/about/Adverse_Syndromes_and_Psychiatric_Drugs.html?id=uV1rE_hOvJ8C

Altostrata said...

Here are 365 case histories http://tinyurl.com/3o4k3j5

Many of these people went off cold turkey or too fast, with no particular apprehension other than they wanted to exit medication as quickly as possible.

They would have vastly preferred not to have withdrawal symptoms, but they did, quite severely.

Among these 365 case histories of withdrawal syndrome are only a few who express any fear at all about saying goodbye to their drugs. Almost all wanted to be rid of them and the merry-go-round of psychiatric treatment.

There is plenty of psychological trauma in withdrawal, mainly because of the realization of betrayal of trust, but not much of what you would call psychological dependency on the drugs.

If there is no psychological dependency or expectation of withdrawal symptoms, the complaints must represent authentic neuropsychiatric symptoms -- unless you want to contend there is an epidemic of factitious illness among people who coincidentally also have discontinued psychiatric medications.

Anonymous said...

I do not believe for one minute that antidepressants are not addictive and I don't care what evidence suggests otherwise - anything literally anything you can put in your mouth has the potential to be addictive

Duncan Double said...

You have an impressive list of references, Altostrata, but I can't find one that confirms that antidepressant discontinuation reactions are due to physical withdrawal. Peter Haddad, of course, was the first author on a BMJ editorial in 1998 that was headed "Antidepressant discontinuation reactions are preventable and simple to treat". He did amend this view a few years later.

Altostrata said...

See Advances in Psychiatric Treatment (2007) 13: 447-457
Recognising and managing antidepressant discontinuation symptoms
Peter M. Haddad and Ian M. Anderson

"....The syndrome was initially reported in case reports and adverse drug reaction reports (Haddad, 1998) but its features have been confirmed in several double-blind studies in which SSRI treatment is briefly interrupted with placebo (Rosenbaum et al, 1998; Michelson et al, 2000; Judge et al, 2002)....

Fava et al (1997) reported that during the 3 days following stoppage of venlafaxine and placebo under double-blind conditions, seven (78%) of nine participants treated with venlafaxine and two (22%) of nine placebo-treated individuals reported the emergence of adverse events, a statistically significant difference...."

Now, why would blinded patients react psychologically or psychosomatically to a discontinuation of which they are unaware?

"....Among the SSRIs several prospective studies have show that paroxetine is associated with the highest incidence of discontinuation symptoms and fluoxetine the lowest (Rosenbaum et al, 1998; Michelson et al, 2000; Bogetto et al, 2002; Judge et al, 2002; Tint et al, 2007)...."

Why would there be variation in psychological or psychosomatic withdrawal symptoms among antidepressants?

How does your theory of withdrawal syndrome being a purely psychological (or psychosomatic) reaction explain the following symptoms as reported by Haddad and confirmed by many, many other sources (as you can see from my post above, too numerous to list):
- Electric–shock-like sensations ("brain zaps") (associated only with drug withdrawal; very unlikely patients have prior experience with this)
- Akathisia (exists only iatrogenically)
- Parkinsonism
- Cardiac arrhythmias
- Extrapyramidal symptoms
- Irregularities in blood pressure
- Generalised seizures
- Neonatal withdrawal symptoms

In addition -- not covered in Haddad, 2007 -- how does your psychological (or psychosomatic) theory explain that people who intentionally quit abruptly develop withdrawal symptoms?

How about those who never felt any benefit from the drug?

How about those who loathe their medication and its side effects?

All of these groups get withdrawal symptoms (in a range of frequency and severity), yet have no psychological attachment to the medication.

How about those who inadvertently forget to take their medication? They aren't even aware they've quit. This happens quite frequently. It's the way most people become aware they're physically dependent on the drug.



Anonymous said...

I was treated for severe chronic pain with opiates. After several.years, I was concerned with opiate addiction (though my dosage didnt escalate) and tapered and discontinued with surprisingly little distress.

When I missed a dose of Effexor over the years, I got withdrawal symptoms within 24 hours: horrible head shocks, dizziness, lightheadedness, nausea. By the time I took the missed dose, I would describe myself as desperate, craving the substance that would stop the physical symptoms, and did. In comparison, I never had similar symptoms or cravings for oxycodone after several years of regular, supervised use. I have taken hydrocode in recent years for wrist fracture and, again, had no difficulty stopping after a few months. I responded the same as I did in past though I had been told by some doctors that tolerance would have diminished its effectiveness.

I tapered off of Pristiq (desvenlafaxine) over approximately 8 months. I did experience akathisia, insomnia, early morning panic awakenings, diaphoretic episodes, but no head zaps, so didn't suspect that withdrawal was the cause. I never experienced panic/anxiety previously and attributed it to life events that coincided with tapering Pristiq. It was an oddly energizing state though the perceptual disturbances of derealization/depersonalization were very uncomfortable. It was after my taper that I learned that my symptoms were classic withdrawal as explained by my endocrinologist as disruption of the entire neuroendocrine system. The morning awakenings were a classic.attempt at readaptation by the HPA axis with a hyperaroused adrenal/cortisol rebound.

In retrospect, i see that my response was physiological as evidenced by the precise daily timing of my symptoms. I woke in a panic state at 4am for months thinking I had started having night terrors that I wasn't remembering. At the time, I did blame life stressors. I had been conditioned to attribute physical reactions to psychological states throughout the years as a "pain patient". That is a very slippery slope that more doctors tread on, I realize now.
I would never claim to understand the full impact and permanent changes/imbalancs that years of assault by serotonin (or any neurohormone) causes. I grasp the complexity and interdependence best thru this article describing a universal endocrine withdrawal concept:

http://m.edrv.endojournals.org/content/24/4/523.long

I believe the terminology must be set aside or strictly redefined. Do SS/NRIs cause "addiction" per classic definition (craving, drug seeking behaviors). Not usually, although my experience with Effexor looked like addiction and withdrawal. Also, many people are put on additional drugs to treat side effects (benzos) or to augment. I could argue that this might be described as "needing more drug" even though tolerance has not developed.

SS/NRIs definitely DO cause physiologic dependence and withdrawal and increased drug use. In comparison to opiates, with a very linear and predictable withdrawal, they cause bizarre and unknown adaptations and symptoms throughout the body upon initiation, prolonged use, and discontinuation.

Duncan Double said...

I would agree with your logic, Altostrata, IF people are really blinded in clinical trials. But people can guess whether they are on antidepressants rather than placebo in a clinical trial by more than chance expectation. So it is possible that antidepressant discontinuation is an amplified nocebo response.

Of course, if there really is as obvious a physical withdrawal as you say, then people will be unblinded in trials because of their hunches related to the fact that they have experienced problems. So, I don't know how we resolve this issue easily by experimental work. Just asking for people's guesses (although as far as I know this study has not been done) is unlikely to resolve the issue.

As I've said before, at least we're agreed that antidepressant discontinuation problems are real - I'm not saying they're factitious - and can be very disabling.

Anonymous said...

Dr. Doubleday,

I am confused in reading this blog entry. You seem to be inferring that the primary antidepressant withdrawal symptoms are due to psychological dependence. Yet in your book, "Why were doctors so slow to recognise antidepressant discontinuation problems", there is this exert:

Many of the reported symptoms associated with SSRI withdrawal are physical rather than psychological. Schatzberg, et al (1997) divided the somatic symptoms into five clusters: (1) disequilibrium (eg. dizziness, vertigo, ataxia) (2) gastrointestinal symptoms (eg. nausea, vomiting) (3) flu-like symptoms (eg. fatigue, lethargy, myalgia, chills) (4) sensory disturbances (eg. paraesthesias, sensations of electric shock), and (5) sleep disturbances (eg. insomnia, vivid dreams). "

Can you please clarify this discrepancy?

Also, you seemed to be inferring that since anxiety was the number one symptom of AD withdrawal as 71% people reported this, that AD withdrawal had to psychologically and physically addictive.

However, dizziness (61%)
vivid dreams (51%)
electric shocks / head zaps (48%) were also reported and these are physical in nature. Therefore, I am perplexed as to how you can reach the conclusion that you did.

Thanks!

AA

Duncan Double said...

Physical symptoms can have a psychological cause, anonymous.

Altostrata said...

Dr. Double, caring psychotherapeutic treatment can do a lot of good, but when the doctor denies the patient's reality, it does a lot of harm.

When patients are suffering withdrawal syndrome, what they need is partial reinstatement of the drug (if very recently quit) and subsequent slower tapering, not to be told they are somehow psychologically generating their symptoms.

It's a primary pitfall of psychotherapy that the mental health expert reinterprets the patient's reality. The doctor, rather, than the patient, holds the correct interpretation of what the patient is feeling.

This can undermine the patient's confidence and mental health. When it comes to withdrawal syndrome, it can undermine physical health as well.

You posit your theory against massive scientific evidence; concordance among medicine, pharma (however reluctant), patient advocates, and withdrawal experts (Breggin, Healy, Glenmullen, Haddad, Fava, etc.); and testimony from the patients themselves.

All but the last might be understandable, as experts may be wrong and, in psychiatry, universal agreement is not entirely trustworthy.

But to deny what patients are telling you about their experience is a very, very grave error.

Patients experiencing withdrawal symptoms run into all kinds of denial from doctors. Sometimes the doctor doesn't "believe in" withdrawal symptoms at all -- apparently the doctor thinks the patient is fabricating or, maybe, picking up some nonsense from the Web.

Sometimes the doctor believes the lie that withdrawal symptoms are invariably mild and last only a couple of weeks, and dismiss further complaints.

Sometimes the doctor tells the patient "it's all in your mind."

Sometimes the doctor tells the patient outright that he or she is deluded.

Patients hear this, compare what they know of their reality versus the doctor's intepretation of it, and lose respect for the doctor.

There is a limit to the mystique of a medical degree.

The hundreds of thousands of postings by patients all over the Web complaining of severe withdrawal symptoms and the 365 case histories on my site are there DESPITE the patients having heard such rationalizations from their doctors.

The patients INSIST they understand their own reality better -- and they're right.

They often say things like "my doctor said it's psychological but I feel there's something physical about it" or "I'm feeling it in my body, not my head."

They find that CBT or other techniques don't eliminate the symptoms. They go through long periods of guilt and frustration thinking they haven't done therapy right.

In fact, it takes time -- months or years -- for the neurological dysregulation of withdrawal syndrome to resolve. Not much can be done to hurry this, which is why gradual individualized tapering, withdrawal symptom recognition, and reinstatement are essential medical knowledge for doctors.

As in any chronic condition, psychological techniques can help the patient cope with symptoms, but they do not eliminate the symptoms.

Anonymous said...

I've had crushing depression, fatigue, nausea, diarrhoea, etc after forgetting a single dose of Effexor. Bearing in mind that I am usually unaware that I've forgotten to take my dose while experiencing these symptoms. It's not until AFTER I go to take the next dose that I realise I've missed one the day before.

They go away about an hour or so after taking the next dose.

Duncan Double said...

I agree, Altostrata, that the way to manage discontinuation problems may well be to reinstate the drug, even partially, and then try again more slowly if the patient wants to and is ready to do so. Just because it hasn't worked once does not mean that it will necessarily not work again.

Anonymous said...

"Physical symptoms can have a psychological cause, anonymous."

Agree but to blame all physical symptoms on psychological causes flies in the face of reality. Alto's example of baby's experiencing withdrawal is a perfect example of this. Also, the personal experiences of other posters are great examples.

You know, I find it very disappointing that an esteemed member of the critical psychiatry network such as yourself is coming across as blaming the patient for withdrawal issues. Yes, by blaming psychological and not physical issues, in spite of the information you list in your book, which I alluded to previously, that is exactly what you are doing in my opinion.

AA

Duncan Double said...

AA, I'm not blaming all physical symptoms on psychological causes. I agree suspected neonatal withdrawal syndrome is evidence in favour of physical withdrawal but I keep an open mind about this. I'm sorry you think I am blaming the patient for withdrawal symptoms, because this is not correct. I'm merely pointing to the psychological difficulty of stopping a drug which is thought to have improved mood. I don't think you can deny the importance of this, however much you think withdrawal is also physical in nature.

Chrys Muirhead said...

I've read briefly through all the comments and wanted to say something about my experience of coming off Venlafaxine (effexor), in 2003/4. Which I managed to do without any problems, mentally or physically. I wasn't aware of other people's experiences at the time and just did what I thought sounded reasonable.

In March 2002 I had a psychosis and was put on risperidone when hospitalised. Then I got depressed on the anti-psychotic, it had happened to me before in 1978 and 1984. The drugs bringing me quickly out of the psychosis put me into a low mood. So the psychiatrist put me on venlafaxine for the depression. This didn’t happen in the earlier episodes so I just worked through it and recovered after about a year. However in 2002 on the venlafaxine I had suicidal thoughts and took an overdose one day on impulse, rushed into hospital in an ambulance etc. Very scary, had never done anything like it before, I was 50yrs old. So the psychiatrist put me on maximum doses of venlafaxin.

I was very flat, couldn’t make decisions, the psychiatrist put me on lithium, to ‘augment’ the anti-depressant, still flat etc. By this time he had taken me off the risperidone. So I decided to take charge of my own mental health, started doing things eg volunteering, going to courses. Didn’t feel like it but got up and went. Started to feel a bit better so began to reduce the venlafaxine, gradually over a few months. I’d been on it about a year I think. I was fine off it. Which left the lithium. 800mgs of it, reduced it by 200mgs a month, against advice of psychiatrist. But I didn’t listen to him. And was fine off it and all the drugs.

Now I don’t smoke or drink alcohol (don’t like the taste) and at that time wasn’t on any other medication. Not sure if this is why it wasn’t too difficult for me to get off the psych drugs. But I had got off the chlorpromazine after puerperal/postpartum psychotic episodes in both 1978 and 1984 so knew that it could be done. I’ve never been in the habit of listening to psychiatrists when in good mental health so it just required me to feel a bit better to be able to take charge again of my own mental health.

I’ve helped family members get off psychiatric drugs after psychotic episodes. My own experience was of use in this. Obviously their journey will have been different to mine but the thing is that all our journeys are not the same. For me I got off the psych drugs with not too much difficulty, the main problem being psychiatry. But even then I was still able to take charge when able to. Which I did.



Diane said...

"Perhaps we need to debate what the evidence is for physical withdrawal - you don't say what it is."

I couldn't agree more. Altostrata has a habit of putting out much disinformation about her beliefs around "nerve damage".

Anonymous said...

Maybe antidepressants are addictive for some, and not for others?

Chrys Muirhead said...

Anonymous you may be right about anti-d's being addictive for some. I'm not sure.

It may be more about what a person thinks about the pill they're taking and the power it has. Eg if they think it made them feel better then they might be fearful of coming off it, for then they could become unwell again.

For me, I didn't think the anti-d worked so had no problem in coming off it. Same with the lithium. Didn't believe it was of any use.

The anti-psychotic did seem to take me out of the psychosis but it was a harsh bringing back to reality and gave me low mood. However it may have been the hospitalisation that brought me out of the psychosis, I don't know, for no-one gave me any time to try and get out of the psychosis by myself.

Psychiatry is a rough treatment. I describe it like taking a skelf (sliver of wood) out of your finger with a sledgehammer. Wrong tools for the job. More damage done than what you went in for. And the skelf probably just came out by itself after the battering the finger got.

Altostrata said...

Diane, where exactly do you think withdrawal symptoms take place?

Do you think brain zaps, a very common antidepressant withdrawal symptom, indicate a normally functioning nervous system?

If you look at the range of symptoms (for instance: Antidepressant Discontinuation Syndromes: Common, Under-Recognised and Not Always Benign, Drug Ther Perspect 17(20):12-15, 2001.), you will see they have the autonomic nervous system in common.

Mithotyn said...

I'm confused because I had always thought that a withdrawal syndrome proved addiction because it could force someone to keep using a substance even if they had chosen not to and isn't that what addiction is?

Somebody decides that they no longer want to take ativan because it makes them feel like a zombie. So they stop and start having panic attacks and seizures therefore they have to start taking it again even though they don't want too - isn't this addiction?

Since when did addiction involve doing things that you wanted to do because you enjoyed them (psychological compulsion, choice)?

Does this mean that people can become addicted to things that do not "trick" the body into thinking that it's needs it? Can people really become addicted to shopping, or chocolate? Is that what addiction really is?


If it is, I think the word should be redefined. I think it's an insult to the many people who have fought and died from biological addictions to suggest that an addiction can exist with no biological withdrawal syndrome producing it.

Altostrata said...

Chrys Muirhead is a psychiatric activist who perhaps does not realize addiction, as defined, has two components: psychological dependency and physical dependency.

She may be unaware that, by definition, non-addictive drugs may incur physical dependency without psychological dependency.

This is, in fact, true of most psychiatric drugs -- they incur physical dependency without psychological dependency -- and why the inserts of many include warnings about discontinuation and advice to taper.

It is physical dependency that causes withdrawal symptoms. Psychological dependency causes recidivism.

(Benzos, a special case, are truly "addictive," incurring both psychological and physiological dependency, although not necessarily both in all individuals.)

Diane perhaps does not know that psychiatric drugs act on the nervous system, and adverse effects arise from nervous system dysregulation.

But, Dr. Double, you surely know all of these facts, as well as psychiatry's definition of "addiction."

To make a fairly tortured argument that antidepressants meet both conditions of "addictiveness," you've thrown people who suffer from the neurological dysfunction of antidepressant withdrawal under the bus.

(This is not appreciated by those of us who have suffered the hell of withdrawal syndrome.)

If withdrawal symptoms are psychosomatic, the rate of tapering would be immaterial, wouldn't it? Even severe symptoms following cold turkey could be treated with psychotherapy.

Really, why should there be an injunction against cold turkey of any psychiatric drug if withdrawal symptoms are only psychosomatic?

Problem solved. I can close my psychiatric drug withdrawal peer support site.

Heretohelp said...

Dear oh dear.

What hope is there is even a respected critical psychiatrist such as Dr Double denies that SS/NRI withdrawal is physiological.

I sit here, 23 months off effexor, in tremendous physical pain, all my nerve endings burning, my head blaring with tinnitus, various muscles visibly spasming - and I'm supposed to simply accept the view that it might all be psychosomatic? Or some other mystery illness that coincided with withdrawal?

Well, maybe that would be reasonable if it wasn't for the HUNDREDS of other people that I am in touch with going through a virtually identical experience. Many of these - myself included - were originally given the drugs for a physical, not mental, disorder.

Altostrata makes so many compelling points and the massive weight of evidence supports a physiological phenomenon. To continue denying this is not just irrational, it's insulting to those of us going through it.

Anonymous said...

Dr. Double, you are an idiot. Altostrata knows far more about this subject than you, despite your arrogant assertions. I suggest you take Effexor for several years and then do a cold turkey withdrawal. THEN let's see if you think the withdrawal symptoms are primarily psychological.Do your homework! You are ill informed and just the type of dangerous "doctor" who has condemned so many of us to this pharmaceutical HELL. (By the way...I did not take Effexor for psychological problems!)

Jennifer said...

I do believe anti-depressants are psychologically addictive in the sense that people BELIEVE they need them because of what they've been told by those who prescribe them. But what's more important to note is that they are physically addictive. This is important for those who wish to come off of them to be aware of so they can begin to educate themselves how to properly come off of them...which has to be longterm, like for many months at least. (Dr. Ann Blake Tracy discusses this at length). If anti-depressants are not addictive, then there would be no w/d symptoms. But because they are EXTREMELY physically addictive, people suffer terrible w/d symptoms when they suddenly stop or taper them too quickly. Then what typically happens is their w/d symptoms get misdiagnosed as their "mental disorders" returning, and they get reinstated on the drugs. For those who taper long-term, w/d symptoms can be more tolerable, and when they finish, they feel less inclined to go back on them. So I would like to see more artivle written by how physically addictive these drugs are. I believe they are as, if not more, addictive than street drugs.

Anonymous said...

Altostrata exaggerates the evidence. I challenge altostrata to table the neurological tests, scans of HER particular nervous system's alleged "damage".

She can't. She thinks "patient stories" prove widespread neurological damage. They don't.

It is quite possible that hypochondria has taken hold in the antidepressant withdrawal syndrome enthusiast community.

Anonymous said...

As I may have previously mentioned or not, (how is that for covering all bases?), I took nearly 4 years to taper off of a 4 med psych cocktail.

I had come to a point where I felt the side effects were greatly outweighing any benefits I was receiving. In fact, I felt no psychological dependency whatsoever since in my opinion, the benefits were so minimal.

Additionally, I had no expectations at all as to what type of withdrawal issues I would have. I mean, how can you really know since at the time I started, withdrawal wasn't exactly a well studied subject.

Well, in spite of tapering very slowly, I definitely had withdrawal symptoms that weren't psychological in nature as they would appear without warning when I was in a great mood.

One symptom that became psychological was insomnia which is totally understandable when you go without sleep for a repeated period.

And because I was diagnosed with apnea a year ago which I am convinced I have had for many years, perhaps if I had been diagnosed with it during my withdrawal from psych meds, I wouldn't have had either physical or psychological issues.

Personally, as one who dealt with a psychiatrist during withdrawal who was waiting for me to fail, I am so grateful for sites like Altos and feel the vicious attacks are completely unwarranted. I am grateful to her for continuing to point out the fallacies in Dr. Double's arguments about antidepressant discontinuation being due to psychological dependence.

Unless these positions are challenged, people who are continuing to experience horrific withdrawal symptoms due to physical reasons will continue to be thrown under the bus by their psychiatrists. As a result, Alto's board will stay in business for years.

AA

SOAP said...

Personally I believe that describing withdrawal as "discontinuation syndrome" is simply a re-branding exercise by pharmaceutical companies.

The type of unusual symptoms such as "brain zaps" which are widely reported all over the internet can hardly be psychological.

Does anybody know if there have been animal studies of these withdrawal effects? If so it would be hard to claim these effects were psychological if they could be shown in animals.

I'm quite surprised to see an article like this from a member of the critical psychiatry network. It seems very a very typical psychiatrist's perspective to me - placing the blame on the patients for damage done by the drugs.

Anonymous said...

Dr. Double apparently you have disengaged from this discussion. But with the hopes of your return, regarding your statement that physical symptoms can have psychological roots, may I also remind you that psychological symptoms can have physical roots. As one with Graves' disease, an autoimmune disease, that accounts for one of the highest rates of psychiatric misdiagnosis.

And hopefully someday, your psych community, will stop making the general assumption that the symptoms caused by the discontinuation of a drug, especially when many of these symptoms were never experienced prior to the initiation of the drug, are direct proof of the preexisting condition returning.

The theory that the symptoms abate as soon as the drug is reinstated being any indication that the drug is necessary is foolhardy and dangerous. If heroin is reinstated to someone who has stopped the drug, odds are their discontinuation syndrome will subside just as rapidly.

Duncan Double said...

Thanks, anonymous, of course I realise the integrated nature of psychological and physical. And I agree discontinuation problems are not necessarily signs of a relapse.

paul pezzack said...

duncan double,you just talk rubbish.you obviously have never taken them.why dont you try taking them and see if what you are experiencing is all in your mind,
when you try to get off them?
go and look at Dr Peter Breggins site.
these drugs have the same effects on the brain as illegal drugs which widely are known to cause physical withdrawal.
or perhaps there are legal and illegal serotonin systems in the brain?
its not even an argument.it sounds stupid to talk about it as one.
im sure going to say,im qualified.
i know all about it.
well,heres an idea.
i know alot about the moon.have read quite abit about it too.
but i wouldnt tell Neil Armstrong what its like to go there though.

Anonymous said...

The stubborness of the medical community makes me furious. Some doctors really are ignorant, arrogant fools. Antidepressants make PHYSICAL changes in the brain. Why, o why, is it so hard then to accept that withdrawal is physical? Hello? Is this a joke? And I agree, first try some SSRI's yourself then come back! Why wouldn't you? They are completely safe! That's what I was told by my doctor before my life was ruined.