Wednesday, April 11, 2018

Antidepressant "Withdrawal": Why Aren't Psychiatrists Seeing this "Common" Problem?

Over on The New York Times website, there is an article titled, "Many People Taking Antidepressants Discover They Cannot Quit. "  Benedict Carey and Robert Gebeloff write about how long-term use of antidepressants is increasing, and some people have difficulties coming off the medications with symptoms that constitute a discontinuation syndrome.  I'll let you read the article rather than quote it, because there was a lot wrong with the piece.
It doesn't feel like a new idea that there are people who have protracted and miserable discontinuation syndromes--distinct from a recurrence of symptoms-- after stopping antidepressants. People have been writing in to Shrink Rap about these difficulties for the past decade, there are online forums around it, and The New York Times Magazine did a cover story by a man who stopped his Effexor and went through a difficult time with discontinuation symptoms back in 2007.  

I don't think any psychiatrists were surprised to read that SSRI's have a discontinuation syndrome, and because of the symptoms that can develop, we routinely advise people to come off SSRIs and SNRIs slowly, especially from those medications that have a shorter-half life like Paxil and Effexor.  The question is not whether people might have symptoms, but about how difficult it is to manage these difficulties and how long they might last.  So while we have all seen people who have some discomfort after stopping a short half-life SSRI or SNRI, we think of this as something we manage by slowing the taper, switching to Prozac with it's very long half-life, or waiting it out with the idea that symptoms will resolve in 1-3 weeks.  What's different in this article is the idea that this is common, that patients struggle with intolerable symptoms even when they undergo a very slow taper, and that these symptoms can last for months or even years. 
 The article is one-sided in that it talks about the misery of the discontinuation syndrome with the overtone that "if only the doctor had told me that this would happen, I never would have taken the medication."  The article completely neglects the misery and dysfunction of the disorders that lead people to start these medications to begin with! 
The article doesn't mention that one common reason for symptoms upon stopping --for example anxiety or sleep problems -- may be the recurrence of the initial problem that they medication was treating.  In some people, depression is an episodic issue and people can come off medications, with other people, depression, anxiety, obsessive compulsive disorder, premenstrual mood difficulties, and other problems these medications are used to treat are more chronic problems.  In these cases, stopping the medication may be like stopping insulin or synthroid: the problem is still there and staying on the medicine may make more sense.

I think it's easy to be dismissive of the prolonged discontinuation syndrome-- to say that the symptoms simply don't last that long or cause that much misery, and if they do then the patient has obviously had a recurrence of their initial symptoms, something else is wrong, or it's all "in their head"--meaning we don't believe the person is actually having the symptoms they say they are having and they are a result of suggestibility or hysteria. 
So what's good about this article is that it increases awareness of the issue and those people who are having difficult discontinuation problems may well feel a sense of validation in knowing that other people have the same constellation of symptoms. 

I believe that there are patients who have these long and miserable discontinuation problems -- many have written into  the comment section of Shrink Rap over the years, and The New York Times found some to interview, including one psychiatrist who was having trouble coming off Cymbalta.   What I haven't figured out is this: Why haven't I ever seen any of these patients? It seems that when people have trouble coming off antidepressants, that slowing down the taper works, or the symptoms  are self-limited and resolve in 10 days, or the patient decides to resume the medication.  So while I've read about these miserable stories for a decade now, I've never seen someone have a protracted and miserable time coming off despite a slow and careful taper.  It's been 25+ years and a lot of SSRIs, including many people who casually mention that they stopped taking their medications without consulting me first.  I asked in an online forum if other psychiatrists have seen this phenomena, and a few mentioned that sometimes patients had trouble stopping antidepressants, but no one offered that they had seen this degree of misery.  So while I do believe it exists, I also think it's not terribly common in psychiatric practice, that for most people discontinuation symptoms can be managed with careful and thoughtful tapering, and that while some people may have extreme difficulties, these awful scenarios are not "common" as The New York Times article asserts.
 But there is a lot wrong with this article.  There is the fear that the article will serve to scare people who might benefit from medications, and thereby discourage people from getting treatment.  We've seen that already: when a black box warning was put on antidepressants regarding suicidal ideation in children and adolescents, prescribing went down, and suicide rates went up.  Figuring out this balance is difficult, and it would be so nice if we knew who might benefit from medications and who is more likely to be harmed than helped by medications.  

Finally, what's really wrong with this article is that it uses language that likens antidepressants to addictive drugs of abuse, and it stigmatizes those who need to continue them.  People don't get addicted to anti-depressants: they don't use them to get high, they don't crave the medications, and they don't engage in addictive behaviors such as escalating the doses without medical guidance  or getting medications in deceptive ways.  Awareness of a problem may be good, but it needs to be done in a responsible and balanced way.


Anonymous said...

I would ask you to look at the list of patients that "stopped" coming. I was one of those patients. My psychiatrist nor therapist believed me when I said I don't think this is relapse THIS is being caused by these drugs.

The normal 2-4 week taper did not work for me. Hospiliaztion threats, increased and additional meds. All because they did not believe the possibility that these drugs were the ones affecting ME. I believed them when they said I was sick. And by all "text books" I was. I wasted 5 years of my life. Almost lost my marriage. But then I found others who's doctors didn't' believe them.

I had to rely on online communities and Rouge Doctors. It took me OVER TWO YEARS to taper. And guess what, I am MED FREE. No sever symptomology. And let me tell you I have suffered SEVERE Life Stressors since being off meds, Two Deaths and Two Miscarriages and I did not have to go back on meds. I've been med free for years now.

Like I tell people I didn't' know what true Depression was until I was put on antidepressants.

I never went back to those doctors. Would you blame me? I'm glad this article is getting attention. Something needs to be done. I just praise God that I figured it sooner rather than later and I have my life back.

Anonymous said...

If you don't believe it can be that bad and you have never seen it, it is because your patient knows how you feel and has put feelers out that you have missed. Some people can stop with no problem, some can't. I didn't tell my doctor because he would have wanted to change my medication or insist that is was the depression. He did that once and it make me worse. So I am doing it myself. From 300mg effexor to 4 yrs later finally down to 75mg. Yes it makes me very sick when I taper and I have a life so I am taking it slow. Just because you don't see it doesn't mean it isn't happening to your patients. Patients leave and miss appoints? Do you actually ask them if they think the medicine is making them better or worse? It took me two years in my drugged out haze to figure out that what I was feeling was not right, in those 2 years I lost my job, was always confused, and basically became a vegetable on my couch, nothing got done. Do some research just because you think it doesn't happen to you. it happens a lot.

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Anonymous said...

"Whats wrong" is the way you pay lip service to the discontinuation syndrome associated with Antidepressant medication. From personal experience I can tell you that it is very real and horribly distressing, even if you do taper. Psychiatry seems intent on digging itself into a deeper and deeper hole. Your comments are a prime example of why people are becoming so dismissive and negative towards your profession. The internet allows people to share experiences the world over and the sheer number of these shared experiences clearly point to the prevalence of antidepressant discontinuation syndrome. So, you ask the question :

"Antidepressant "Withdrawal": Why Aren't Psychiatrists Seeing this "Common" Problem?"

Its very simple, it is very common and very obvious if you would only look. Perhaps the average Psychiatrist cannot see what is blindingly obvious to every body else.

Joel Hassman, MD said...

Frankly, I think a sizeable portion of the people who complain the loudest about discontinuation syndrome issues with antidepressants are not just mood disordered patients, but have at least some subtle characterological issues in place as well.

After 25 years of working with patients, the ones who make such a big deal needing to be tapered for months off meds like paroxetine or venlafaxine, even if on them for less than a year's time prior, bring a lot of interpersonal strife and other drama into the office.

Yes, patients deserve to have an independent approach to getting off medication, irregardless of what the meds are, but, no one has died or had profound long term sequelae being responsibly tapered to discontinuation of the medication. Really, I knew a colleague who was opening up Effexor 37.5 mg capsules and counting out the pulvules every day, she estimated about 100 in the capsule and was cutting back by 10 every 3 days??

Just my opinion, but, it's like watching Methadone patients act like the world is ending when they are down to under 20mg after being on more than 100mg for years prior. This NY Times article is only intended to forward more antipsychiatry narrative at the end of the day, I'll bet looking for relations from the author to other sources could be illuminating.

Anonymous said...

Prescription Drugs go in and out of fashion. They usually get discarded after a prolonged period of denial about side effects or negative long term health implications. Drugs cost money to develop and must pay back with interest before being cast to the wayside. Anybody remember the Benzodiazapine revolution and its fall from grace ? The 'Z' drugs ? Antidepressants are heading the same way. Oh well, theres always Ketamine or MDMA. What could possibly go wrong ? After 25 years of working with patients, I would think you would show more compassion.

Joel Hassman, MD said...

Compassion is at least half perspective. Interesting I once heard a Nazi supporter claim there was compassion for the Jews to exterminate them the way the Nazis did. I honestly do not think I would have lasted 25 years without having compassion, especially working most of this time in community mental health care clinics. So, maybe you can educate me and other readers what is your definition of what meets compassion as a provider? Just give people what they want, and note not what they truly need? Maybe not give any meds at all?? Maybe call people on what they bring to the office that is not going to be fixed by meds and then risk being harassed and conjured to instead be foolishly complicit with quick fix agendas???

Compassion is sometimes saying no, and that point gets a lot of dissent.

I genuinely am interested to hear what defines compassion from your perspective. Just be prepared I will call you on a false narrative if that is my interpretation.

I know that Dr Miller does not agree, but, I find that those who go by anonymous as their title as commenter are often with agendas, but, I have been wrong at times. Curious, do you read often at

Anonymous said...

Your bringing the Nazis into this ? really ?

Joel Hassman, MD said...

Yeah, let's ignore that chapter of history, it fits well to gloss over with certain narratives, eh? Oh, until it's convenient later...

And I guess an excuse to dismiss the rest of my prior comment inquiry?...

Anonymous said...

I'm not ignoring this chapter of history. Your argument is ridculous. So a Nazi once said that they showed compassion towards the Jews. For any reasonable person, this is obviously not true. In the context of this discussion, it is irrelevant. Lets agree that you show people more compassion than the Nazis did to the jews. I don't often visit "Mad in America". Do you often read "Mein Kampf" ?

Joel Hassman, MD said...

Thanks for a reply, nope, don't read Mein Kampf prior or now, and hope your week goes well.

My point to the Nazi example is asking to show compassion is perspective and intent, I became a doctor because I believed, and still do to a point, of being concerned and caring, but, I see less people as patients who show insight to be concerned and caring of their choices and goals. Can't help people who won't instinctively help themselves, so hope that clarifies my comments of late.

Again, the gray zone, not about all or none per meds. But, we live, no, we are entrenched in a quick fix, immediate gratification zone of demanding to be better yesterday. Meds won't do it, and certainly doing the same thing over and over won't give different results.

Done commenting here, be safe and well to you and all readers.

Anonymous said...

ok, take care