The Mystery of When to Stop Antidepressants

http://www.wsj.com/articles/the-mystery-of-when-to-stop-antidepressants-1457377316?mod=e2fb

by Jasamba • 10 years ago

67 69 10 years ago

pc2g4d4• 10 years ago

There's a disconnect between what the meta-analysed randomized clinical trials are saying about antidepressants (that they are at best minimally effective relative to placebo) and what relapse rates suggest (that people relapse when withdrawn from antidepressants because the antidepressant was effectively treating the underlying depression).

This conflict is resolved when antidepressants are acknowledged as addictive. Long-term use of antidepressants creates a biochemical dependency that is only removed with long, slow tapering.

I've experienced this fact personally. When I first attempted to go off antidepressants, I did so at what I thought was a slow pace, but in fact turned out to be far too fast. My life completely fell apart. I was depressed, anxious, obsessive, worse than I had been in many years. I thought this proved that I really "had depression" (as a discrete illness) and needed the drugs, so I increased my dose back up to more or less the original level. Soon after doing this, my depression/anxiety/OCD went away, and I felt normal again.

But a few years later I tried getting off the drugs again, going much more slowly. And now I'm at the same point I was last time when things fell apart, and I'm doing fine. Overall this withdrawal (from 200mg Zoloft) will probably take me 3 or 4 years. (I'm down to 25mg now.)

I'm convinced that I'm succeeding now where I failed before simply because my previous approach was triggering horrible withdrawal effects, whereas my current slower approach does not.

One secret to successful antidepressant withdrawal: the rate of dose reductions needs to decrease as the overall dose decreases. So when I'm at 200mg maybe I decrease by 20mg in a month. But now that I'm at 25mg maybe I decrease by 2.5mg in a month. The rate of decrease should be proportional to the current dose.

Before I was decreasing in constant increments all the way down (200->150->100->50) but then I started going crazy.

Sorry this is so long. It's a favorite subject of mine ;-)

lololomg2• 10 years ago

The annoying thing about (for example) SSRIs is that it's annoying to take accurate doses like that.

My escitalopram comes in 5mg, 10mg and 20mg. If I want to slowly taper down from 20mg a day, I have to start chopping off bits from an already tiny pill every day for months on end. I can't just drop down to 15mg a day, it's too abrupt.

saurik• 10 years ago

Maybe it would be simpler to grind the pills into a more easily-measurable powder and put it into your own empty capsules?

jackfrodo3• 10 years ago

I'm on 20mg of escitalopram as well. If you don't mind me asking, why are you wanting to taper down? Is this recommended by your doctor?

biturd6• 10 years ago

Worse, keep in mind that pill, broke perfect in half, will not have equal amounts of the active or inactive ingredients in each side. Further, if it is a generic, it doesn't even have to have the same mg amount of the active ingredient, only within a margin of something like 90%, which is huge when dealing with these types of meds.

facetube2• 10 years ago

Can confirm. The part that's really telling IMO is that a lot of the withdrawal symptoms are not at all related to depression: they're dizziness, vertigo, and strange electrical feelings in your head – not symptoms of depression or relapse. Minimally reinforcing in terms of "drug liking" or "wanting to take more" in my experience, but there is definitely profound physical dependence.

meowface• 10 years ago

Probably not a good idea to generalize the withdrawal symptoms. Some people do report severe anxiety and depression from withdrawal in addition to those other symptoms.

biturd6• 10 years ago

Anyone who tells you anti-depressants are not habit forming is a rep for a pharma co. that has not been sued to change their stance on that statement yet.

erikw• 10 years ago

Interesting customer retention scheme Big Pharma has come up with. Find a pool of folks at risk for suicide, and then get them addicted to expensive chemicals that will exacerbate suicidal ideation if they try to quit.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4172306/

"The FDA requires two adequately conducted clinical trials showing a significant difference between drug and placebo. But there is a loophole: There is no limit to the number of trials that can be conducted in search of these two significant trials."

majewsky• 10 years ago

That's why we need mandatory pre-registration and publication for trials: You have to announce in advance when you're doing a trial, and you have to publish the results afterwards, so that you can't cherry-pick the ones you like.

gusfoo• 10 years ago

Interesting customer retention scheme Big Pharma has come up with.

Yes, keeping the customer alive is indeed good for business.

GFK_of_xmaspast3• 10 years ago

Lot of SSRIs are generic and cheap these days.

joveian• 10 years ago

Really interesting article all around, thanks for posting. I didn't realize the FDA's procedures were that bad :(.

julie1• 10 years ago

Could antidepressant just be a placebo requiring to be addictive then?

And could hooking off an addiction be very similar to depression?

Would any psychoactive works? If so maybe why not using a less dangerous psychoactive drug if it is a placebo that works good enough to alleviate the pain?

biturd6• 10 years ago

Opiates will cure depression, stop it dead in it's tracks for a large majority of people. Good luck finding a Dr to help you down that road though. There is a reason people have an illicit drug of choice, and that is a good indicator of what anti-d's may work best for you.

Opiates, you are screwed, meth, there is Adderal or Ritalin, ( All these probably have had their names changed by now to something else ), if you like cocaine, then an SNRI may be better for you. Anxiety, ideally they lighten up and give you a benzodiazepine, more than likely you will get a med that was initially a smoking cessation medication.

Psychiatry is a black art, I really almost feel unless you are clinically depressed, schizophrenic, etc, if you are going to be a human medicine dart board, don't, be a human health dartboard. Exercise, diet, etc, but be insanely specific, insanely calculative in what you do if you choose the non-med way, as it is just as much a mystery as are the pills.

biturd6• 10 years ago

I suspect you need not go that slow. I am NOT a Dr., but have talked at length with mine about this. I won't go into specifics or detail as people need to talk to their Dr.s about these methods.

All meds have a half life, your taper rate will be based on that and your personal metabolism rate, which can and almost always is altered by the meds themselves.

Further confused that a huge percentage of people who suffer depression need no meds and instead need a thyroid test, and not just a "give blood and see where you were at that moment" test, but a real, pain in the butt, complicated test, which I suspect is why they don't give them as a first line test. I was blown away I was never offered one.

As you get down to the lower doses, it gets harder, some you will have to take to a compounding pharmacy, others you can crush and get a good scale and weigh out what milligram or microgram you need; others, if you feel safe doing so can be taken intranasaly via a Flonase sprayer depending on if the med is water soluble and what the mixed shelf life is, which can be hard data to get at times.

I can say there is no worse kick than Effexor, that is for damn sure, and that was only 2-3 weeks in. That had a permanent change on me for life, instilling a bit of timidness in me regarding certain things that happened as I was detoxing.

Good Luck, hope you get off them and manage to learn how to manage your life without them, that is exactly where I am as well. They work, but I don't like the fake happy feeling. They try to tell me that is what my normal is, and I am just not remembering my true normal, that I don't buy, I remember my youth before this all started.

DigitalJack• 10 years ago

effexor, aka venlafaxine, gave me some amazingly horrible vertigo if I missed more than 1 dose in a row. I was off antidepressants for about 2 years, and then I was hit with severe depression. I'm on the generic for paxil now, and it has made a huge difference. The impact was a night and day contrast.

DanBC2• 10 years ago

Further confused that a huge percentage of people who suffer depression need no meds and instead need a thyroid test

You can't say things like "huge percentage" without citation.

jobu2• 10 years ago

A close family member was on antidepressants for almost two years after being misdiagnosed with depression (that's a whole different story though).

The tapering process was _very_ rough. At first the doctor recommended tapering by 1/4 each week for four weeks, but with the first reduction she had headaches, vertigo and nausea for nearly two days.

After that the doctor changed the recommendation to tapering by 1/8 of a dose over the following 6 weeks. The first day of each reduction was more bearable, but still similar to a nasty hangover,

SSRIs may be a lifesaver for many people, but starting them is not something to be taken lightly.

johnchristopher3• 10 years ago

A close family member was on antidepressants for almost two years after being misdiagnosed with depression (that's a whole different story though).

What was the good diagnostic then ? What were the overlapping symptoms ?

I am personally really interested in learning more about illnesses that look like depression but aren't.

arc_of_descent2• 10 years ago

I experienced this in mid 2014. I was feeling great and decided to stop taking anti-depressants. I was on 10 mg of an SSRI.

Man, I fell into a well. I was depressed for 3 months. Couldn't get _any_ work done. Had a constant headache. I then checked myself into a hospital after 3 months for a full medical check up. Not surprisingly all the tests were fine. Finally the psychiatrist there put me back on anti-depressants.

Still I was in the funk for a month more. I think what really got me out was going for long walks everyday. For an hour minimum. Seriously, I think sweating it out really has its benefits. I'm now taking 10 mg daily, and when I think about stopping it, the anxiety takes over. :)

digi_owl• 10 years ago

Dunno about the sweating, but i think doing something physical allows part of the mind to focus on something rather than fluttering about.

It may well be that our stationary modernity and our hindbrain simply don't mix.

pc2g4d4• 10 years ago

I'm glad you've been able to pull out it. Did you go off cold turkey? That'll do crazy things to you. But if you're extremely gradual, I believe it is possible to get off the drugs if that's what you want.

tallanvor• 10 years ago

Most people who get depressed get through it without any special intervention, while some of us require a period of time on medication and/or counseling. But we still don't know enough about depression to figure out who will respond best with medication vs counseling, or for how long treatment will be required. That's one of the reasons for tapering - to give you time to adjust to the lower dosage, both in terms of letting your body adjust to the biochemical changes, but also give you a chance to gauge how you're doing emotionally and decide whether to continue tapering, stay where you are, or even go back up to a previous dose.

It sounds more like you weren't at a point where you could manage to get off the medication completely, and maybe you should have stayed at either your original dose, or one of the steps along the way for a while.

But - and this is the key - if you are working with your doctor, and you're both comfortable with the plan you've come up with, then that's what you should do.

pc2g4d4• 10 years ago

It's definitely true that there's more than a biochemical adjustment that has to happen. The way your brain/mind work changes as you get off the drugs, so you have to relearn how to manage your emotions without them. For me who was on the drugs since I was a teenager this requires learning some skills I never developed to begin with! Kinda crazy.

Most doctors have no clue about the real effects of SSRIs etc., and many are invested in the "SSRIs for life" model. Prescription refill visits, after all, form a large part of their business. So sometimes you have to go it alone because the docs know less than you do about SSRI dependency and withdrawal.

seibelj• 10 years ago

Lexapro (Escitalopram) saved my life. I don't care what any meta-analysis says: years of diet, exercise, and meditation did 5% of what 1 month of Lexapro did for me. I will take it until I die.

exolymph• 10 years ago

I've had a similar experience with venlafaxine (Effexor). I feel no need to go off the drug. I don't care if it's addictive -- I'm able to function and feel happy. That far outweighs $60 every couple of months. I wouldn't want to risk losing my stability and capacity to enjoy life.

stevedonovan2• 10 years ago

Myself likewise. I don't wish to revisit the pit and wallow through the cognitive fog. An interesting aside: why do users of antidepressants feel the need to reduce their dose? It's a benign addiction, like moderate caffeine dependency. One reason is that there _is_ a trade-off; these drugs make us a little dull and less interesting to ourselves.

biturd6• 10 years ago

side effects.

Jasamba• 10 years ago

Just the nagging feeling that this is not really you but a 'drug' induced state. In any case, I'm generally paranoid of medications given the frequency of hidden side effects that aren't revealed/discovered years later and the general evilness of the pharma industry. Down from 100mg to 25mg now, I've constantly been trying to find a way to replace it with more 'natural' things like meditation, reformulation of stressful situations. That being said, the effect of the SSRI's was like day/night for me, and I would recommend anyone who's been suffering for depression to atleast give it a go with the caveats in mind.

a3n• 10 years ago

Same.

jackfrodo3• 10 years ago

Anyone know how to get around the paywall?

roghummal• 10 years ago

Google for "The Mystery of When to Stop Antidepressants" and click through there. Didn't work for me in 'incognito mode' but it did when running normally. YMMV.

biturd6• 10 years ago

I was totally unable to bypass it as well.

venomsnake• 10 years ago

There seems to be sites that think of private browsing as ad blocker. A watchdog script and firefox with new profile takes 10 seconds ... why do they even bother.

narsil• 10 years ago

This seemed to work for me:

    curl -H "User-Agent: Mozilla/5.0 (compatible; Googlebot/2.2; +http://www.google.com/bot.html)" http://www.wsj.com/articles/the-mystery-of-when-to-stop-antidepressants-1457377316 | tee file.html

(changing the user-agent slightly on each attempt)

Used https://www.npmjs.com/package/http-server to start a local webserver to view the file for CORS purposes.

dexterdog• 10 years ago

If you're still having trouble, adding it to a reader like Pocket will get it for you.

jackfrodo3• 10 years ago

That worked. Thank you!

skyhatch1• 10 years ago

Unfortunately, you cannot cite clinical trials as the sole means to determine individual patient relapse potential.

Many doctors, especially psychiatrists, use clinically-proven if-then-else type criteria tools created by professional psychiatrist bodies.

As your therapy progresses, depending on how you score with the criteria, the doctor will opt to:

- Taper down and cease medication

- Reduce medication dose and supplement with behavioral therapy

- Stay on the current dose

- Increase dose if your symptoms worsen

partomniscient• 10 years ago

- That one didn't seem to work (or was intolerable), try this one. (Continue to repeat cycle until something gives...)

exabrial3• 10 years ago

While SSRIs and SNRIs have been around for years and have shown questionable efficacy, opioids have been around for centuries and have shown to provide instant and effective relief to depression. Unfortunately, opioids have a side effect called "ruining your life". Based on this though, there's a new generation of antidepressants that target a completely different part of the brain. Essentially it's the depression blocking effects of opiods without the euphoria, so low to no addiction potential. alks-5461 is the one that will hit the market soon... hoping it's not too expensive. http://mentalhealthdaily.com/2014/08/05/new-antidepressant-a...

exabrial3• 10 years ago

And actually... if you have MDD, you might consider signing up: https://clinicaltrials.gov/ct2/show/study/NCT02218008?term=a...

The Mystery of When to Stop Antidepressants

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