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Stopping SSRI Antidepressants Can Cause Long, Intense Withdrawal Problems

Originally posted "In the News" at Mad In America - Full text of research article has been added to the Critical Research section of this blog:

In the first systematic review of withdrawal problems that patients experience when trying to get off SSRI antidepressant medications, a team of American and Italian researchers found that withdrawing from SSRIs was in many ways comparable to trying to quit addictive benzodiazepine sedatives and barbiturates. Publishing in Psychotherapy and Psychosomatics, they also found that withdrawal symptoms can last months or even years, and entirely new, persistent psychiatric disorders can emerge from discontinuing SSRIs.

The authors analyzed 15 randomized controlled studies, 4 open trials, 4 retrospective investigations and 38 case reports of SSRI withdrawal. They found that paroxetine (Paxil) was the worst, but that all the SSRI antdepressants could cause a wide range of withdrawal symptoms from dizziness, electrical shock sensations and diarrhea to anxiety, panic, agitation, insomnia and severe depression.

The prevalence of such withdrawal syndromes was "variable" and difficult to estimate from the studies, they wrote, but generally seemed very common. "Symptoms typically occur within a few days from drug discontinuation and last a few weeks, also with gradual tapering. However, many variations are possible, including late onset and/or longer persistence of disturbances. Symptoms may be easily misidentified as signs of impending relapse."

"Clinicians need to add SSRI to the list of drugs potentially inducing withdrawal symptoms upon discontinuation, together with benzodiazepines, barbiturates, and other psychotropic drugs," they concluded. "The term ‘discontinuation syndrome' that is currently used minimizes the potential vulnerabilities induced by SSRI and should be replaced by ‘withdrawal syndrome'.

An accompanying editorial noted that, "This type of withdrawal consists of: (1) the return of the original illness at a greater intensity and/or with additional features of the illness, and/or (2) symptoms related to emerging new disorders. They persist at least 6 weeks after drug withdrawal and are sufficiently severe and disabling to have patients return to their previous drug treatment. When the previous drug treatment is not restarted, post-withdrawal disorders may last for several months to years."

The editorial also stated that, "With SSRI withdrawal, persistent postwithdrawal disorders may appear as new psychiatric disorders, in particular disorders that can be treated successfully with SSRIs and SNRIs. Significant postwithdrawal illnesses found with SSRI use include anxiety disorders, tardive insomnia, major depression, and bipolar illness."

While the study authors found no difference between gradual tapering over relatively short periods and abrupt discontinuation of SSRIs, the editorial authors argued that there was evidence to suggest benefits to tapering.

Chouinard G, Chouinard V, -A, New Classification of Selective Serotonin Reuptake Inhibitor Withdrawal. Psychother Psychosom 2015;84:63-71. DOI:10.1159/000371865

The Genetics of Schizophrenia: Compare and Contrast

Here's an example of how challenging it can be to pursue accuracy as it pertains to mental health.  Before getting into the example, a quick comment about the word "accuracy" itself:

I generally try to avoid the terms "truth" or "fact."  While I believe that it is possible to define "facts" and identify things that reasonably meet the criteria as fact, it still seems less helpful than talking about the pursuit of accuracy.  Talking about "truth" in my opinion, should be left entirely to the philosophers.  Accuracy on the other hand, is a term I like very much.  How do I define it?  I define accuracy as "an intentional effort to fully understand the scope and limits of what we can reasonably claim to know, and working only within those limits."

Today's example of the challenges inherent in pursuing accuracy comes through the subject the "Schizophrenia" diagnostic label and the search for a genetic origin.   Two pieces, written on the same subject of research with conclusions that could not be more opposite.  The first piece is written by psychiatrist Emily Means, and appears in her blog Evolutionary Psychiatry as well as on Psychology Today.  I am posting several excerpts from the article in an attempt to offer a fair summary:

Last month, a veil was lifted from the mysterious and devastating disease of schizophrenia in this article in the green journal (online advance release).
Because schizophrenia is so devastating and highly inherited, researchers have been searching for the schizophrenia “gene” for a long time. Finding the gene could mean more targeted treatments and aggressive early intervention in those who have the highest risk, so that perhaps the disease wouldn’t progress. What they’ve found so far in very large genome-wide association studies is not a single gene, but sets of different ones that together confer greatly increased risk of developing the disorder. It’s difficult to find these gene networks, because the ways genes interact is extremely complex, changes during development, and in many cases is poorly understood. For the first time, researchers were able to combine three large sets of data of folks from varying populations with and without schizophrenia that had not only information about the genes, but more specific information about patients’ symptoms.
Using an immense amount of data crunching, researchers found what small genetic differences were in common between different folks with symptoms of schizophrenia, then more precisely define which of these hundreds of risk genes were more or less risky. They found one set in 9 different people where every single person had schizophrenia (100% risk), and others that conferred far less risk…but there were 42 different sets of genes that had risk for schizophrenia of >70%. By crunching even more numbers for these high risk sets of genes, they found that some of these sets “grouped” together in what is called a genotypic network. Then they overlapped the data from the risky genetic networks with the symptoms of the sick individuals to come out with eight different distinct diseases, now all known as “schizophrenia.”
If this research holds true on reexamination, we might be taking the first steps toward isolating the pathology of a major psychiatric disorder, as infectious disease doctors did a hundred and fifty years ago with the development of germ theory. 
Wow.  So this momentous study (hyperlinked in the excerpt) has "lifted the veil" from what we label schizophrenia?  That would be nothing short of earth shattering, something that over a half a century of gene-finding expeditions has utterly failed to do.  Means goes on to double down on her assertion, by stating that the study's findings identified sets of genes that "greatly increased the risk of developing the disorder."  Greatly.  Means goes on to state that the study found one set in 9 (whole!) people where every single person had schizophrenia.  However, there seem to be a few critically important omissions in her article.

So now let's contrasts Means article with that of Joanna Moncreif, who writes about the exact same study on her blog:

Psychiatric diagnosis as a political device (Journal of Social Theory and Health)

I want to draw attention to an article written by Joanna Moncrieff and published by the Journal of Social Theory and Health in 2010. One of the issues that is very important to me is the ways in which the subject of mental health is a subject of political, economic, and cultural issues. Underrepresented in discussion about "mental health" are issues of poverty and class prejudice, issues of cultural bigotry toward persons labeled as "mentally ill, and issues of political power that impact policy and practices within the public mental health system. Below is the introduction of Moncrieff's article:

Modern diagnostic systems in psychiatry, like the Diagnostic and Statistical Manual (DSM), now in its fourth version and soon to be updated, have been enormously influential. Many formal concepts like ‘clinical depression’, attention deficit hyperactivity disorder (ADHD) and more recently bipolar disorder have been incorporated into lay language and understandings, helping to shape the way ordinary people view themselves and their situations (Healy, 2004; Rose, 2004). These systems also form the basis of a vast research effort aimed at mapping the prevalence, aetiology, outcome and treatment response of the entities defined. They are also used in pharmaceutical marketing, which often starts with raising awareness of a particular diagnostic category, before going on to promote a drug for its treatment (Koerner, 2002).
The basis of modern diagnostic systems, the idea that psychiatric disorders can be conceptualized in the same terms as medical diseases, has been challenged for decades now. Antipsychiatrists such as Laing and Szasz, and sociologists such as Conrad, stressed the differences between medical diseases and psychiatric conditions and pointed out the social control function served by dressing up normative judgements about behaviour as medical facts. Although their work provided an important conceptual analysis, it often relied on extreme and exceptional examples of the use of psychiatric diagnosis, such as the incarceration of dissidents in the old Soviet Union. Less attention has been paid to the nature of routine psychiatric practice. More recent analyses have highlighted the tautological and redundant nature of psychiatric diagnoses (Bentall, 1990). A diagnosis is applied on the basis of observations of an individual's behaviour, but diagnostic categories are defined by collections of typical behaviours.
Champions of the idea that psychiatric disorders are like other medical diseases have continued to assert their position (Craddock et al, 2008), but have not answered the basic arguments posed by their challengers. David Pilgrim recently argued that the debate had been rehearsed so many times that the question that remained was not about the validity of psychiatric diagnosis, but why it has survived, and what interests it serves (Pilgrim, 2007).
In this paper I examine the gulf between what psychiatric diagnosis purports to be and how it functions in everyday practice. I have returned to the analyses of Jeff Coulter, a sociologist with an ethnomethodological orientation, and David Ingelby, a psychologist and philosopher, whose work examines the differences between psychiatric diagnosis and diagnosis in the rest of medicine. In particular, it suggests that contrary to other areas of medicine, where diagnosis determines the appropriate treatment to be given, in psychiatry diagnosis is merely a ‘signal’ for the application of pre-existing institutional arrangements. I shall present the stories of two real psychiatric patients, who are reasonably typical of people with severe and long-standing psychiatric problems. These stories illustrate how psychiatric diagnosis can be understood as functioning as a political device, in the sense that it legitimates a particular social response to aberrant behaviour of various sorts, but protects that response from any democratic challenge.

I would encourage you to read the full text HERE.

Against Psychiatry? Criticisms Worth Heeding Across Mental Health Professions

Recently, an article was published online by The Psychiatric Times entitled “Getting It From Both Sides: Foundational and Antifoundational Critiques of Psychiatry,” written by Ronald Pies, MD, Sairah Thommi, and Nassir Ghaemi, MD, MPH. While the article is academic in nature and the language is opaque, some important points are raised for psychiatrists and mental health practitioners across the professional spectrum. Specifically, what are the criticisms levied against psychiatry (and, in a broader sense, all mental health professions) and when are those criticisms legitimate?

I wish to focus on what the article terms “antifoundational” criticisms of psychiatry because it is my intention to show that such criticisms are largely accurate. Rather than causing anyone to conclude that mental health professions have no value, such criticisms should be embraced and used to inform responsible practice. To begin, examine the description of “antifoundational” criticisms as interpreted by the authors of the article:

Antifoundational philosophies and philosophers assert that there are no objectively demonstrable truths; rather, there are only various perspectives or narratives that cannot be privileged as uniquely or objectively true . . . Thus, the postmodern theorist Francois Lyotard denies the legitimacy of “grand narratives”—essentially, cultural myths that merely serve “. . . to mask the contradictions and instabilities that are inherent in any social organization or practice.”4Western science, in the postmodern view, tends to be associated with coercive power and oppression.
Michel Foucault’s analysis of psychiatry is perhaps the archetypal antifoundational critique. Foucault holds that psychiatric medicine has merely fabricated a set of pseudo-objective technical terms—“delusions,” “paranoid,” “acute schizophrenia,” etc—and imposed this linguistic framework on a largely powerless group of social misfits. According to Foucault,5 these unfortunates—labeled “insane” or “mentally ill” by psychiatrists—have been denied their own “discourse” and made to conform to the collective discourse (the episteme [systems of understanding]) of psychiatric medicine. There is some degree of convergence between Foucault’s claims and those of Szasz, in so far as both castigate institutional psychiatry for its supposed coercive or authoritarian practices . . .

It is important to remember that this description of antifoundational viewpoints is offered by authors who generally disagree with the viewpoint. Thus, its accuracy should not be automatically assumed without critical investigation. Michel Foucault, for instance, articulated a very robust social critique of which psychiatry and its role within society in the mid-20th century was but one small part. His broader themes are important and difficult to dispute. Namely, he argues that institutions have a strong vested interest in protecting “social norms.” But what are social norms? Who has defined “normal” and “abnormal” actions, behaviors or activities and for what purpose have they so defined them?

The authors of the article further interpret Foucault’s positions as follows:

Foucault argues that all disciplines—whether scientific, legal, political, or social—operate through a system of self-legitimizing texts and linguistic conventions. Truth, therefore, cannot be absolute and claims of objectivity are impossible. More specifically, Foucault maintained that the definition and treatment of insanity constitutes a form of social control. In his classic Madness and Civilization, Foucault held that involuntary confinement of those deemed insane is really a coercive attempt to confine and marginalize madness.

While this may be a difficult notion for psychiatrists and other mental health practitioners to embrace, we must be aware at some level that diagnosis and treatment of mental illness is not based on clearly empirical or objective data. We have as of yet not traced mental illnesses such as Schizophrenia to genetic defect, disease, virus or some other tangible cause. Our diagnosis of mental illness relies on subjective interpretations of diagnostic criteria which list a series of symptoms to be observed and interpreted by an authority. There are no medical tests for the “disease” of Bipolar, for example. The judgment of the authority figure or group of authority figures is foremost. When Foucault points out this truth, he should not be criticized for doing so.

A Culture of Invincible Ignorance

I believe that as a society and culture, we in the United States have lost most of our collective capacity for healthy thinking and responsible decision making. Our social groups, organizations, and institutions are dominated by biases, false premises, false assumptions, sweeping generalizations, and subjective opinion masquerading as objective fact. And these are only the characteristics imbedded into modern social interaction which might be said to be accidental rather than deliberate. Then there are direct assaults on accuracy and reason in the form of deception, manipulation, coercion, and willful obfuscation that are much more intentional.

I believe that concern for critical thinking, effective reasoning and evidence-informed decision making has been replaced by a new culture of invincible ignorance. It is a culture in which everyone feels equally entitled to their personal opinion and in which it is culturally frowned upon to ask someone to support their opinion with some kind of tangible rationale. It is a culture in which perceived “authority” confers a sense of entitlement to make unsupported assertions and irrational decisions without being questioned. It is a culture in which personal “gut feelings” are treated as both empirically accurate and broadly generalizable when they are neither. It is a culture that believes that objectivity is something that can actually be achieved and largely ignores the impact of cognitive and emotional biases on our thinking experiences.

But most significantly of all, it is a culture that is so radically self-absorbed that individual egos assume that whatever they think or feel has legitimacy and should not be subject to critical scrutiny by others. If there is anything reasonable or accurate about my beliefs on this, then it has substantial implications for institutions such as psychiatry, shared social ideas such as “mental health” and “mental illness,” and for organizations and groups either working for or intersecting with the institution of mental health. So allow me to make a case for why I believe we live in a culture of invincible ignorance.

A culture of deference to perceived authority

I was sitting in a meeting one day when a colleague made a declarative statement that I was unsure was accurate. I asked my colleague what she was basing her statement on, and when she gave a very general answer, I asked for more specifics. I did not say I disagreed. I simply asked for information to determine what rationale or evidence supported the statement being made.

This created tension in the room. The colleague I was questioning happened to have a title larger than mine and more letters after her name. After the meeting, another coworker (who I will call Ted) approached me very distressed and even angry that I had dared to “challenge” another colleague on her opinion. Ted believed that my act of asking for evidence in support of a claim was actually an act of rudeness and disrespect. I was surprised to say the least. I told Ted that it did not seem to matter to me whether a person was a janitor or the President of the United States, I still ought to be able to ask them to support statements they make if they expect me to take the statements seriously. He looked at me in complete shock, as though I had just said something absurd.

What Will Cause Psychiatry to Change?

I have had one question on my mind lately: what would motivate Psychiatry to drastically change its mission and practices in a way that is most consistent with contemporary evidence and moral responsibility?

I've been thinking about this in earnest again lately after a recent interview of Robert Whittaker by Bruce Levine referenced last year's statement by the head of the National Institute of Mental Health, Thomas Insel. Insel's statement publically acknowledged the validity of a body of research that consistently shows long term use of "antipsychotic" medications may be contraindicated in the majority of cases, and called for a fundamental rethinking of best practices when it comes to psychiatric prescribing.

Obviously what was so striking about his statement is the fact that it comes from one of the most mainstream mental health bodies in the world. This was not a voice from the "fringe" - the term so often used by certain psychiatrists to trivialize evidence that disrupts their paradigm. This was a voice from the heart of the mental health machine. And 2013 was no stranger to staggering criticism and challenges to conventional psychiatric thinking from within some of the most respected and mainstream institutions of mental health.

In fairness, Mr. Insel seems to draw conclusions based on his stated premise (that a fundamental rethinking of best practices is needed) that differ from my own. Mr. Insel wants to devote even more NIMH money to finding biological root causes for "mental illness," presumably with a goal of developing "better" medical treatments.

But all I am interested in right now, is the fact that Mr. Insel and scores of others from within mainstream mental health institutions are stating the this premise: it is no longer possible to reasonably ignore the implications of available data, that we must question our long held assumptions about "best practices" in mental health. Different individuals will suggest different conclusions from this premise, many of which I will personally disagree with. But it should no longer be considered radical or "fringe" to question the dogmas which have long gone unchallenged in psychiatry. Asking questions is no longer radical.

An Open Letter to Persons Self-Identifying as Mentally Ill

My name is Andrew, and like you I have experienced severe cognitive and emotional distress in my life. This distress was sufficient that I once received a psychiatric diagnosis of Major Depressive Disorder and Generalized Anxiety Disorder, though I imagine other diagnosis could have easily been applied as well.

I know what panic attacks feel like. I know what it feels to experience a "dissociative episode" from the inside out. I know what it feels like to believe that you are going crazy. I know what it feels like to convulse in sobs so intensely that you tear muscles. I know what it feels like to want to die.

I remember that in the midst of my terror and confusion there came a point where I desperately wanted a label - a diagnosis. I wanted someone to tell me, in explicit terms, what was wrong with me and how to fix it. I can recall scouring the internet through tears trying to find a diagnosis that described my symptoms. I needed to believe that I was ill, just like if I had a virus, so that I would have hope of a "cure." It felt like the only thread of hope I had.

I have been on (admittedly mild) psychiatric medications, and those did help to some degree, especially in the short term. I was also blessed to find a therapist who practiced compassionately and genuinely listened to my voice as I expressed my needs. Many of you were never so lucky, and many others across the world are also less fortunate.

While I felt that I needed the label of mental illness to give me hope that I could be "treated," my therapist and my medical doctor - surprisingly - were less eager to give me what I wanted. They managed to express deep and genuine empathy for my distress and show their willingness to partner with me on a path to healing, but they did so without ever willingly giving me a diagnosis. It was only at my strong insistence that they finally conceded.

I was never told that I had a disease that was "just like diabetes." I was never told that I would likely have this "illness" for the rest of my life. I was never told that I would need to take psychiatric medications for the rest of my life and should never stop them. But every day, thousands and thousands of people are told exactly that.

Today I can share the good news with you that I have experienced full recovery from even these most extreme of cognitive and emotional states. My pathway to this recovery was not drugs (though I understand that medications might be an helpful and important part of your own healing.) Instead, the primary source of my recovery was the genuine empathy expressed by those partnering in my recovery.