Doctors are finally learning to manage antidepressant withdrawal

AWS Gemini-20 below $100

Or a precision one for $$$

All the other sub-$100 ones are mostly junk, with a few decent ones. But just get the Gemini-20

Relative precision is enough if you just want to get rid of pills

This. If there is one thing I've learned it is certainly not that you can generalize from yourself to others, especially for medication and its side-effects and withdrawal effects. I get so sick from taking novalgin that its a medical emergency (Agranulocytosis). Apparently, this occurs in like 1 case in a million. Conversely, I've heard of horrible side-effects or withdrawals from other medications where I experienced absolutely none of them.

Your psychiatrist looked at you like you were crazy?

Interesting is your doctor a general practitioner or a psychiatrist? A psychiatrist definitely knows about this stuff. GPs in my experience know almost nothing about anything beyond what seems like a script they operate from.

I can believe it. They are used for general anxiety disorder which I imagine can be kind of similar - an over-reaction to some stimuli.

Sure seems like it to me, but my doctor seemed bemused when I mentioned it to him and I don't think they're routinely prescribed for them. I reckon if I'd have paired the SSRI with some exposure therapy, it would have cured me of it long-term. I do have an additional phobia however (I'd rather not say which) and it didn't make any impact on that at all, so YMMV.

Worth noting as well that I had no expectation of any changes to my arachnophobia going in. It didn't even cross my mind.

both my social phobia and my fear of dark almost vanished on venlafaxine. i take walks in the dark these days, what the fuck.

Exposure seems to be the best way out.

Thanks, yeah, but if I’m honest I don’t really care enough to go through with it. I almost did once, years ago, the London Zoo have a programme.

I mentioned it though as one of the most stark changes I noticed after getting on an SSRI was pretty much immediately losing my fear of spiders. It was the first sign I had that showed it was doing something.

I used to literally, on occasion, launch my phone across the room if I was scrolling and came across a spider (sometimes drenching myself with coffee or whatever in the process!) and then one day, shortly after getting on it, I stumbled across some awful tarantula video or something and I just stared at it like “huh, why am I not freaking out”.

Exposure therapy does not work for everyone in all areas. Sometimes not at all.

Also, see the debate around discussing traumatic events in therapy immediately versus waiting a year.

Throwing people in the deep end doesn't always result in a swimmer :)

YMMV of course.

> SSRIs do not have the same level of supporting evidence, and the effects are not as durable.

To the extent that we can measure depression, SSRIs have been widely proven in gold standard phase III clinical trials to help with the treatment of major depression. What exactly is supposed to be lacking in the supported evidence?

for my snri i lessened the dose by 25% and that alone cost me a week of work, i was so fucked over. when i quit this i will for sure do the thing where you open the capsules and remove a little of the contents, gradually removing more each day.

i read online about people doing this and thought they were nutjobs. well, now i know.

It's probably less "modern antidepressants are uniquely bad" and more "we got much better at starting people on safer drugs than we did at figuring out how to stop them"

Much of medicine (especially mental health related) is rather primitive. We are literally reverse engineering discoveries that seem to work on some other animals, and then figuring out how (to the best of our limited ability).

I liken SSRIs to carpet bombing - also their mechanism to increase seratonin in the brain is by making something else not use it (reuptake inhibition). We’re guessing that other thing isn’t a big deal. But who knows. Serotonin is produced in the gut and it controls melatonin, which controls our sleep. It’s all connected in a bizarre way.

> school crazy

Yep, that’s how I associate SSRIs.

Just want to underscore that this is the right answer.

They all do and my reading has always been that bupronion has less scary side effects than e.g. escalitopram.

I don’t think “most doctors” is accurate any more, but a doctor prescribing a month of klonopin for insomnia needs some urgent continuing professional development.

I've tried 20-some-odd antidepressants titrating off and on and usually back off again.

Mirtazapene (ATeCA) is the only one that could manage my depression. Unfortunately, it leads to severe weight gain that my health plan's formulary refuses to cover GLP-1 for because obesity is considered "a choice". It's the only one where the depression mostly goes away and the side-effects aren't life-threatening/-debilitating for me. If I forget a single dose at night or anytime I go to sleep without taking it first, I end up with almost exactly the feeling of an alcohol hangover. It's also a pretty powerful antihistamine. I also usually can't get to sleep if I don't take it. :/

Vortioxetine gave me horrific myoclonus and vestibular symptoms.

Atomoxetine is mostly for ADHD and gave me tachycardia, profuse sweating, uncomfortable nervousness, and anxiety. It didn't do shit for my ADHD or depression.

YMMV.

> It’s not surprising you didn’t feel anything noticeable after a few weeks. It’s also unfortunate, but not too surprising, that your doctor wasn’t informed enough to communicate these things.

He probably did inform me, I was probably not paying attention at that time. Family does not know the details either, I'm dealing with this myself.

Anyway: depression is the least of my issues now, the clock is ticking.

Right now I'm sorting out my affairs without letting the kids know.

The other problem with SSRI treatment is that individually they are only barely better than placebo. They're among the worst classes of drugs as far as NNT, effect size or remission rate (individually! STAR-D treatment algorithm works for the vast majority of people)

Especially in acute cases, I think they should be replaced or augmented by something stylistically in the direction of esketamine. 6-8 weeks per medication trial is an absolute eternity, especially since some minority of major depressive episodes resolve spontaneously after a few months to a year.

I start getting effects the same day if I miss my morning dose, but like you, it was life changing (in a good way) for me.

I've got two friends who didn't benefit from it, so it isn't a miracle cure for everyone, sadly.

> You look at a patient who doesn't get out of bed, is in trouble at work/school for performance, doesn't spend social time with friends, etc, and 6 months after starting an SSRI they're indistinguishable from other people but still have other issues, we call that a "mild impact" because they self-report other problems.

This really lines up with what I've seen anecdotally. My partner literally doesn't remember how bad things were before he took antidepressants because depression impacted his ability to form memories. He self reports that antidepressants had a mild impact, but from an outside perspective nearly everything about his life changed.

> But you pivot to TMS and you see 60-80 percent improvement rates. Esketamine is close too.

I have received both rTMS and esketamine and the providers themselves told me they saw roughly a 30-40% response rate (not remission, that's even lower!). Upon researching the topic myself, I found that the meta analysis usually agreed with this 30% figure, but recent research papers mark eskatamine even lower. Both treatments can be miraculous for a few select people and it makes a good headline, but it's a total failure for the majority of people.

I agree with you that those treatments should be easier to access, though.

> Too many therapists dismiss meds and too many psychiatrists dismiss therapy.

This is the only factually true statement in your entire comment.

The problem with the entire argument that you're making is that the natural rate of remission in uncomplicated major depressive episodes is very close to the rate that SSRIs create, individually, and very close in terms of timing. If you do something more like STAR-D you see higher rates, but that also takes so long that many people naturally remit.

Well I think that we do not know enough about genesis of depression and other mental issues. So this is just symptomatic therapy. And as such it should be prescribed only for very short terms. Analogy: how would you perceive someone who prescribed his febrile patient paracetamol for 10 years just because it works? And in his defense he/she claims that febrile condition has well known metabolic chain and that paracetamol lowers fever mainly by interrupting the COX → PGE₂ part of the fever pathway in the brain.

> The truth is antidepressants have a larger effect on mental health than actually gets reported because of how improvements are measured.

The truth is actually exactly the opposite, and I provided very high-quality evidence demonstrating this to be the case. You have nothing but bald assertions.

For some people the emotional blunting is desirable, especially as you said, if the problem is chronic anxiety. But for many other people, their depression is defined by a lack of positive affect and anhedonia, meaning that emotional blunting is literally making things worse.

Depression is highly heterogenous, and I am glad the medication helped you.

SSRIs have much more clinical evidence of efficacy for addressing anxiety disorders vs a placebo than depression. The effect size is ~0.7 vs 0.2 in meta studies.

> I find it funny that people complain about emotional blunting when that is the entire purpose of the drug.

The ideal would be to blunt the negatives but not the positives. The effect of some of the older antidepressants can be to blunt both, across the board.

Some of the newer atypical antidepressants can address depression without making everything flat.

See also: The Serotonin Theory of Depression: a Systematic Umbrella Review of the Evidence (2022). It's worth reading the introduction and results in full, but here are two important quotes (footnote markers removed):

> Our comprehensive review of the major strands of research on serotonin shows there is no convincing evidence that depression is associated with, or caused by, lower serotonin concentrations or activity. Most studies found no evidence of reduced serotonin activity in people with depression compared to people without, and methods to reduce serotonin availability using tryptophan depletion do not consistently lower mood in volunteers. High quality, well-powered genetic studies effectively exclude an association between genotypes related to the serotonin system and depression, including a proposed interaction with stress.

> The chemical imbalance theory of depression is still put forward by professionals, and the serotonin theory, in particular, has formed the basis of a considerable research effort over the last few decades. The general public widely believes that depression has been convincingly demonstrated to be the result of serotonin or other chemical abnormalities, and this belief shapes how people understand their moods, leading to a pessimistic outlook on the outcome of depression and negative expectancies about the possibility of self-regulation of mood. The idea that depression is the result of a chemical imbalance also influences decisions about whether to take or continue anti-depressant medication and may discourage people from dis-continuing treatment, potentially leading to lifelong dependence on these drugs.

https://www.nature.com/articles/s41380-022-01661-0

Yup, I would agree. The meta-research / methodological research and awareness here is really quite impressive, even though its conclusions are a bit grim and not well-known.

Have we reigned in the number of perscriptions?

Because the 1 in 10 stat I find seems a bit low, at least in my circle, and those are the ones who are open about it.

And the people I know have been on them approximately a decade. What baffles me is that a fair number of them triggered their own depressive episodes, and likely did need therapy and something at the time - but have all long since move past those "moments".

> As you point out, placebo antidepressants are fairly effective.

This is a misunderstanding of concepts like regression to the mean, and also the active placebo elements involved.

> but the experienced reality is that they help people a lot

And the evidence is that the reality people think they are experiencing is wrong, i.e, they are improving and factually experiencing improvement, but misattributing the cause to the drug.

> "As effective as placebo" does not mean worthless

In one sense of worthless, perhaps, but since drugs have larger costs relative to placebo, well, we can argue they are worse than worseless in another.

Better instead to talk about cost-benefit tradeoffs, number-needed-to-treat vs number-needed-to-harm and etc though, and try to get better at prescribing more carefully to those they clearly benefit.

It’s unethical to prescribe a patient a placebo in a way that suggests that what they are receiving is scientifically proven.

In a clinical trial setting, you can prescribe a placebo, because the patient is fully aware and clearly consenting to the fact that they may receive a placebo. Lying to a patient, in a clinical setting, from a position of authority, is a completely different matter. The informed consent would be completely absent, the patient’s ability to make informed choices about their own healthcare would be undermined and withheld, and the provider would be deriving financial benefit from the patient and / or through insurance claims for what amounts to a scam.

The patient, who would be seeking a treatment from a trusted expert, would believe that they are receiving proven treatments in exchange for their time, patience, money, reduced quality of life due to side effects, and opportunity costs in terms of not going to a different provider or trying something else, but in reality their provider would be misleading them. Some patients would even die as a result of taking a particular placebo and depending on it—either because of side effects or due to the lack of effectiveness—when they tragically would have been better off trying a different approach or medication. How could a patient possibly give informed consent in such a scenario, for one thing? How could they meaningfully compare treatment options and make their own informed choices when the advice they receive includes lies?

Alas, some providers believe in placebo effects so much more strongly than their patients’ right to autonomy that when faced with complaints of side effects, they will just lie more and more to their patients in hopes that the side effects will go away, but that’s really just more gaslighting to people who are already in difficult situations.

Honestly, every time I look into if the "treatment by severity effect" is clearly established, I feel I come away only able to shrug. It is at least plausible, but hasn't been clearly established or refuted.

What does seem clear to me is that the whole cost-benefit considerations change in favor of anti-depressants when the depression is severe. I wouldn't say anti-depressants should be first-line treatments for ordinary depression, but for severe depression, I think they are a very reasonable first-line option.

Sure, they still might not help, but the costs / harms don't seem so bad compared to the potential costs / harms of leaving the severe major depression untreated, and the other options look all pretty terrible here too.

Clothes too. If you're cold, why not just move to a tropical country where you can be naked, as nature intended?

> I’m not trying to discount mental health, I just think there are better solutions than drugs to fix your state of mind.

Find one that's as effective on the general population.

I mean, sure, perhaps lifestyle changes are better. Can you get a higher percentage to change them and improve people's lives than we currently can with drugs?

As a top performer in school, I definitely think (and still point out), that you can get fantastically high results in SAT/GRE without paying any test prep service. I and many of my peers did it. There are better solutions than paying those services. But how many who don't pay do as well as those who do? I can tell them how to study as much as I can, but the reality is that statistically, people who attend will do better than if they don't.

From a medical standpoint, telling people to change how they live and think has a fairly low success rate. The best options usually don't work on the masses.

Agreed. They have to be significantly helping at least some, but we can't say who these people are for certain yet, or how many there really are.

And yes, in some cases, no other options are possible, so even if the evidence is pretty dismal for their effectiveness, they are still broadly safe enough to definitely be worth a try. They probably just shouldn't be the first-line approach.

I don’t get why people are so negative about drugs. They’re just a medical treatment, with pluses and minuses. If they help and they’re not too costly then what’s the big deal? Half the population is addicted to caffeine and nobody cares. A huge number of people need medical intervention for other things and we don’t get this quasi moralistic opposition to them.