Nielsen, 2011 What is the difference between dependence and withdrawal reactions?

[Altostrata]

"Referring to these reactions as part of a dependence syndrome in the case of benzodiazepines but not SSRIs does not seem rational."

 

Addiction. 2012 May;107(5):900-8. doi: 10.1111/j.1360-0443.2011.03686.x. Epub 2012 Jan 23.

What is the difference between dependence and withdrawal reactions? A comparison of benzodiazepines and selective serotonin re-uptake inhibitors.

Nielsen M, Hansen EH, Gøtzsche PC.

 

Source

 

Department 3343, The Nordic Cochrane Centre, Copenhagen, Denmark. marn@phmetropol.dk

 

Abstract at http://www.ncbi.nlm.nih.gov/pubmed/21992148

 

AIMS:

 

To explore the rationale for claiming that benzodiazepines cause dependence while selective serotonin re-uptake inhibitors (SSRIs) do not.

 

METHODS:

 

We analysed the definitions of dependence and withdrawal reactions as they had appeared over time in the Diagnostic Statistical Manual of Mental Diseases (DSM) and the International Classification of Diseases (ICD). We also compared the discontinuation symptoms described for the two drug groups in a systematic review.

 

RESULTS:

 

The definition of substance dependence has changed over time in both the DSM and ICD. In the most recent classifications several criteria, including behavioural, physiological and cognitive manifestations, must be fulfilled. This change was published with the revision of the DSM-III revision in 1987 (DSM-IIIR), after the recognition of benzodiazepine dependence and just before the SSRIs were marketed in 1987-88. We found that discontinuation symptoms were described with similar terms for benzodiazepines and SSRIs and were very similar for 37 of 42 identified symptoms described as withdrawal reactions.

 

CONCLUSIONS:

 

Withdrawal reactions to selective serotonin re-uptake inhibitors appear to be similar to those for benzodiazepines; referring to these reactions as part of a dependence syndrome in the case of benzodiazepines, but not selective serotonin re-uptake inhibitors, does not seem rational.

[bubbles]

I was very interested when I first read this post and the link. I'm still interested! However, I'm surprised that it doesn't seem to have gone anywhere. Is anyone aware of any response to this?

Bubbles

[Altostrata]

It may not have been published yet.

 

For those of you who have access to journal articles, please add the pdf to this topic if you can get it.

[Barbarannamated]

NOTE FROM ADMIN: There are two responses published April 4, 2012 in the pdf attached to this link http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03736.x/full

 

Full text is also online:

 

Dependence and Withdrawal: Comparison of the Benzodiazepines and Selective Serotonin Re-Uptake Inhibitors by Malcolm Lader at http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03736.x/full

 

Withdrawal or Dependence: a Matter of Context by Kathleen Brady at http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2012.03862.x/full

 

_______________________________

 

Comparison of SSRI and Benzodiazepine Dependence and Withdrawal

Addiction, May 2012

Lader, M

Emeritus Professor of Clinical Psychopharmacology, King's College, London

 

*Excuse the abbreviated post. I wanted to get this up earlier, however, technical difficulties persist.

This appears to be a review of a full article that I have not been able to get full text on yet.

The author draws excellent parallels between the time course and severity of SSRI and benzodiazepine withdrawal complexes. I haven't seen this stated previously. Benzodependence dependence and withdrawal is well recognized and this paper brings attention to SSRI withdrawal through this comparison.

I disagree that SSRIs have a more favorable Risk/Benefit ratio although I am not as familiar with the risks and long term dangers of benzos. I believe the delayed response to SSRIs may allow for dependence in some people compared to the much shorter response to benzos (weeks for SSRIs; almost immediate sedative/anxiolytic effects with benzos).

_________________________________________________________________________________________________________________________________________________________________________________________________________________________

This erudite paper raises major issues of definition of disorders, description of syndromes, and indirectly of clinical management. The nub of the matter, pharmacologically and clinically, relates to the detailed phenomenological dissection of the syndromes that accompany discontinuation of a drug given in a therapeutic context, and the pharmacological mechanisms involved. Briefly, the clinical syndromes include:

 

Rebound, where the initial target symptoms reappear in exaggerated form. This has been studied most intensively with hypnotic drugs, because the polysomnogram provides a precise measure of sleep stages [2].

Relapse, in which the initial disorder recurs because the medication has suppressed but not ‘cured’ the disorder, and natural remission has not supervened.

Recurrence: this is the onset of a new episode of illness after a period of normality, usually arbitrarily defined.

Withdrawal syndromes, which have a characteristic if not pathognomonic collection of symptoms and signs in a well-defined temporal relation with stopping the drug. By arbitrary definition, clinicians will expect to see at least three new symptoms, i.e. not reported previously by the patients.

Pseudo-withdrawal: one syndrome which is often overlooked is pseudo-withdrawal in which the patient, warned that discontinuation is imminent, reports vague symptoms.

Dependence is generally regarded as a physiological state implied from the emergence of withdrawal symptoms, divided traditionally into physical and psychological dependence.

Discontinuation syndromes are descriptions of all of the above.

Addiction, abuse, etc. can be associated with withdrawal, but contain a kaleidoscope of features such as self-destructive drug-related life-style, social deterioration, cravings and high but not inevitable rate of relapse on discontinuation.

 

Margrethe Nielsen and her associates rightly emphasize the changes over time in various definitions and how these have altered the perception and management of drug users; but these changes reflect the attitudes of those involved in this field, sometimes based on political and economical biases, and not always on data. Indeed, the evidence base in the area of ‘addiction’ is always limited, at least clinically but not in animal experiments, because of the inability to assign subjects randomly to drug, placebo and perhaps no-treatment groups. For example, the rate of successful withdrawal in drug users is influenced strongly by whether or not the individual is in therapy ([3], p. 65–67).

 

 

The basic thesis of this paper is that benzodiazepines and selective serotonin re-uptake inhibitors (SSRIs) are associated with similar reactions which meet the usual criteria for withdrawal and are part of a dependence syndrome. Juggling the changes in definition is an academic exercise and many clinicians would go straight to the practical implications; namely, how frequent, severe, prolonged and disruptive of everyday life are these syndromes? Importantly, how easy are they to avoid or minimize by tapering and how can they be managed successfully? The authors concentrate on the symptom patterns, reporting that the symptoms were very similar for 37 of 42 identified withdrawal reactions. However, this obscures differences in symptom spectra, relating mainly to the distress caused by each individual symptom. For example, perceptual hypersensitivities bedevil the patient attempting to withdraw from BZDs, and these may be protracted [4].

 

BZD withdrawal has been recognized since the 1980s [5] and SSRI withdrawal since the 1990s [6]. There are many general similarities [7]. Drugs in both classes differ widely in the frequency and severity of withdrawal. Not everyone suffers withdrawal. The time–courses of withdrawal are similar. Relapse and resumption of medication are common. Management relies on tapering, psychological treatment and social support. Tapering is not fully effective [8,9]. Thus, BZD and SSRI withdrawal reactions are very similar in their clinical impact despite the differences in the underlying pharmacology, but there is one major difference. Withdrawal reactions, and by implication the state of dependence, are common in a proportion of both BZD and SSRI users, despite their being maintained on normal therapeutic dosages. SSRI users rarely escalate their doses, nor do they seek illicit supplies. Similarly, the bulk of BZD users are maintained on therapeutic doses by their prescribers. However, some do escalate their doses, becoming high-dose users with severe dependence. Also, the BZDs are well recognized as drugs of abuse, either on their own or as adjuncts to polydrug abuse with diamorphine and cocaine [10]. This is an important difference between the SSRIs and the BZDs.

 

Finally, we should not lose sight of another fundamental difference. Despite withdrawal reactions, most SSRIs have a favourable risk/benefit ratio. By and large, BZDs do not meet this criterion and should be avoided wherever possible [11]. We must be careful not to blur the distinctions between the two classes of drugs and discourage the careful use of SSRIs as antidepressants and anxiolytics.

Edited October 14, 2012 by Altostrata
merged related topics, added intro

[bubbles]

Thanks for posting this response, Bar.

 

I can't comment on any comparison of benzos to ssris, because I have never taken a benzo, but I do also agree that the long onset of benefit with the ssri seems to me to mean that you've already reached a point where you can't just CT them before you get any benefit.

 

I can say that I do not find the risk:benefit ratio of SSRIs to be particularly reassuring. However, the only time I went to my doctor with a side effect (headaches) it was dismissed as not related (though after the doc looked it up). I have never mentioned the other side effects, and he has never asked. It might seem to my doc that I have a clear benefit (remission) and zero side effects, and thus the risk:benefit ratio looks quite balanced. To me, I see the clear side effects, possible zero benefit (Irving Kirsch's placebo effect) and potential future health problems caused by the SSRI.

 

Bubbles

[bubbles]

I would also like to make a point with regard to the ssri user not escalating dose or seeking illicit supply. If an ssri poops out (which seems to be fairly common), the doctor ups the dose, or switches to a new drug, or adds another drug. We, therefore, do not need to escalate dose ourselves or seek illicit supply, and it has always seemed to me to be a bit of a non-comparison.

 

B

[Barbarannamated]

Excellent point - the antipsychotics are a primary add-on -

[Barbarannamated]

I would also like to make a point with regard to the ssri user not escalating dose or seeking illicit supply. If an ssri poops out (which seems to be fairly common), the doctor ups the dose, or switches to a new drug, or adds another drug. We, therefore, do not need to escalate dose ourselves or seek illicit supply, and it has always seemed to me to be a bit of a non-comparison.

 

B

 

Bubbles,

This is such an excellent point. I hope you'll post a comment on Mad In America.

Antipsychotics, Wellbutrin, lithium, benzos, ADHD drugs are all added to SSRIs for 'augmentation' or to treat side effects.

 

Article at Mad In America/Robert Whitaker site

[bubbles]

Another comment: http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2012.03862.x/full

[Skyler]

I disagree that SSRIs have a more favorable Risk/Benefit ratio although I am not as familiar with the risks and long term dangers of benzos. I believe the delayed response to SSRIs may allow for dependence in some people compared to the much shorter response to benzos (weeks for SSRIs; almost immediate sedative/anxiolytic effects with benzos).

 

Hi Barb, first, thanks for this excellent post. Most interesting.

 

I think the article is 'apples to oranges'. In my experience taking both benzos and antidepressants, and from what I've picked up on benzo forums over the last couple of years..

 

Benzos are more a hazard for addiction, easier to get hooked on. (People can get hooked in a week)

 

SSRIs cause more side effects and long term health issues.

 

While benzos may have a longer track record when it comes to recognition of the addictive potential, the info has been smothered by Big Pharma. And doctors do not understand the need for slow tapers any better with benzos than antidepressants. With benzos there is more stigma because abuse may accompany the use of street drugs, etc.

 

This said, my 3 months on imipramine came within a hair of firing off a Grand Mal seizure. Very nasty stuff.

 

The weakness of the article is in the fact the scope is too broad. A separate paper would have better served had each topic been covered seperately.. one to compare side and long term effects, and a second to compare dependence and addiction. Of course the plus is it has been written at all!

 

Just my two cents

[Barbarannamated]

 

I think the article is 'apples to oranges'. In my experience taking both benzos and antidepressants, and from what I've picked up on benzo forums over the last couple of years..

 

Benzos are more a hazard for addiction, easier to get hooked on. (People can get hooked in a week)

 

SSRIs cause more side effects and long term health issues.

 

While benzos may have a longer track record when it comes to recognition of the addictive potential, the info has been smothered by Big Pharma. And doctors do not understand the need for slow tapers any better with benzos than antidepressants. With benzos there is more stigma because abuse may accompany the use of street drugs, etc.

 

This said, my 3 months on imipramine came within a hair of firing off a Grand Mal seizure. Very nasty stuff.

The weakness of the article is in the fact the scope is too broad. A separate paper would have better served had each topic been covered seperately.. one to compare side and long term effects, and a second to compare dependence and addiction. Of course the plus is it has been written at all!

Just my two cents

 

Thanks for your input on this article. I agree that it lacks focus. I look forward to seeing the original work by Nielson.

 

I have not spent time on benzos boards and am not in tune with the level of knowledge of tapering by MDs. Several years ago, my husband spoke with an Addictionologist who told him that Klonopin (and benzos, in general) SHOULD take about 2 years to taper off and that it's a very difficult process. That stuck with me. Husband has no recollection of the conversation or who the doc was. There is a doc in SoCalifornia who pioneered 'rapid detox' for benzos and opiates. This method does not seem to be respected by other docs although I have not discussed details of why or how they believe benzos should be tapered. I frequently hear that they should be avoided at all costs. They have no knowledge of Heather Ashton, MD, or The Ashton Manual for Benzo Withdrawal.

Most docs seem to hold the opinion that SSRIs are a 'safer' treatment for anxiety (from my perspective). I feel it is exchanging one danger for another and am not aware of any other pharmacologic treatments for anxiety aside from beta blockers.

Of course, non pharmacologic interventions (therapy, exercise, lifestyle modification) and natural supplements should be used but we know that doesn't happen on a regular basis.

 

When I first read The Ashton Manual, I was struck by how accurately the withdrawal symptoms described my withdrawal from Pristiq (in retrospect - I didn't realize all that was going on with me was due to w/d until done tapering). I have not attempted to taper Klonopin yet. I have had far more distress with protracted withdrawal from Pristiq (SNRI) than from 8 years of low dose opiates. I did use extremely low dose Suboxone for awhile - a fraction of recommended. I suspect every person has different degrees of difficulty with each drug and am NOT attempting to compare. My issue is when i hear doctors proclaim that benzos and opiates are to be avoided at all costs and use SS/NRIs IN THEIR PLACE (or Lyrica, etc.).

 

From my perspective, SS/NRI withdrawal is far less acknowledged than benzo w/d so i was surprised to read this bold statement of comparison. I may retract that when I see the full paper with the specific item comparison.

 

RE: Kathlenn Brady response. She specializes in dual-diagnosis, I believe. I agree with most of her statements regarding terminology. I DISAGREE that SSRI withdrawal does not cause functional impairment. She had me up until that point.

[Skyler]

Several years ago, my husband spoke with an Addictionologist who told him that Klonopin (and benzos, in general) SHOULD take about 2 years to taper off and that it's a very difficult process.

Wow.. good to know that some docs are aware. Would that addictionologists could get the word out.

 

They have no knowledge of Heather Ashton, MD, or The Ashton Manual for Benzo Withdrawal.

This is the norm. I could not see where people coming off benzos had any better success finding docs who were willing to help than those taking antidepressants.

 

Most docs seem to hold the opinion that SSRIs are a 'safer' treatment for anxiety (from my perspective). I feel it is exchanging one danger for another and am not aware of any other pharmacologic treatments for anxiety aside from beta blockers.

Do antidepressants really help anxiety? If so.. for how long. Can you see many if any situations that would justify their use?

 

I have not attempted to taper Klonopin yet. I have had far more distress with protracted withdrawal from Pristiq (SNRI) than from 8 years of low dose opiates. My issue is when i hear doctors proclaim that benzos and opiates are to be avoided at all costs and use SS/NRIs IN THEIR PLACE (or Lyrica, etc.).

Avoid ALL psychotropics at all costs. Sheesh. Btw… having taken strong and highly addictive opioids.. getting off them is a cake walk by comparison.

 

From my perspective, SS/NRI withdrawal is far less acknowledged than benzo w/d so i was surprised to read this bold statement of comparison. I may retract that when I see the full paper with the specific item comparison.

The problem with the article is not that they compare the difficulty getting off, but that there was a comparison of the addictive potential.. not that this makes one better than the other. Personally, I can’t see where the efficacy of either vs. the long term harm justifies their use.

[Barbarannamated]

Agree - in an effort to decrease use of drugs with 'abuse potential' (per traditional definition) we now have drugs with longer onset of effect and must be taken daily - it allows for no situational application or treatment b/c -theoretically- anything that works immediately is abuseable - there was an antidepressant in trials not long ago that was nixed b/c it worked too quickly - THERE IS SOMETHING VERY WRONG WITH THIS THINKING -

 

I never suffered from generalized anxiety prior to being on SSRIs - situational stress/anxiety is different and should not be medicated as a chronic condition which I think it often is- I never felt benefit from SS/NRIs and knowing that the real data shows negligible benefit over placebo I have difficulty seeing any utility -

However I know people who swear they've improved their lives dramatically -

 

I'm more comfortable with a drug whose effect is either 1) measureable with testing or 2) has effect (or lack of) in short term -

[bubbles]

To me, there are two things here to consider. First of all, practically, how hard is it to *stop* taking the drug. If it takes a long time and/or involves withdrawal symptoms, then I can see no practical difference between tolerance/dependence/addiction/whatever else they might call it, and everything else is (to me) an exercise in semantics. The second thing is side effects (which might include a rebound effect as the dose wears off in the case of a benzo, or the worsening of bruxism that I've experienced with the SSRI, among other side effects) and/or long term damage. It is the side effects and long term damage that particularly worry me at this point.

 

Added to the fact that, quite possibly, there is no clinical benefit of SSRI over placebo (Irving Kirsch), and I think there is - to me at least - a very clear risk:benefit outcome. And it does not come out in favor of an SSRI. Though, perhaps if you'd had zero side effects you might see that equation differently...

 

What kind of side effects and long term damage do people get with benzos?

 

Please excuse my poor grammar today - I've had an upsetting couple of days (nothing serious, just upsetting) and I'm bit rattled.

 

B

[Barbarannamated]

Posting link to thread that refers to this paper

http://survivingantidepressants.org/index.php?/topic/2131-dependence-withdrawal-comparison-of-benzos-and-ssris/page__pid__20659#entry20659

[Altostrata]

Paper requested from the lead author.

 

Madinamerica.com topic here: http://www.madinamerica.com/2012/04/benzo-ssri-addiction-and-withdrawal/ :

 

From the Journal:

 

This erudite paper raises major issues of definition of disorders, description of syndromes, and indirectly of clinical management [1]. The nub of the matter, pharmacologically and clinically, relates to the detailed phenomenological dissection of the syndromes that accompany discontinuation of a drug given in a therapeutic context, and the pharmacological mechanisms involved. Briefly, the clinical syndromes include:

 

1 Rebound, where the initial target symptoms reappear in exaggerated form. This has been studied most intensively with hypnotic drugs, because the polysomnogram provides a precise measure of sleep stages [2].

 

2 Relapse, in which the initial disorder recurs because the medication has suppressed but not ‘cured’ the disorder, and natural remission has not supervened.

 

3 Recurrence: this is the onset of a new episode of illness after a period of normality, usually arbitrarily defined.

 

4 Withdrawal syndromes, which have a characteristic if not pathognomonic collection of symptoms and signs in a well-defined temporal relation with stopping the drug. By arbitrary definition, clinicians will expect to see at least three new symptoms, i.e. not reported previously by the patients.

 

5 Pseudo-withdrawal: one syndrome which is often overlooked is pseudo-withdrawal in which the patient, warned that discontinuation is imminent, reports vague symptoms.

 

6 Dependence is generally regarded as a physiological state implied from the emergence of withdrawal symptoms, divided traditionally into physical and psychological dependence.

 

7 Discontinuation syndromes are descriptions of all of the above.

 

8 Addiction, abuse, etc. can be associated with withdrawal, but contain a kaleidoscope of features such as self-destructive drug-related life-style, social deterioration, cravings and high but not inevitable rate of relapse on discontinuation.

 

Margrethe Nielsen and her associates rightly emphasize the changes over time in various definitions and how these have altered the perception and management of drug users; but these changes reflect the attitudes of those involved in this field, sometimes based on political and economical biases, and not always on data. Indeed, the evidence base in the area of ‘addiction’ is always limited, at least clinically but not in animal experiments, because of the inability to assign subjects randomly to drug, placebo and perhaps no-treatment groups. For example, the rate of successful withdrawal in drug users is influenced strongly by whether or not the individual is in therapy ([3], p. 65–67).

 

The basic thesis of this paper is that benzodiazepines (BZDs) and selective serotonin re-uptake inhibitors (SSRIs) are associated with similar reactions which meet the usual criteria for withdrawal and are part of a dependence syndrome. Juggling the changes in definition is an academic exercise and many clinicians would go straight to the practical implications; namely, how frequent, severe, prolonged and disruptive of everyday life are these syndromes? Importantly, how easy are they to avoid or minimize by tapering and how can they be managed successfully? The authors concentrate on the symptom patterns, reporting that the symptoms were very similar for 37 of 42 identified withdrawal reactions. However, this obscures differences in symptom spectra, relating mainly to the distress caused by each individual symptom. For example, perceptual hypersensitivities bedevil the patient attempting to withdraw from BZDs, and these may be protracted [4].

 

BZD withdrawal has been recognized since the 1980s [5] and SSRI withdrawal since the 1990s [6]. There are many general similarities [7]. Drugs in both classes differ widely in the frequency and severity of withdrawal. Not everyone suffers withdrawal. The time–courses of withdrawal are similar. Relapse and resumption of medication are common. Management relies on tapering, psychological treatment and social support. Tapering is not fully effective [8,9]. Thus, BZD and SSRI withdrawal reactions are very similar in their clinical impact despite the differences in the underlying pharmacology, but there is one major difference. Withdrawal reactions, and by implication the state of dependence, are common in a proportion of both BZD and SSRI users, despite their being maintained on normal therapeutic dosages. SSRI users rarely escalate their doses, nor do they seek illicit supplies. Similarly, the bulk of BZD users are maintained on therapeutic doses by their prescribers. However, some do escalate their doses, becoming high-dose users with severe dependence. Also, the BZDs are well recognized as drugs of abuse, either on their own or as adjuncts to polydrug abuse with diamorphine and cocaine [10]. This is an important difference between the SSRIs and the BZDs.

 

Finally, we should not lose sight of another fundamental difference. Despite withdrawal reactions, most SSRIs have a favourable risk/benefit ratio. By and large, BZDs do not meet this criterion and should be avoided wherever possible [11]. We must be careful not to blur the distinctions between the two classes of drugs and discourage the careful use of SSRIs as antidepressants and anxiolytics.

[Skyler]

Finally, we should not lose sight of another fundamental difference. Despite withdrawal reactions, most SSRIs have a favourable risk/benefit ratio. By and large, BZDs do not meet this criterion and should be avoided wherever possible [11]. We must be careful not to blur the distinctions between the two classes of drugs and discourage the careful use of SSRIs as antidepressants and anxiolytics.

Very succinct.. I hope this last paragraph gets around. Benzos should be avoided because they do not have a favorable risk benefit ration. It's way to easy to end up dependent on them. Thanks for the post. ~S

[Barbarannamated]

I have a different take on that last paragraph. I don't disagree that benzos are to be avoided, however I don't believe they have a worse Risk/benefit ratio than SSRIs. I know others will disagree with me, but I think benzos may have a SLIGHT advantage because they reveal their efficacy almost immediately unlike SSRIs which are to be used for weeks to see effect. Under controlled circumstances, benzos can be used prn and do not have to be taken for weeks to see benefit (I'm not convinced that's not a marketing strategy for SSRIs).

 

I think benzos are dangerous, but I do know people who have used them VERY JUDICIOUSLY, 1-2 tabs to break a situational stress/anxiety cycle a few times per year, max. I'm not referring to any regular or daily usage. Just saying that it can be done. Not advocating.

 

Ok, go ahead, shoot.

[Skyler]

I think benzos are dangerous, but I do know people who have used them VERY JUDICIOUSLY, 1-2 tabs to break a situational stress/anxiety cycle a few times per year, max. I'm not referring to any regular or daily usage. Just saying that it can be done. Not advocating.

 

Ok, go ahead, shoot.

 

The problem is, prescription guidelines are too lax, and they are not used on a no more than 1 to 2 times a week prn basis. And, like antidepressants and other psychotropics, peeps are left on them for eons. I know it can be done, problem is, it is not. And I've read too many stories about how people become addicted in 2 weeks.. not so seldom only one for the short half lifers.

 

I think ADs have a higher side effect profile, though long term issues with benzos can be the pits. ~S

[bubbles]

My concern is that, if we believe Kirsch (and I do believe him), SSRIs have very minimal benefits to most of us. The side effects are quite significant, and if we're looking it as a ratio of good:bad, well, if good is almost nil, and bad is significant, then the ratio does not look favourable.

[Barbarannamated]

Absolutely agree.

 

I know a few people who are really anti-drugs and will take Xanax 1-2 tabs every several months on extreme emergent basis only. A script of 10 pills last them a year or more. THEY ARE THE RARE EXCEPTION!

 

This is not an endorsement. Can't emphasize that enough!

 

I have an automatic dislike of anything that must be taken daily. I suspect that lends to placebo effect. Very difficult to know when it's working (aside from withdrawal effects) and stop taking when not needed. Pharma wants everyone on daily meds, of course. The septre of addiction is used to dissuade responsible prn usage ("opiates are evil, use Cymbalta for pain", for example).

 

Any opportunity to get on my soapbox.

[Altostrata]

I believe if all the risks of SSRIs were factored in, they would not have a more favorable risk-benefit profile than benzos. But there is too much denial in medicine about ANY adverse effects from SSRIs for any real assessment of their risk at present.

[jr1985]

What is the general opinion here in ADHD stimulants? I found them very helpful before I came off Effexor and had w/d. Afterwards they just made me feel depressed and weird.

 

Although, I find it highly ironic that I was able to quit the "controlled drug" fairly easily. But the "safe" Effexor caused serious problems.

[Barbarannamated]

What is the general opinion here in ADHD stimulants? I found them very helpful before I came off Effexor and had w/d. Afterwards they just made me feel depressed and weird.

Although, I find it highly ironic that I was able to quit the "controlled drug" fairly easily. But the "safe" Effexor caused serious problems.

 

I went thru 15 years of "antidepressants" (SS/NRIs, antipsychotics, lithium, you name it) with absolutely no improvement, just one drug after another. My pdoc finally tried Vyvanse and it snapped me out of "depression" and apathy almost overnite. Other stims/amphetamines/dopamine agonists did not, even Dexedrine, which is very structurally similar. It did not give me energy as much as stopped my ruminating and perseverating and helped me see forward.

 

I have run out of Vyvanse off and on and crash after a few weeks. Very few docs are willing to prescribe because of the Schedule II/"Addiction potential". HIGHLY IRONIC, agreed. Also, highly ironic that I (and others) have expressed similar about "addictive" opiates - less problematic to DC than "nonaddictive" SS/NRIs.

 

I agree that the withdrawal is very linear and expected, unlike the bizarreness of Pristiq withdrawal.

 

I think the Vyvanse counteracted the depressogenic effect that serotonin had on me. An "upper" to offset the "downers".

[Skyler]

I have run out of Vyvanse off and on and crash after a few weeks. Very few docs are willing to prescribe because of the Schedule II/"Addiction potential". HIGHLY IRONIC, agreed. Also, highly ironic that I (and others) have expressed similar about "addictive" opiates - less problematic to DC than "nonaddictive" SS/NRIs.

 

I agree that the withdrawal is very linear and expected, unlike the bizarreness of Pristiq withdrawal.

 

I think the Vyvanse counteracted the depressogenic effect that serotonin had on me. An "upper" to offset the "downers".

 

Barb, this is just a thought, and perhaps impractical. But I am sharing the experience My PC is a geriatrician and hospice doc. Because he is hospice he is not as fearful of the authorities looking over his shoulder re prescriptions. He has had me on opioids and diazepam to name a couple. I've never had a problem getting a reasonable script. ?? ~S

[Barbarannamated]

Barb, this is just a thought, and perhaps impractical. But I am sharing the experience My PC is a geriatrician and hospice doc. Because he is hospice he is not as fearful of the authorities looking over his shoulder re prescriptions. He has had me on opioids and diazepam to name a couple. I've never had a problem getting a reasonable script. ?? ~S

 

Interesting point. Dopamine agonists are being studied and used to counteract low mood/energy in the sick and elderly. I will keep that in mind.

 

Ive also found Work Comp/OccMed/Industrial Medicine docs to be more open and accustomed to writing for opiates because they treat so many injuries and chronic pain.

[Altostrata]

Merged topics, all commentary is now in one place.

[Barbarannamated]

Bumping this.  It is the discussion related to off-topic discussion I just commented on.