NY Times article about Lancet tapering study: How to Quit Antidepressants: Very Slowly, Doctors Say

[Henosis]

https://www.nytimes.com/2019/03/05/health/depression-withdrawal-drugs.html

[WiggleIt]

Was just going to post this!

[Altostrata]

A major breakthrough. I am proud to report Why taper? SERT transporter occupancy studies show importance of gradual change in plasma concentration  and other tapering discussions informed Dr. Horowitz's thinking.

 

Quote

How to Quit Antidepressants: Very Slowly, Doctors Say.

By Benedict Cary March 5, 2019

Thousands, perhaps millions, of people who try to quit antidepressant drugs experience stinging withdrawal symptoms that last for months to years: insomnia, surges of anxiety, even so-called brain zaps, sensations of electric shock in the brain.

But doctors have dismissed or downplayed such symptoms, often attributing them to the recurrence of underlying mood problems.

The striking contrast between the patients’ experience and their doctors’ judgment has stirred heated debate in Britain, where last year the president of the Royal College of Psychiatrists publicly denied claims of lasting withdrawal in “the vast majority of patients.”

Patient-advocacy groups demanded a public retraction; psychiatrists, in the United States and abroad, came to the defense of the Royal College. Now, a pair of prominent British psychiatric researchers has broken ranks, calling the establishment’s position badly mistaken and the standard advice on withdrawal woefully inadequate.

In a paper published Tuesday in Lancet Psychiatry, the authors argued that any responsible withdrawal regimen should have the patient tapering off medication over months or even years, depending on the individual, and not over four weeks, the boilerplate advice.

The paper is by far the strongest research-backed denunciation of standard tapering practice by members of the profession.

“I know people who stop suddenly and get no side effects,” said Dr. Mark Horowitz, a clinical research fellow at Britain’s National Health Service and University College London, and one of the paper’s authors.

But many people, he said, “have to pull apart their capsules and reduce the dosage bead by bead. We provided the science to back up what they’re already doing.”

The field of psychiatry has conducted few rigorous studies of antidepressant withdrawal, despite the fact that long-term prescription rates in the United States and Britain have doubled over the past decade, with similar trends in other Western countries.

More than 15 million Americans have taken the medications for at least five years, a rate that has almost more than tripled since 2000, according to a New York Times analysis of federal data.

Outside researchers who have studied withdrawal said the new paper was a welcome contribution. “I think what they’ve presented really reinforces what I’ve observed in clinical practice in many patients, and it’s almost identical to the tapering regimen I use,” said Dr. Dee Mangin, the chair of family medicine at McMaster University in Canada, who was not involved in the paper.

Dr. Mangin, who is completing her own two-year study of Prozac withdrawal, added, “The other important thing is that it validates patients’ own reports of their experiences. It’s tremendously frustrating when patients describe a different experience than physicians expect, and don’t feel they’re being heard.”

Dr. Horowitz and his co-author, Dr. David Taylor, a professor of psychopharmacology at King’s College London and a member of the South London and Maudsley N.H.S. Foundation Trust, decided to address the topic in part because of their own experiences with medication.

Dr. Horowitz said he had severe withdrawal symptoms after tapering down after 15 years on antidepressants. Dr. Taylor had previously written about his own struggles trying to taper off.

The two researchers began by visiting online forums in which people on antidepressants advised one another how best to withdraw. Those sites consistently recommended “micro-dosing,” reducing doses by ever smaller amounts over months or years, sometimes by removing one bead at a time from capsules.

The two researchers dug into the literature and found a handful of studies that provided evidence for that method.

In one 2010 study cited in the new paper, Japanese researchers found that 78 percent of people trying to taper off Paxil suffered severe withdrawal symptoms. The research team had them taper much more slowly, over an average of nine months and for as long as four years. With this regimen, only 6 percent of subjects experienced withdrawal.

In another study, Dutch researchers in 2018 found that 70 percent of people who’d had trouble giving up Paxil or Effexor quit their prescriptions safely by following an extended tapering regimen, reducing their dosage by smaller and smaller increments, down to one-fortieth of the original amount. This is the regimen recommended in the new paper.

Dr. Horowitz and Dr. Taylor also cited brain-imaging evidence. ....

But the brain-imaging studies found that inhibition of the transporter increases sharply with addition of the drug and, by extension, also drops sharply with any reduction in dosage. The standard medical advice, to reduce dosage by half — for instance, by taking a pill every other day — and end medication entirely after four weeks, does not take this into account, the two researchers argued.

“Doctors have in mind that these drugs act in a linear way, that when you reduce dosage by half, it reduces the effect in the brain by a half,” Dr. Horowitz said. “It doesn’t work that way. And as a result, there’s a huge load in terms of the effect on brain receptors, and patients are being advised to come off way too quickly.”

....

Dr. Horowitz and Dr. Taylor called for more, and more careful, research to be done on withdrawal, to bring their field up to speed, and to develop withdrawal strategies tailored to individual patients and individual drugs.

“I think psychiatrists are taught to learn things from textbooks and from well-conducted studies,” Dr. Horowitz said. “We don’t have many of those for withdrawal, so it makes it hard to believe it’s real. And psychiatrists spend a lot more time prescribing things than stopping them.”

 

 

 

[Altostrata]

To Benedict Carey. with whom I have corresponded before:

 

Quote

 

Thanks for your recent articles, Ben, and your just-published How to Quit Antidepressants: Very Slowly, Doctors Say.

 

Dr. Horowitz, with whom I have been in correspondence for months, found the SERT transporter discussion on my Web site https://www.survivingantidepressants.org/topic/6036-why-taper-sert-transporter-occupancy-studies-show-importance-of-gradual-change-in-plasma-concentration/ and other papers, including Murata, 2010 in our Journals collection

We also have detailed topics on gradual tapering, including the Why taper by 10% of my dosage? (a schedule of exponential decay, as proposed by Drs. Horowitz and Taylor), see https://www.survivingantidepressants.org/topic/300-important-topics-in-the-tapering-forum-and-faq/

 

Please note that this gradual taper schedule is not “micro-dosing” as mentioned in your article — micro-dosing is reinstating a very tiny amount should withdrawal symptoms arise after going off the drug.

 

I believe the term you were looking for is “micro-tapering,” see https://www.survivingantidepressants.org/topic/2878-micro-taper-instead-of-10-or-5-decreases/

Given the haphazard tapering methods used commonly in psychiatry, a taper of 10% per month (amount of reduction calculated on the last dosage) might seem like “micro-tapering,” in fact some people cannot tolerate even that rate of reduction and need to taper by even less than 10% at a time. That is true micro-tapering.

 

The implications of the necessity to very gradually taper go far beyond correcting the risk-benefit assessment for antidepressants. Almost invariably, withdrawal symptoms are misdiagnosed as relapse or emergence of a psychiatric disorder and re-medicated, often with higher dosages and exotic drug combinations, with poor results. The person is deemed “treatment-resistant” as a result of iatrogenic injury.

 

Many, many people believe they have a chronic psychiatric disorder because they cannot go off drugs without terrible symptoms. Misdiagnosed withdrawal syndrome may underlie the majority of “treatment-resistant” and even “bipolar II” diagnoses, with unnecessary treatment and adverse effects that destroy lives.

 

Given the millions on psychiatric drug merry-go-rounds, this is a not insignificant addition to the world’s burden of sorrows.

 

Please note that patient experience on SurvivingAntidepressants.org also has informed Dr. Peter C. Groot’s papers and his Cinderella tapering strips project — and other scholarly articles. Laura Delano repackaged much of the content for The Withdrawal Project from SurvivingAntidepressants.org (without authorization).

 

Given that I’ve worked so hard on this for 15 years, I am so happy that medicine might finally take responsibility for properly tapering people off psychiatric drugs. Given a recalculated risk-benefit profile — the drugs have long been held to have very rare and minor side effects — maybe it will be even more conservative in diagnosis and prescribing.

 

Now that people can shoot psychedelics up their noses, maybe the medieval days of the blunt instruments like SSRIs are over.

 

We can only hope.

 

Regards,
Altostrata
SurvivingAntidepressants.org

 

 

[thecowisback]

it's good that this is finally getting into the mainstream media 👌

[Nadia]

I was so thrilled to see this article this morning! Alto, congrats on all your hard work (acknowledged and credited or not) on this. I cried at the sentence that said stinging withdrawal symptoms that last for months to YEARS. It was so unbelievably frustrating and lonely to go through this with zero support from doctors (thank you Alto for this site or I have no idea what I would have done). The last doctor I mentioned what I went through still categorically denied my experience within seconds without hearing  me out. This kind of article could help move mountains and make for a better experience for everyone to come.

[Altostrata]

You're welcome, Nadia. Good to hear from you!

[marconyc]

The psychiatric community should be ashamed. So glad this article came out. 

[marconyc]

Thank you @Altostrata and the other mods for this site. The way that shrinks have dismissed patient reports of withdrawal has done an incredible amount of damage. Your work has helped people survive.

[Bee5]

I too, was thrilled to read this, the message is finally getting out! @Altostrata, have you considered going on to Twitter?

[Andie]

Thank you Alto. Your website definitley helped prevent any further damage to my nervous system after many years of trials and tribulations trying to come off Pristiq. 

[JackieDecides]

10 hours ago, marconyc said:

Thank you @Altostrata and the other mods for this site. The way that shrinks have dismissed patient reports of withdrawal has done an incredible amount of damage. Your work has helped people survive.

 

this ^

[lavendertealatte]

My friend sent me this too!  At first  thought it was going to be something old but I was surprised to see it was a really recent article and it was the NYTimes!  I'm so glad this is finally getting out into mainstream!

[Altostrata]

Thanks, everyone.

 

I've spent a lot of time on Twitter but didn't find it very productive.

[marie123]

The first thing my husband did when he came home last night was show me this NYT article on his IPAD. The first NYT article from last year he read also but did still did not believe me that w/d could take so long. After this one he finally believes me --- but it took four years. I could get angry if I let myself, but I have better things to do.

 

Thanks for posting the article.

 

Marie

 

 

 

 

 

 

 

D

[ghm2018]

This is great news and thank you, @Altostrata for your hard work and efforts. Are there any similar articles or research related to adverse reactions such as what many of the other members here are experiencing, such as myself, or have experienced?  Just curious. 

[Altostrata]

We have a forum full of journal articles about adverse reactions and other aspects of psychiatric drugs.

[FleeingFluoxetine]

I was going to post the NYT article but I’m glad to find it here. Thank you @Altostrata for all the work you have done. My friends and family didn’t believe me about the meds until I found this site. ❤️

[India]

I have just finished reading the media articles report on this and I too felt elated. So many need this “breakthrough”. It feels like collateral. @marie123 I also started visualising sending this to various people who I suspect don’t subscribe to the gravity of the WD or believe it just “stress”. I am glad it has come from the inner circle so to speak. Happy for that to add credance. I hope to get a wave in order that I might read through the full journal article. 

I hope this breakthrough is exponential. A result of all the work of those who came before. Thanks to this site. Thanks to Altostrata!

 

Also, the experience of having ones reality denied by the medical community  is surely a variable in WD. A huge underlying stress that impacts on healing. I felt that terror everyday, knowing that i could easily fall down the rabbit hole of diagnosis. I obsessed regularly over this fear. Like many, staying away from doctors and terrified they may lose their credibility. Imagine feeling safe enough to discuss withdrawal issues with your doctor knowing you will be aided and helped. 

[marie123]

India I have found that I can only count on myself (and everyone here on the forum) to believe in withdrawal. I do not discuss my experience with my doctor, but have hinted about it here and there. I just tell him I'm sensitive and need to taper slowly. I have said that there are others like me who are also this sensitive. You know the doctor writes notes as you talk to him/her. I don't want any erroneous comments written down about me. As long as he continued to write the scripts is all I cared about. I am hoping one day he will have an "Ah hah" moment. I've stopped telling friends because I hear their silence and see the looks. I do not care anymore if anyone believes in long withdrawals. You just have to be a strong person and have your beliefs that you are in the know and right about withdrawal. We are the smartest people about withdrawal after all.

 

Marie

[Andie]

A psychiatrist says there is no “boilerplate advice” to give patients.

https://www.nytimes.com/2019/03/15/opinion/letters/antidepressants-psychiatry.amp.html

Edited March 18, 2019 by Altostrata
merged similar topics

[DrugfreeProf]

Any chance you could cut and paste the entire article, Andie? Some people won't be able to access articles due to the NYT paywall.  Thank you. Looks like a good one!

[ChessieCat]

17 hours ago, DrugfreeProf said:

Any chance you could cut and paste the entire article, Andie? Some people won't be able to access articles due to the NYT paywall.  Thank you. Looks like a good one!

 

If it has to be paid to view the article then posting it in full may breach copyright.

 

Please refer to this topic:  copyright-and-fair-use

[JB1234]

Hi just read this one tonight. Looking for support on dealing with the strange discontinuation symptoms. Celexa from 40mg to 6 mg in 8 months time period.

 

MOD NOTE:  I have been in contact with this member and JB will create an Intro when he is able to.

 

 

 

Edited March 21, 2019 by ChessieCat
added mod note

[DrugfreeProf]

NYT typically allows you a certain number of free articles per month. Not sure of the copyright implications of that one!

[Altostrata]

It's a letter to the editor, and says nothing about how to taper. Surprised they even gave it space.

 

@Andie @Henosis always helpful for conversation to post a selection from the article but not the entire article, see Copyright and fair use

 

Quote

 

....

As a psychiatrist who has been prescribing antidepressants for more than 35 years, I have observed a problem with tapering off antidepressants with resultant withdrawal symptoms in a small but important group of patients. I have come to learn that there is no “boilerplate advice” to give to patients.

 

In determining the safest and most effective way to taper down antidepressants, we must focus on the individual. Just as patients differ on the necessary dose and time schedule of increasing the dose of antidepressants to elicit a clinical response, they also differ on the necessary schedule of reducing and stopping their medication.

....

Peter Kudler
New York

 

[Kristine]

Interview with Dr Mark Horowitz on ' Mad in America' regarding his recent paper published in 'The Lancet' and his own battle with WD from an antidepressant. He mentions Altostrata and SA as an invaluable resource. Bravo https://www.madinamerica.com/2019/03/peer-support-groups-right-official-guidelines-wrong-dr-mark-horowitz-tapering-off-antidepressants/ 

 

[Kris73]

NY times article here is unfortunately behind a paywall.... does anyone have a copy to access without this?

Thanks in advance anyone who can help🙂

[FleeingFluoxetine]

 

[FleeingFluoxetine]

Bah. I’ll try copy and paste. 

How to Quit Antidepressants: Very Slowly, Doctors Say

Mustering solid evidence, two researchers have denounced the standard psychiatric guidelines for how best to wean patients from depression medications.

Patients who very gradually reduced their daily dose of antidepressants over time, after years of use, were less likely to experience withdrawal symptoms.Credit...Joe Raedle/Getty Images

By Benedict Carey

March 5, 2019

Thousands, perhaps millions, of people who try to quit antidepressant drugs experience stinging withdrawal symptoms that last for months to years: insomnia, surges of anxiety, even so-called brain zaps, sensations of electric shock in the brain. 

But doctors have dismissed or downplayed such symptoms, often attributing them to the recurrence of underlying mood problems.

The striking contrast between the patients’ experience and their doctors’ judgment has stirred heated debate in Britain, where last year the president of the Royal College of Psychiatrists publicly denied claims of lasting withdrawal in “the vast majority of patients.” 

Patient-advocacy groups demanded a public retraction; psychiatrists, in the United States and abroad, came to the defense of the Royal College. Now, a pair of prominent British psychiatric researchers has broken ranks, calling the establishment’s position badly mistaken and the standard advice on withdrawal woefully inadequate. 

 

In a paper published Tuesday in Lancet Psychiatry, the authors argued that any responsible withdrawal regimen should have the patient tapering off medication over months or even years, depending on the individual, and not over four weeks, the boilerplate advice.

The paper is by far the strongest research-backed denunciation of standard tapering practice by members of the profession.

“I know people who stop suddenly and get no side effects,” said Dr. Mark Horowitz, a clinical research fellow at Britain’s National Health Service and University College London, and one of the paper’s authors. 

But many people, he said, “have to pull apart their capsules and reduce the dosage bead by bead. We provided the science to back up what they’re already doing.”

The field of psychiatry has conducted few rigorous studies of antidepressant withdrawal, despite the fact that long-term prescription rates in the United States and Britain have doubled over the past decade, with similar trends in other Western countries.

More than 15 million Americans have taken the medications for at least five years, a rate that has almost more than tripled since 2000, according to a New York Times analysis of federal data.

Outside researchers who have studied withdrawal said the new paper was a welcome contribution. “I think what they’ve presented really reinforces what I’ve observed in clinical practice in many patients, and it’s almost identical to the tapering regimen I use,” said Dr. Dee Mangin, the chair of family medicine at McMaster University in Canada, who was not involved in the paper.

Dr. Mangin, who is completing her own two-year study of Prozac withdrawal, added, “The other important thing is that it validates patients’ own reports of their experiences. It’s tremendously frustrating when patients describe a different experience than physicians expect, and don’t feel they’re being heard.”

Dr. Horowitz and his co-author, Dr. David Taylor, a professor of psychopharmacology at King’s College London and a member of the South London and Maudsley N.H.S. Foundation Trust, decided to address the topic in part because of their own experiences with medication. 

Dr. Horowitz said he had severe withdrawal symptoms after tapering down after 15 years on antidepressants. Dr. Taylor had previously written about his own struggles trying to taper off.

The two researchers began by visiting online forums in which people on antidepressants advised one another how best to withdraw. Those sites consistently recommended “micro-dosing,” reducing doses by ever smaller amounts over months or years, sometimes by removing one bead at a time from capsules.

The two researchers dug into the literature and found a handful of studies that provided evidence for that method.

In one 2010 study cited in the new paper, Japanese researchers found that 78 percent of people trying to taper off Paxil suffered severe withdrawal symptoms. The research team had them taper much more slowly, over an average of nine months and for as long as four years. With this regimen, only 6 percent of subjects experienced withdrawal.

In another study, Dutch researchers in 2018 found that 70 percent of people who’d had trouble giving up Paxil or Effexor quit their prescriptions safely by following an extended tapering regimen, reducing their dosage by smaller and smaller increments, down to one-fortieth of the original amount. This is the regimen recommended in the new paper.

Dr. Horowitz and Dr. Taylor also cited brain-imaging evidence. Antidepressants such as Paxil, Zoloft and Effexor work in part by blocking the serotonin transporter, a molecule that works in the synapses between brain cells to clear out the chemical serotonin, which is thought to help impart a sense of well-being in some people. By blocking the transporter, antidepressants prolong and enhance serotonin’s effects. 

But the brain-imaging studies found that inhibition of the transporter increases sharply with addition of the drug and, by extension, also drops sharply with any reduction in dosage. The standard medical advice, to reduce dosage by half — for instance, by taking a pill every other day — and end medication entirely after four weeks, does not take this into account, the two researchers argued.

“Doctors have in mind that these drugs act in a linear way, that when you reduce dosage by half, it reduces the effect in the brain by a half,” Dr. Horowitz said. “It doesn’t work that way. And as a result, there’s a huge load in terms of the effect on brain receptors, and patients are being advised to come off way too quickly.”

Laura Delano, executive director of Inner Compass Initiative, a nonprofit organization that runs The Withdrawal Project and focuses on helping people learn about safer psychiatric drug tapering, said: “I didn’t know about the benefits of slow tapering when I came off five meds in five months, and had a very difficult time in withdrawal.”

The new paper, she added, “speaks to how hard it is to get this information into the clinical world. We laypeople have been saying this for a long time, and it’s telling that it took psychiatrists coming off meds themselves for this information to finally be heard.”

Dr. Horowitz and Dr. Taylor called for more, and more careful, research to be done on withdrawal, to bring their field up to speed, and to develop withdrawal strategies tailored to individual patients and individual drugs.

“I think psychiatrists are taught to learn things from textbooks and from well-conducted studies,” Dr. Horowitz said. “We don’t have many of those for withdrawal, so it makes it hard to believe it’s real. And psychiatrists spend a lot more time prescribing things than stopping them.”

[Kris73]

Many thanks @FleeingFluoxetine, it's greatly appreciated🙏

[FleeingFluoxetine]

My pleasure. You’re welcome. 😁

[GrievingFirefly]

Is there any data from Mark Horowitz' research about how being on SSRIs for two decades or more affects rate of long term success being off meds even after long-term tapering?