The Mystery of When to Stop Antidepressants | Hacker News Reader

The Mystery of When to Stop Antidepressants

wsj.com

67 pointsJasamba69 comments

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they are at best minimally effective relative to placebo) and what relapse rates suggest (that people relapse when withdrawn from antidepressants because the antidepressant was effectively treating the underlying depression).

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

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

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

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

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

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

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

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

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

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

A lot of people take them to a compounding pharmacy and have a solution made out of them, making it easier to measure specific amounts.

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

No I don't want to taper down. I've tried that and decided that it's not worth it for me. I'll probably take them till the day I die. There's almost no side effects and I function so much better on them. Why stop?

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

Why does the error margin only apply to generic medicines? Surely all pills have the same manufacturing issues and legal tolerances?

Presumably because patented drugs don't have any bioequivalent drugs to compare to and the margin of error is based off of how different the generic is from the original. Originals do have stricter regulations on the amounts of inactive fillers used though.

> Most regulators worldwide have decided that a 20% variation is generally not clinically significant.

>Two versions of a drug are generally said to be bioequivalent if the 90% confidence intervals for the ratios of the geometric means (brand vs. generic) of the AUC and Cmax fall within 80% and 125%. The tmax (brand vs. generic) must also be comparable — and there should not be any significant differences between different patients.

[1]https://www.sciencebasedmedicine.org/generic-drugs-are-they-...

[2](cmax, auc, graph comparison) http://www.bpac.org.nz/BPJ/2007/March/bioequiv.aspx

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

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

Too late to edit, but I'm definitely only speaking for my personal experience. You're absolutely right.

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

Habit forming - addiction - tends to include tolerance (doesn't exist for anti depressants), pre-occupation (doesn't exist), drug seeking and holding (doesn't exist).

There are problems with anti depressants being over prescribed and misprescribed to people who should have had a talking therapy, and they are difficult for some people to stop, but calling them hanit forming is incorrect.

Wouldn't the withdrawls qualify them as habit forming? Calling them extremely addicting would probably be inaccurate, but "There's a good chance you'll feel awful if you stop taking this" seems like it may encourage forming a habit.

Apparently there may be tolerance for antidepressants: https://en.wikipedia.org/wiki/Antidepressant_treatment_tachy...

>ADT tachyphylaxis incorporates drug sensitivity as a potential causal factor for the decreased response. However, tolerance provides a more accurate explanation. While the exact cause of ADT tachyphylaxis in individual cases is unknown, drug tolerance is a more comprehensive model, as it includes mechanisms of pharmacodynamic tolerance, metabolic tolerance, and others.[7]

There is a difference between 'addiction' and 'physical dependence'.

See: https://www.drugabuse.gov/publications/teaching-packets/neur...

Sure, but 'habit forming' is a lower bar to cross than either.

You're right, probably "addictive" was the wrong word. "Physical dependency forming" perhaps is better.

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

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

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

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

> Interesting customer retention scheme Big Pharma has come up with.

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

Just like vendor lock-in is good for business.

Keeping the customer addicted is good for business.

Lot of SSRIs are generic and cheap these days.

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

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

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

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

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

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

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

> Anxiety, ideally they lighten up and give you a benzodiazepine,

I was on ativan for anxiety a couple years back, and jesus if you thought ssri withdrawls were tough, don't try getting off benzos.

the dx doesn't always match the rx, illicit or licit. seems logical that anxiety = not stimulants...

but it depends on the underlying cause of the anxiety, sometimes uppers is just what the doctor called for

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

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

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

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

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

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

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

Someone I know who took it said they got what they could only describe as "head shocks" - the effect of small pulses of electricity flowing through their brain during withdrawal.

Ah yes, those jolts of electricity. I got those for a month after escitalopram.

I got these when I first began taking antidepressants with fluoxetine/Prozac, never felt myself for a very long time afterwards.

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

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

10% of the us population on antidepressants, even 1% is 350,000 people...

According to this [1] about 12 million people have a thyroid problem and don't know it. (maybe a bad source?)

Given there's no test for depression, and it's a pretty unreliable judgement call [2], it's a pretty reasonable claim.

[1] http://www.thyroid.org/media-main/about-hypothyroidism/ [2] http://www.medscape.com/viewarticle/706714

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

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

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

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

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

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

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

It was/is a combination of a couple MTHFR gene mutations and black mold exposure. The mutations make it more difficult for the body to process mycotoxins, and those started messing with her nervous and endocrine systems.

The misdiagnosis happened because there were some similar symptoms to depression. (She was very tired, but could never sleep. Dark moods, but in hindsight that was mostly because she felt crappy.) The doctor had no idea and she was willing to try anything to feel better, but SSRI's never really helped.

>The doctor had no idea and she was willing to try anything to feel better, but SSRI's never really helped.

I just found out last year that i have a MTHFR mutation myself and this pretty much sums up my life up until then. Doctors, psychs had no idea and I tried so many pharmaceutical combinations.

I also had an underlying thyroid issue. I do wish testing for MTHFR gene defects and looking at thyroid performance were more common steps to take before psychiatric medications are prescribed.

I am considering getting some check-up on the thyroid. It's really easier to get some anti-depressants from a GP than getting this checked and it's not normal considering my generation had the Chernobyl cloud over our collective head in our childhood.

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

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

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

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

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

I've heard that the human animal evolved to walk/run 12 miles per day, and that some people suspect that our sedentary lives are at the root of all sorts of mental and cognitive issues.

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

Yeah, I had to. The doc I was seeing at that time diagnosed me with bipolar disorder and discontinued all anti-depressants.

I'm no judge, and I believe medical science is tough. But there's no real empirical evidence. So anyways, me going back to the 10 mg escitalopram kind of helped.

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

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

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

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

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

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

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

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

side effects.

Fair enough, I've been lucky. The only side-effect I've noticed over long-term use is a slight dullness. Some people suffer all kinds of weirdness.

The worst luck is experiencing side effects/personality change from the meds, but not being able to notice them _because_ of the medication.

May try reducing the dose without going off? Sure things will be a little bit wilder, but there's non-drug therapy (exercise, CBT, etc)

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

Same.

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

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

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

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

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

- Taper down and cease medication

- Reduce medication dose and supplement with behavioral therapy

- Stay on the current dose

- Increase dose if your symptoms worsen

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

Anyone know how to get around the paywall?

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

I was totally unable to bypass it as well.

Same here. Tried Chrome and FF in regular mode, all extensions off.

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

This seemed to work for me:

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

(changing the user-agent slightly on each attempt)

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

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

That worked. Thank you!

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