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Comment by thowaway91234 | Hacker News Reader

I recently was forced off of SSRIs after nearly ten years because I lost my psychiatrist and couldn't get a new one because the waitlists were ridiculous.

After 10 years on them, the next 6 months were absolute hell (i legit thought at one point I might go full Joaquin Phoenix in Joker) but I made it through, no small part thanks to my wonderful amazing wife.

Rebound depression have been an issue - though in general I feel like I am much better off without the antidepressants now than with them - and I've also noticed that pulling an all nighter would actually fix the rebounds for a bit. A small dose of melatonin before bed worked wonders for me now. I sleep better and the rebounds are extremely rare.

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Just a side note for anyone reading: you can get an SSRI prescription from your GP (general practitioner i.e. normal doctor) you don’t need to go through a psychiatrist.

This is especially true if you are at risk for withdrawal, they will want to prevent that.

any medical doctor of any specialization can legally prescribe anything. that doesn't make it a good idea. a piece of supporting evidence is that the doctor's malpractice insurance may not cover any "cowboy" prescribing tendencies.

GPs routinely prescribe SSRIs. Even pediatricians. At least in the US.

A lot of non-psychiatrist doctors prescribe SSRIs around the world, and that's a very good thing. These drugs are safe.

Agreed.

Please don’t make such blanket statements. They can have many harmful side effects, including sexual dysfunction.

I think OP meant to say, these are not drugs is not something you can OD with easily and kill yourself, not that they are side effect free .

In many cases they have induced suicide. There are many ways something can be unsafe.

There are many ways to regulate too. SSRIs are not OTC for the same reason.

There are many drugs a GP can prescribe that are just as dangerous or more so.

There is a reason SSRI are schedule 4 and not schedule 2 . They cannot kill you the same way [1]

---

[1] While there is a lot of politics in the classification and putting weed or LSD in schedule 1 is very questionable the list is generally medically accurate.

That’s fair. But I’ll note that the “General” in “General Practitioner” means they specialize in the wide range of health problems that occur frequently in the general population. That includes things like depression, anxiety, ADHD, etc.

I wouldn’t advocate you get a prescription for antipsychotics from your orthopedist, but SSRIs from a GP is probably pretty safe.

Obviously, it depends on the doctor and the symptoms. But a good GP will also refer you out to a specialist when needed. That’s a big part of their job: assessing when to call in a specialist.

As other comments said, GPs routinely prescribe SSRIs. Moreover, it's not remotely cowboy to ensure continuity of care arising from exigent circumstances.

I didn't say it was "cowboy" which I put in quotes and you didn't, I simply said what I said, that insurers can put restrictions on doctors based on their specialties (true fact), that you (as a doctor) fear your insurer considering you to be a cowboy (also a true fact). Malpractice is something to worry about, including whoever educated you :) to look for the worst possible interpretation of what somebody says.

If all you need is a refill on a prescription you’ve been taking for 10 years, how is that “cowboy” prescribing? Also, these are trained professionals with years of education we’re talking about, not some random dude off the street.

anti depressants (and other drugs) have side effects, both in the short term and the long. Patients who want drugs may lie. Trained professionals, yes exactly, but need to have practical experience in an area of medicine to be an effective advocate for the patient.

I can't even believe I'm having to defend this position in front of this crowd, but now many GP's dismissed the symptoms of women's post-partum depression before it become a topic of mainstream discussion on television talk shows? Doctors are not perfect and are not free from various biases, and having had experience with your particular condition is invaluable to you.

> but now many GP's dismissed the symptoms of women's post-partum depression

Weird example given you're arguing against GPs prescribing antidepressants because patients may lie.

And I'd like to see someone lying to get SSRIs out of all the possible choices.

I'm arguing that in the US doctors can prescribe all medications regardless of their specialty (because it's true) and that it's not always a good idea, for example if the doctor is not familiar with recognizing the side effects which are outside of his specialty. (because that's also true) Your shrink is not going to prescribe you statins, as an example, but they could. It's important for a GP to recognize depression, but that doesn't mean they should treat depression, just as they should not give you a heart transplant.

You're arguing like something as at stake for you or you have bone to pick, I'm saying very generic anodyne things, i'm arguing for sober reasonableness.

In the US it’s common for a GP to prescribe SSRI’s. https://bmcprimcare.biomedcentral.com/articles/10.1186/s1287...

More broadly, in rural settings specialists are often impractical to access. So, the best possible standard of care is effectively off the table.

We are talking about SSRIs here, not highly addictive substances. They're among the most prescribed drugs worldwide, I can guarantee you a GP knows very well how they work. Comparing that to a heart transplant is absurd.

> I'm saying very generic anodyne things, i'm arguing for sober reasonableness

You're saying vague things that are roughly as controversial as "water is wet" when read literally, but are out of place and tone-deaf in the context of above discussion.

This is one topic that used to surprise me but I learned better. Hackernews readers seem to be a higher percentage than typical on SSRIs. That and I think we have no idea just how many people are really on them.

This works unless you GP is a huge jerkface in which case find a new one.

Just be honest: tell your GP that your previous provider quit/retired/changed insurance. Bring your prior RX bottles or paperwork. Let them know you have an appointment with your new provider on X date and ask them to cover you until then.

I've done this when changing insurance (twice) and when moving states (New provider had a waitlist. First time she wrote one month then when I reported the waitlist situation she ended up covering it for 3-4 months).

People in Canada aren't allowed to "find a new one".

My parents live on a fairly highly populated island, and the only doctor decided to leave. No new one is allowed to move in to serve the population until the government gets around to setting that up. It will probably be a year or more of thousands of elderly people having no medical care at all.

I explained on the phone that in the US, this demand and lack of supply would quickly sort itself out by someone moving in and setting up. Being a certified MD in the state is all they'd need. This was mind-blowing to my socialized-medicine parents.

I tried this once, Family Doctor actually ended up giving me a dose that was twice the maximum anyone is ever supposed to take. Thankfully the Pharmacist told me that was an extremely bad idea and he just gave me my normal dose and I continued on for a bit.

After that was when I ended up cold turkey because I lost my doctor and psychiatrists during a big move and couldn't get a refill at any clinic in the new town.

It ended up working out, but it took about a year of absolute torture and probably about another year of just "weirdness". But these days I'm "normal" and off the drugs and never been happier.

Those drugs you used contains benzodiazepine [1]. It's addictive and if used long, do more harm than helping. I'm glad you get rid of it.

[1] https://en.m.wikipedia.org/wiki/Benzodiazepine

Why would you think they're taking benzos on a thread about SSRIs?

Benzos and SSRIs are different things. The former is a CNS depressant that acts instantly. The latter builds up in your system over a month to increase the seretonin levels in your brain. They’re not really related except that someone with, e.g., anxiety might be prescribed both

Thankfully I wasn’t on Benzos, but my mother has been and they definitey can do a lot more harm than good.

2 years of recovery just sounds scary

At the time, very. In hindsight, nearly 10 years of being numb to the world was worse.

In Australia it’s standard for a GP to prescribe SSRIs.

Indeed, and this easy availability is potentially a double edged sword.

My pharmacist can even prescribe a month’s supply if I’m running out. Stopping an SSRI cold turkey is a really bad idea.

Definitely a very bad idea. The first 2 or so weeks felt euphoric to me but after that it was pure hell for months and months.

> would actually fix the rebounds for a bit.

I can't prove it, but even dumb teenage me felt instinctively that extreme sleep deprivation was likely to take a long and possibly permanent toll. I don't think anything that extreme can really be practiced in moderation, because it's more like taking heroin than eating too many cakes, etc., i.e., it's not a 'granular' indulgence.

I would hesitate to call this a hot take on my part, since I am guessing that in that period of my life, I probably stayed up for two days on several hundred occasions, if not more.

For anyone else suffering from severe depression, this is an easy answer, maybe; but there are better easy answers than this. Cannabis (I am not a partaker since I was an student) would be better than this.

Really, do anything but this. It's not 'free'; nothing that works is free.

Sometimes I wish I wasn't so cynical, but I've suspected that SSRIs are a preferred treatment because it is almost impossible to get off of them. They say "It can take up to a month for it to work" is just a way to make sure dependency is strong enough by that point to make withdrawal unbearable. Many people don't fully understand the concept of withdrawal or chemical dependency, and will think the "medicine" works because they feel awful without it.

I mean, obviously removing a serotoninergic med will change your homeostasis.

The real reason SSRIs are so popular is that they work (not always, but often to some extent) and for depression it's much cheaper to make a pill than book a therapists time

Well no, SSRIs (essentially) work by becoming tolerant to their effects, which takes 3 weeks to 3 months. It's not a conspiracy, it's just how they work.

They're a preferred treatment because they're usually effective and they're far safer than other medication classes for depression.

Interestingly enough, SSRIs are only slightly but statistically significantly better than active placebos. While early trials showed a big difference between antidepressants and placebos, more recent studies have significantly narrowed that gap. FDA data shows a reduction of symptoms of about 30% in placebo vs 40% in antidepressants. [1]

[edit] Doctors note that the difference between antidepressants and placebo isn't clinically significant. They do something, but not much which is why the revival and breakthrough drug designation of psychedelics in the treatment of - especially major - depression is so exciting.

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4592645/

Contrarians and cynics have been trying the "barely better than placebo" angle for decades, but antidepressants are indeed superior to placebo.

You can find articles and reviews that play games with statistics, cherry pick studies, and use various thresholds for effect size to try to downplay it, but they do work for a lot of people.

> While early trials showed a big difference between antidepressants and placebos, more recent studies have significantly narrowed that gap.

The part you're leaving out is that the placebo effect is quite strong in studies for depression and even pain. It's misleading to say "barely better than placebo" without explaining that placebo works quite well in those studies.

Placebo effect is also getting stronger over time: https://bigthink.com/health/placebo-effect-worse/

> Contrarians and cynics...

I don't think they're contrarians and cynics although some undoubtedly are. They seem to be study authors. The fact is treatments, even broadly used ones, aren't always super effective. Sometimes they're just the only ones we have, and we as humans have a bias towards action being over inaction in medical care.

I may be contrarian and cynical in a lot of things, but modern medicine isn't one of them. I just like to be data driven.

> ... but they do work for a lot of people.

They work for most of those people just about as well as a sugar pill would, yes. Slighly better. There's a real mismatch in terms of public perception of how much better they actually work.

> Contrarians and cynics have been trying the "barely better than placebo" angle for decades, but antidepressants are indeed superior to placebo.

The study that I linked showing the 30%-40% numbers are from FDA data. There's no games played, the study authors got the FDA data by FIOA.

The fact that placebo effect is strong doesn't really mean much other than depression is something that you can treat through things like therapy, which the data shows is exactly as effective as antidepressants. A psychosomatic angle, even if that's not the right word. The desire to heal is sufficient to change the way you think about your situation, and that exists no matter what you're taking.

If taking your conclusion to an extreme, the placebo effect was exactly as strong as an antidepressant - or stronger - why wouldn't we just prescribe sugar pills instead? In fact since the delta between SSRIs and sugar pills is clinically insignificant - while SSRIs have tons of side-effects - why wouldn't we just prescribe sugar pills now? Does that mean sugar pills are effective against depression, or are SSRIs treating depression largely through placebo?

Putting it another way, the placebo effect doesn't treat punch biopsy wounds. [1]

[1] https://pubmed.ncbi.nlm.nih.gov/30212845/

>The study that I linked showing the 30%-40% numbers are from FDA data. There's no games played, the study authors got the FDA data by FIOA.

Most people who take SSRIs and swear by them have had to try multiple of them to find one that works (usually very well) for them. A study that only looks at one drug will have a much lower rate of success than a study that looked at SSRIs as an entire class of medicine.

SSRIs replaced older-generation antidepressants because they're similarly effective and much safer - that's not to say that they don't have side-effects, but they probably won't kill you. TCAs are extremely toxic in overdose (an obvious and serious shortcoming in patients with elevated suicide risk) and MAOIs come with a really difficult set of drug-drug interactions and dietary restrictions.

We know from the data that SSRIs work about as well as psychotherapy. We also know that SSRIs and psychotherapy work considerably better than either treatment alone. SSRIs don't work nearly as well as we'd like, they can cause significant side-effects, but they do deliver very important benefits for many patients and they're an important tool in the psychiatric arsenal with no adequate substitute yet. We need more and better treatment options, but we shouldn't unfairly denigrate the treatment options we have right now.

I don't mean to diminish anyone's lived experience, but I've always been slightly sceptical of claims about withdrawal effects of antidepressants. I suffer from TRD and have withdrawn cold turkey from maximum doses of several antidepressants with no ill-effects, but I didn't get any significant benefits when I was taking those drugs. If you stop taking a drug that was effectively reducing your depressive symptoms and you feel terrible, there's a fairly obvious explanation.

I strongly agree with everything you say, but...

> but I've always been slightly sceptical of claims about withdrawal effects of antidepressants.

Even the manufacturers warn against discontinuation effects. See the "If you stop taking venlafaxine" paragraph here: https://www.medicines.org.uk/emc/product/764/pil#gref

The UK NICE has advice about stopping antidepressant meds: https://www.nice.org.uk/guidance/ng215 and the UK BNF will mention withdrawal for some meds: https://bnf.nice.org.uk/drugs/venlafaxine/#treatment-cessati...

The Royal College of Psychiatrists has advice about stopping anti-depressants: https://www.rcpsych.ac.uk/mental-health/treatments-and-wellb...

Clearly, it's not a problem that affects everybody, and it's more common with some meds than others, but that doesn't mean these effects are not real.

Sorry, in hindsight my comment was unreasonably broad and unclear.

I think it's obviously true that someone might feel anywhere from "a bit weird" to "really quite unwell" for a couple of weeks after discontinuing an antidepressant. I don't know how effective GPs are in communicating that, but you're right that it's there in the patient information leaflet.

What I don't see as particularly plausible are the extremely long withdrawal syndromes reportedly lasting many months or years, or the extremely prolonged tapering regimes that involve tiny fractional doses. I cannot conceive of any plausible biological mechanism for these symptoms, or a plausible mechanism by which a tiny fraction of a clinically relevant dose might alleviate them. Prolonged post-withdrawal effects are reasonably common with GABAergic drugs, but the mechanism and mode of action of these drugs is radically different.

If someone has been taking 20mg of escitalopram, it's perfectly sensible to step down to 10mg and perhaps 5mg over a few weeks to allow their serotonin system to upregulate without too much drama. If they're a year down the line, they're taking 0.2mg and they feel suicidal if they miss a dose, I don't think there's a biochemical explanation for their symptoms.

> Sometimes I wish I wasn't so cynical, but I've suspected that SSRIs are a preferred treatment because it is almost impossible to get off of them.

That is indeed very cynical! However, it's not correct. SSRIs are actually much easier to quit than our previous generation antidepressants. The first "S" in SSRI stands for "Selective", meaning they more or less selectively work on the serotonin transporter. Older medications were less selective and worked on a lot of different systems, which often meant withdrawal was even more difficult as multiple different systems were in rebound all at once.

The older medications can be more effective for resistant cases, but due to the higher side effect profile and more difficult withdrawal they are second line treatment.

> They say "It can take up to a month for it to work" is just a way to make sure dependency is strong enough by that point to make withdrawal unbearable.

Quite the conspiracy theory.

But again, it's unfounded. SSRIs are known to take up to a month to work because the antidepressant effect is the result of a sequence of changes that happens over time. The brain has to arrive at a new equilibrium with medication, and the various systems and feedback loops don't immediately recalibrate.

The biggest flaw in the theory that “they” prescribe SSRIs to get people addicted is that most SSRIs are cheap. $4/month at Walmart cheap, or $10 every 3 months. The common ones are long off patent.

I hope nobody takes the parent comment too seriously. If you're suffering from major depression, don't let HN conspiracy theory comments scare you away from trying treatments that work well for many people (though not everyone, but you don't know if you don't try)

You just discovered most prescriptions in the US. Big example, insulin, once you take it, ooof, never going back...

I’ve yet to meet anyone who didn’t eventually do better off the SSRIs and the data supports this as well.

You need to right plan and support, but it’s worth it in my opinion.

Have you tried any trauma work or Transpersonal work?

That's terrible man.

I hate being dependent on a doc. Try to reduce this horrible risk by going up and down on dose to get a little stock pile to feel a bit safer.

But changes little I guess

I'm totally off the SSRIs now and will never go back. Rebounds used to be frequent, then like 6-12 months apart now - now I don't remember when my last one was...

Going cold turkey was absolute hell, but it worked out well for me because of my excellent support system.

Would not recommend at all for anyone else though, absolutely not: tapering with a doctor is 100% the best course of action.

I get them (sertraline and escitalopram) pretty much on demand from Hims and Lemonaide.

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