Millions of people start taking antidepressants every year. But how many stop? Despite what we have heard for years, the process of withdrawing from antidepressant medications can be long, unpleasant, and even dangerous. Today’s guest is one of the foremost researchers in “deprescribing” or withdrawing from antidepressants. Join us as Dr. Mark Horowitz from University College London explains the possible side effects of withdrawal, how to taper slowly and safely, and why you might want to consider going off antidepressants.
Dr. Mark Horowitz, MBBS, PhD, is a Clinical Research Fellow in Psychiatry at the National Health Service (NHS) in England, an Honorary Clinical Research Fellow at University College London, and is a training psychiatrist. He has a PhD from the Institute of Psychiatry, Psychology and Neuroscience at King’s College London in the neurobiology of depression and antidepressant action. He is an associate editor of the journal Therapeutic Advances in Psychopharmacology. He co-authored the recent Royal College of Psychiatry guidance on “Stopping Antidepressants,” and his work informed the recent NICE guidelines on safe tapering of psychiatric medications. He has written several papers about safe approaches to tapering psychiatric medications, including publications in The Lancet Psychiatry, JAMA Psychiatry, and Schizophrenia Bulletin. He has an interest in rational psychopharmacology and deprescribing psychiatric medication and co-founded Outro Health, the first personalized, clinician-guided service for coming off antidepressants. He has experienced the difficulty of withdrawing from psychiatric medications firsthand, which has informed much of his work.
Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author.
Gabe makes his home in the suburbs of Columbus, Ohio. He lives with his supportive wife, Kendall, and a Miniature Schnauzer dog that he never wanted, but now can’t imagine life without.
To book Gabe for your next event or learn more about him, please visit gabehoward.com.
Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.
Announcer: You’re listening to Inside Mental Health: A Psych Central Podcast where experts share experiences and the latest thinking on mental health and psychology. Here’s your host, Gabe Howard.
Gabe Howard: Hi, everyone. I’m your host Gabe Howard and calling into the show today we have Dr. Mark Horowitz. Dr. Horowitz is a clinical research fellow in psychiatry at the National Health Service in England and an honorary clinical research fellow at University College London. He co-authored the recent Royal College of Psychiatry guidance on stopping antidepressants, and he has personally experienced the difficulties of coming off psychiatric medications, which has informed much of his work. Dr. Horowitz, welcome to the show.
Dr. Mark Horowitz: Thanks for having me on, Gabe.
Gabe Howard: Well, thank you so much for being here. Last week we had the author of “May Cause Side Effects,” Brooke Siem, on the show to discuss her personal journey with antidepressant medications and antidepressant medication withdrawal. Now, Brooke did an awesome job. We absolutely loved her. And I do want to point out that all of our episodes do go through a medical review process. But her story was just that, her personal story. And we wanted to avoid getting emails that said, hey, this is a very serious topic. Why did you have a reality TV star cover it? So we wanted to have on a doctor. We wanted to have a researcher to help us fill in the rest of the information so that we could be very balanced. Now, Dr. Horowitz, that’s you. And it leads me straight into my first question, which is, is there data showing that antidepressants are overprescribed?
Dr. Mark Horowitz: It’s a very, it’s a very hard question to answer. What we know is that the rates of prescriptions have gone up every year essentially for the last quarter century. So at the moment in America, about one in six people, one in six adults, are on an antidepressant at any time. That goes up by a few percent every year. Similar rates, although slightly less around the Western world. So in Australia and England, in Europe, one in seven or one in eight people are on an antidepressant. Going back about 20 years ago, it was about one in a hundred and it slowly crept up. And we know that a lot of these drugs are prescribed to people who don’t have approved indications for taking the medications. In England, for example, we have guidelines here that are put out to direct doctors, including GPS and psychiatrists, in order to help them treat patients with the best evidence possible. And this guidance specifically recommends not to be giving patients antidepressants for mild depression.
Dr. Mark Horowitz: We know that mild conditions tend to abate over time. When people turn up to their doctor’s offices, they’re often in upset, they’re anxious. Given time, most people will settle back down to their baseline because that’s the nature of the human condition. But we also know that lots of doctors feel they want to do something. That’s what our training is all about, and they’ll often intervene with a medication. We know that in lots of these cases people will do just as well without getting a medication. So in that context, it probably is fair to say there is widespread over prescription of these drugs.
Gabe Howard: Just to clarify, when you say that there is evidence that antidepressants are overprescribed, you’re not saying that antidepressants are a fraud or a fake or or alluding to some big conspiracy by the evil big pharma industry to take our money and keep us sick? You’re not saying anything like that at all. What you are saying is that antidepressants have good points and bad points and that while the data shows that they’re overprescribed, the data also shows that they can be useful and that we need to have a fair and balanced conversation about that to better understand where they are useful and where they are not.
Dr. Mark Horowitz: Right. So it’s a good point that you bring up. And I agree. You know, medications, as I’ve probably indicated so far, are not the not the answer and the solution to all human problems. I also wouldn’t say there’s no place for them. I work as a psychiatrist. I work in clinic. I prescribe these medications. But I’m going to draw on the work of Joanna Moncrieff, a professor of psychiatry in England. And I think her frame for understanding these medications makes it clear what they do and I think helps me to use them wisely. And I think it’s helpful for patients to understand. There is two ways of thinking about what psychiatric drugs do. One is called the disease-centered model, and it’s borrowed from mainstream medicine. An example would be antibiotics for a bacterial infection. The antibiotics kills the bacteria and solves the underlying cause of the infection. And for a long time, drugs like antidepressants were marketed in that way. That in some way antidepressants are reversing the process of depression. And the story for a long time was depression is probably caused by low serotonin, and antidepressants will increase serotonin and therefore fix the underlying problem, which sounds like a very neat solution. That, it turns out, was basically a marketing line. Yes, there was a hypothesis 50 years ago that perhaps depression is caused by low serotonin, but 50 years of research has not borne that out.
Dr. Mark Horowitz: There is no difference in levels of serotonin in depressed people or healthy volunteers. We’ve just published a paper on that topic, but the drug companies amplified that story because it makes their medications sound like a very sensible drug to take. Of course, if you’ve got low levels of a chemical, it makes sense to take it. We all know that from insulin and diabetes. If you were told you had a thyroid deficiency, you would certainly be keen to take thyroid hormones. So there’s no evidence that antidepressants are reversing this underlying chemical cause of depression. So they’re not acting in the same way as antibiotics. There’s also now a whole range of other theories about what antidepressants do, all of them not yet proven. So if we were being straight about antidepressants, we would say we don’t know how they work. Now, if there’s no proof that they fix an underlying chemical problem, then what could they be doing? And there’s another way of thinking about what psychiatric drugs do, and that is what Professor Moncrieff calls the drug-centered model. An example would be we know that alcohol is very effective for social anxiety. If you drink alcohol, it will calm you down. It will reduce anxiety.
Dr. Mark Horowitz: We all know it will make us feel more at ease in social situations. It will do that whether you have a social anxiety disorder or whether you’re just someone a little bit anxious in large groups. We don’t think that alcohol is reversing the underlying cause of social anxiety disorder. We know it’s a drug that acts on the brain. It causes certain changes to our emotions and thoughts, and that is superimposed on top of whatever anxiety you have. And when the drug wears off, the anxiety will come back. And that is probably a more appropriate way to think about what psychiatric drugs do. So antidepressants are the most widely used drugs, so I’ll focus on them. Antidepressants involve different kind of compounds. Some of them are a bit energizing. Some of them are a bit sedating. Many of them cause emotional numbing in the long term. That’s one of the most common effects that people will report when they’re asked and surveys people who are on antidepressants and all of those being energizing, being sedating, being numbing, all of that can improve someone’s experience. If they’re in despair, if they’re beside themselves with anxiety, then those effects might be quite welcome to them, give them a reprieve from those symptoms. And when you think about them in those terms, I think you can you can be a bit more discerning about when they’re useful or when they’re not useful, because you can also see how some of those things might be harmful in the long term.
Gabe Howard: Dr. Horowitz, there has been a lot in the news lately about research showing that antidepressants just don’t work. Some of that news has been inspired by your research. What have you found, are antidepressants effective? At least in the short term?
Dr. Mark Horowitz: Study after study finds it very difficult to distinguish between antidepressants and placebo. So in all of these studies and now there have been hundreds done comparing antidepressants to sugar pills, everybody gets better after eight weeks. Everybody improves by quite a large amount, whether they’re given an antidepressant or a sugar pill. To summarize hundreds of studies essentially on a 52 point depression scale, people given sugar pills improved by about eight points over about eight weeks, and people given antidepressants improved by about 9.8 points over eight weeks. That’s in studies done by drug companies and studies done by independent people. They all come out with the same answers. And there is there’s debate about this difference of 1.8 points between placebo and antidepressants. Many people say that’s not a big enough effect to be noticed by anybody.
Dr. Mark Horowitz: And there are all sorts of reasons why people on antidepressants might do better than people on sugar pills. People will know they’re on an antidepressant because of the side effects. And we know that can lead to expectations of improvement. And also the studies that are done for antidepressants are very short-term. An eight-week study, it’s not clear how relevant that is to people using these drugs for years and decades. We know, for example, that drugs like opioids look pretty good at eight weeks, but they cause all sorts of problems in longer term use, in part because people become tolerant to them. There are withdrawal effects and there are all sorts of other negative effects. So I think the effectiveness of antidepressants have been greatly overstated. They are only marginally better than sugar pills. That effect is likely to wear off in the long term. In studies that have gone for long periods of time, like a study from the American government called the STAR*D study. After 12 months of treatment with antidepressants, only 5% of people were doing well. So we really don’t have very good evidence that these drugs are useful in the long term.
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Gabe Howard: And we’re back with Dr. Mark Horowitz discussing the overprescribing and withdrawal symptoms of antidepressants. So let’s talk to our listeners who are on antidepressants and they’re thinking to themselves and which may well be why they’re listening and they’re thinking to themselves, Hey, maybe, maybe I do need to to stop taking these medications now. There has to be a way to do this that is safe, because everything that I have read and reminding the audience I’m not a doctor. The cold turkey method almost sounds dangerous. Are there withdrawal symptoms from going off of antidepressants?
Dr. Mark Horowitz: Yes. So, Gabe, that’s a very important point to anybody listening who’s considering stopping their antidepressants. I’ll advise them to talk to a knowledgeable clinician about that and absolutely do not stop these drugs cold turkey. That is a very dangerous thing to do. We know now that there are withdrawal symptoms from antidepressants. We know that for some people these can be very severe symptoms. We know they can last for long periods of time. And it is very unwise to come off them abruptly. Like lots of drugs taken long-term, being on antidepressants causes physical dependence. That’s different from addiction. You know, addiction involves people who are craving a drug, all they can think about is the drug. And they’re you know, some people break the law to get more of the drug.
Dr. Mark Horowitz: That, of course, doesn’t happen with antidepressants, but you don’t need that to become physically dependent on a drug. So probably most of your listeners and me are dependent, physically dependent on caffeine. We’re not craving it, not thinking about it all day. We’re not stealing from our neighbors to get it. But if we stop caffeine, we’ll get withdrawal symptoms. And similarly, antidepressants cause physical dependence. We also know that withdrawal symptoms from antidepressants are much more common, can be more severe and longer lasting than official guidance has said for many years. So about three years ago in England, they did the first systematic review of withdrawal symptoms from antidepressants, where they put together all the existing studies on this topic. As you can imagine, there are many less studies than there are for starting the drugs because drug companies are the major funder of most of these studies. So there’s a thousand studies on starting antidepressants, but only 14 on stopping them. If you look at these studies, about half of patients will experience withdrawal effects when they stop antidepressants. In surveys of patients, about half of those with withdrawal symptoms will say the symptoms are severe. So about one in four people will have severe symptoms. There’s physical symptoms like headache, like dizziness, nausea.
Dr. Mark Horowitz: Some people have these very particular electric shocks in their heads, which they describe as either their brain being shut off for a second or a little zap in their head, sometimes moving their eyes. People can get muscle tremors or spasms. They can find their vision is slightly changed, they can have nightmares. And all of these symptoms are because these drugs affect serotonin and other transmitters that don’t just affect our brain, but almost every system in the body. And that’s why these symptoms can be so myriad. And doctors are often poorly informed about these withdrawal symptoms. And they’re very poor at making this diagnosis. The second category of withdrawal symptoms that people have are emotional symptoms, because, of course, antidepressants affect the brain, they affect the way we think and feel. And so some very common withdrawal symptoms are depressed mood, anxiety, panic attacks. Crying, fear, trouble sleeping, nightmares. And so obviously, these symptoms of
withdrawal can look a lot like the underlying condition, like anxiety or depression. And it can confuse a lot of people. So doctors can jump to the conclusion that this must be a relapse, that is a return of an underlying condition rather than withdrawal symptoms. It can even confuse patients because many of the emotions that we experience are typical. If someone is prone to rumination or obsessive thinking, withdrawal can bring that out of us. And so it can be very confusing for both patient and doctor.
Dr. Mark Horowitz: These symptoms, which drug companies used to say would only last a week or two, We now know that these symptoms can last for months and in some people for more than a year. And we know that because these drugs can cause long-lasting changes to the brain and it can take months or years for the brain to go back to normal. And that’s what causes these withdrawal symptoms to last so long. So so do anybody out there reconsidering their medication, you should see an informed doctor. And when you do come off the drug, if you do decide to do that after thinking about the pros and cons, we know you’ve got to do it slowly. There’s new guidance in England, which is starting to influence European practice. But I don’t think it’s got over to America yet, which suggests that we should stop these drugs, especially after long-term use over many months and sometimes more than a year, and go down by small amounts to very low doses before stopping. And that’s what I’ve done in the clinic that I run in the public health system, in London, in England, and many other doctors are taking that up. And we know that that has a much greater chance of success coming down slowly than stopping very quickly over a few weeks, as doctors used to do. And actually, I’ve got to say, I feel that America is a bit behind England and Europe on this account because there has been an update to guidance on how to stop antidepressants in the last year in England. In America, there’s been no update to the guidance since 2010. And I’ve got to say my inbox is full of Americans emailing me to ask, can I help them come off their medication? And local doctors don’t seem to understand the latest science in how to get people off safely. So what I really hope is that the American guidelines will catch up to those in England and that more doctors will be educated in how to get people off these drugs safely.
Gabe Howard: I’m struggling a bit here. You say that a lot of doctors don’t understand this. They don’t know how to go about helping their patients to stop taking antidepressants safely. But sincerely, I am not a doctor. And I’m asking you, how is that possible? That seems very wrong to me. It seems like something that doctors should be required to know and be very well-versed in. If they’re going to prescribe these medications, they should understand the side effects, the possible consequences, and they should know how to help their patients safely stop taking them. I’m having a very hard time wrapping my head around this.
Dr. Mark Horowitz: Right. I’m going to say I share your bafflement, I mean, I’m a psychiatrist. I, I did my I did medical school. I’ve done training in psychiatry. I like to say that the first lecture that I ever heard about how to stop psychiatric drugs was one that I gave. I never, I was never given a lecture on this topic in my medical school or my training. It is a huge blind spot in psychiatric and medical education. I think there’s a few reasons for that. I think that most of the studies that are conducted are paid for by drug companies. They are more interested in starting medication than stopping medication. That informs what is then taught in medical schools and training schemes.
Dr. Mark Horowitz: People think that the major concern of doctors should be getting on top of acute conditions and what happens down the track is less important than than what’s happening in in an urgent or emergency situation. So there’s much less focus on what happens after the fact after the crisis has been averted. As I’ve said. There’s a thousand studies on how to start antidepressants and there’s 14 on how to stop them. So that in itself tells you where the focus of research has been. And I think there has been a lot of misinformation put out by drug companies, in part amplified by academic psychiatrists taking their messages to the public. In the late 1990s, they came up with this term discontinuation symptoms. They said that they were brief and mild and they printed several academic papers where the main words were brief and mild, brief and mild discontinuation symptoms.
Dr. Mark Horowitz: And they sent it out to doctors in America and England. And that became the mantra. Stopping antidepressants. It’s very easy. You get a few discontinuation symptoms, they’re brief and mild, and that was what I was taught in medical school. That was what the guideline said for many years. And if that is what’s in your mind as a doctor and there’s no big deal in how to stop these drugs, if you stop them and people have trouble, if someone turns up with severe symptoms that are long lasting, it can’t be withdrawal effects, it must be the underlying condition. And that becomes the medical education that junior doctors are exposed to. This misinformation fueled the widespread prescribing of these drugs. That message has been being conveyed to the public through advertisements, but also through academic leaders. And I think that’s what has led to this incredible focus on prescribing and this lack of a focus on deprescribing, stopping these medications, because doctors have been told these drugs are easy to stop. No big deal. And that’s led to this absurd circumstance where patients are now forced to go on to online websites, peer support websites or private Facebook groups to get advice from other patients on how to stop these antidepressants. You know, it’s normally you’d think, well, the doctors know what they’re talking about and social media has no idea. And they’re and they’re, you know, maybe an echo chamber of misinformation. It’s actually the opposite in this circumstance. Doctors are very poorly informed in how to stop these drugs, especially antidepressants. And it turns out that these online forums have worked out quite effective ways to stop antidepressants.
Dr. Mark Horowitz: And I’ll I’ll give you a piece of evidence for that. I learned I, as an academic psychiatry trainee, learned how to stop my antidepressants from online groups, not from one of the best institutions in psychiatric research in the world when I was doing my PhD. And in fact, the guidance now in England has been updated on how to stop antidepressants is very much informed by what patients have worked out themselves over years on how to stop these medications.
Gabe Howard: It’s so complex. And I. I wish that I had, like, a single question that could wrap this whole show up. And the best that I’m coming up with is why don’t people just stay on the antidepressants? I mean, going off of them seems worse than just staying on them. And I, I, I know I sound like a moron for asking it that way, but there’s this piece of me that’s just like, I don’t know, these things are like $10 co-pay a month, and then you don’t have to worry about these withdrawal symptoms and going to and from your doctors and being in the waiting room, I don’t know, just stay on them. But that’s clearly, clearly a bad decision. Why is that a bad decision?
Dr. Mark Horowitz: No, that’s that’s a completely valid point. I mean, I’ve just outlined all the terrible things that could happen when you stop an antidepressant. And so it’s completely valid to say, well, maybe it’s more trouble than it’s worth. It’s a legitimate decision for some people to stay on the drug if they think that this is too hard or they’ve had too bad a time in the past. Although I’ve got to say, most people I encounter who say I can’t get off this drug, it’s just too hard, have generally done it too quickly, especially at the end. We know it’s the last few milligrams of the drug that causes people the most trouble where you have to go slower. So, most people haven’t come off these drugs in the most sensible way. And then I guess the flip side is the I’ve talked about the difficulties of coming off the drug, I’ve given kind of the worst-case scenario, and then there’s the difficulties of staying on the drug. So, there are a number of long-term adverse effects of being on antidepressants. You know, one thing I, I say to patients in my clinic is just open up the packet of the drug that you’re taking the antidepressant and pull out the patient leaflet.
Dr. Mark Horowitz: I think a lot of doctors are trained to say, well, throw that away. It’s written by the lawyers. I say, don’t throw it away. It’s written by the lawyers, written it for a reason. It lists all of the side effects of the drug. What I often find is that when patients sit down and actually read that list, they will tick five, ten, or even 15 symptoms from that list of side effects. And the side effects range from nausea. You can have for years on these drugs and headache too. To things that can affect people’s lives like weight gain. So we know that people who are on these drugs, on antidepressants long term. 30% will go from being a normal weight to being overweight over similar people who are not on the drugs. And 30% of people will go from being overweight to being obese using these drugs long term, even though they were first marketed as not having a very big effect on weight. We know that more than half of people will have sexual problems on these drugs. They’ll have decreased sensation. Men will have trouble with erections or trouble with orgasm. Women will lose interest in sex. They’ll also have a harder time with orgasm. Different studies show upwards of half of people on antidepressants will experience those problems. We also know people will have trouble with concentration, with memory.
Dr. Mark Horowitz: These drugs often cause sleep disruption, which can lead to daytime fatigue. You know, a lot of people come to me and the number one issue they have is numbness. And so, like I said, it’s this double-edged sword of beginning. That was a very welcome effect. But down the track, they feel they’re walking around in a fog. There’s even a name for the syndrome. The SSRI Amotivational Syndrome, sort of. You know, you’re not thinking quite as clearly. You’re a bit tired. Your emotions aren’t as clear. You’re in a little bit of a fog. I think that’s what really gets people and people say, I want to feel like myself again. I want to feel the ups and downs of life. Often these are people who are ten years down the track from whatever crisis, put them on the drugs. And in my case, there are a different person. You know, they’ve grown up, they’ve worked out ways of coping. Their lives have changed. The problems that were there when they went on the drugs are no longer there or they’re more capable of dealing with them. So I have lots of very positive stories from the patients that I’ve seen who say coming off the drugs has given them back to themselves. They’ve been able to their interests and thoughts and hobbies that they had lost interest in over the years.
Dr. Mark Horowitz: They’ve regained they felt more connected to family and friends and loved ones even though the process is coming off can be a little bit extended and a little bit tricky. They felt it was worthwhile because of the benefits they had afterwards. And so I guess it’s those comments from people that stick in my mind. And the last thing is to say, a lot of those people say they hadn’t realized whilst being on the drug what it was doing to them. And it was only when they were on much less of the drug or off it that they understood that they had been in a bit of a fog for many years. And I think that that to me is, is one of the reasons why it may be worth considering coming off the drug.
Gabe Howard: Dr. Horowitz, thank you so much for being here. We really appreciate your time. And you’ve given, of course, everybody a lot to think about and a lot of information. And we really, really appreciate it. Where can folks find you online if they want to learn more?
Dr. Mark Horowitz: I’m on Twitter. My Twitter handle is @markhoro. Mark with a K, H O R O. The service that I am starting to build for Americans to help them come off unnecessary antidepressants is Outro.Health. Find a web page and I’ve got an academic profile on the web at MarkHorowitz.org.
Gabe Howard: Thank you so much for being here, Dr. Horowitz. And thank you to all of our listeners. My name is Gabe Howard and I am the author of “Mental Illness Is an Asshole and Other Observations.” I’m also an award-winning public speaker who could be available for your next event. My book is on Amazon because, well, everything’s on Amazon. Or you can grab a signed copy with free show swag or learn more about me over at gabehoward.com. Wherever you downloaded this episode, please follow or subscribe to the show. It is absolutely free. And hey, can you do me a favor? Recommend the show to your friends, family members. Colleagues. Sharing the show is how we grow. I will see everybody next Thursday on Inside Mental Health.
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