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M.d.'s Notes On Withdrawal And Informed Consent


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#1 thismoment

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Posted 09 January 2014 - 09:22 AM

Stuart Shipko, M.D.

August 12, 2013

If I thought that it was possible, I would have opened a string of clinics all over the country to help get people off of antidepressants.  Unfortunately, the problems that sometimes occur when people try to stop an SSRI antidepressant are much more severe and long-lasting than the medical profession acknowledges, and there is no antidote to these problems.

 

Outside of using a benzodiazepine, I don’t have a lot of suggestions.  Reinstating the medications often does not help and sometimes there is a negative reaction. In the past I worked with SAM-e, thought to enhance neurotransmitter synthesis, and L-tryptophan, a precursor of serotonin.  It had placebo value, but was not an ‘antidote’ to the problem.

 

The problem starts with nomenclature.  The citizen scientists of the Internet have labeled the problem ‘protracted withdrawal.’  To physicians, withdrawal is a phenomenon that starts when the blood level of a substance drops to near zero and persists for a week or two.  The concept of ‘protracted withdrawal’ is inconsistent with the very definition of withdrawal.  So when a patient tells their doctor that they have ‘protracted withdrawal’ the doctor draws a blank.

 

Citizen scientists developed a set of corollary beliefs; primarily that the protracted withdrawal is largely due to stopping the drug too fast and that if one waits long enough that the symptoms of protracted withdrawal are going to go away.  My clinical observation is that long lasting symptoms occur even in patients who taper very slowly, not just those who stop quickly, and that there is no guarantee that these symptoms will go away no matter how long the patient waits.

 

What I have observed is that the ‘withdrawal’ symptoms occur while patients are on a steady dosage of the drug, shortly after stopping the drug and weeks or months after stopping the drugs.  The only precedent for this type of presentation is tardive dyskinesia (TD).  Tardive refers to symptoms that occur later and dyskinesia refers to movement disorder. TD is generally associated with antipsychotic medication, and is also a manufacturer labeled side effect of the SSRIs.  TD occurs while on antipsychotics, primarily occurs shortly after stopping them, and may occur months or even longer after stopping the drugs.  With the SSRIs, it is not so much a tardive movement disorder as a tardive problem with akathisia, a sort of constant restlessness or agitation that is accompanied by an agitated anxious/depressed state.  It is a very  uncomfortable sensation.

 

It is generally unappreciated that people who stop SSRIs often develop a new onset of severe depression or anxiety months after stopping the drugs.  It took me years before I realized that this is what was occurring, but this seems to be fairly common.  Patients often did well for months, only to develop fairly acute profound states of anxiety and or depression.  The anxiety and/or depression was not a relapse, because the patients never had these symptoms before starting the drugs.  Because people are thinking of the discontinuation problem as withdrawal, they are not considering the later onset symptoms as related to stopping the drugs.  What is somewhat frightening to consider is that patients with tardive dyskinesia sometimes do not manifest symptoms for years after stopping antipsychotics.  Will this be the fate of those who stop SSRIs?  This won’t be known for a long time, particularly if nobody is doing careful research on the topic.

 

Tapering the drug slowly definitely minimizes the acute symptoms that occur when stopping an SSRI but does not appear (IMHO) to have much bearing on the longer-term and late-onset symptoms that occur when stopping an SSRI.  I have not found a meaningful antidote to the longer-term symptoms.  L-tryptophan boosts serotonin in the central nervous system, but has not benefitted my patients.  Some websites advertise supplements that increase glutathione, a liver detoxifier, as an antidote.  SAM-e increases glutathione, and has not proven to be particularly helpful.  SAM-e also increases neurotransmitter synthesis, and even when taken with L-tryptophan, does not seem to make much difference.  Benzodiazepines seem to offer some relief, but they are dependency-forming and if taken regularly result in another dependency – although this is worth it for some patients.

 

Not only do some patients stopping SSRIs develop a variant of tardive akathisia,  a percentage of the patients who develop this problem will find that reinstating the SSRI will not alleviate the problem and may actually make the problem worse.

 

The difficulties that occur when patients stop SSRIs, particularly after 5 or more years on the drug, have not been fully acknowledged by physicians and citizen scientists alike.  In my experience stopping SSRIs after 5 years of cumulative exposure can be risky, and I am not advising anyone who has taken the drugs for 10 years or more to try to stop unless they are willing to risk disabling symptoms.  The documentary movie, “Numb” by Phil Lawrence shows what can happen when a person taking Paxil for a decade tries to stop the drug.  I’m sure that there are some people who can stop SSRIs after taking them for long periods of time, but prior to making such a decision, people are entitled to have a good idea of what can happen to them.

 

Those who are on self-help websites want to believe that if they wait long enough (however disabled they may be in the meantime) that they will get better.  The people that I have seen, suffering and disabled, waiting years for the ‘withdrawal’ to end are heartbreaking – particularly when they may be waiting for something that is not going to end.  If tardive dyskinesia is any guide, sometimes TD does go away, and sometimes it persists indefinitely.  I expect that the same is true for SSRI withdrawal.  The incidence of the late-onset and longer-term symptoms is not known because there has been no systematic study of the problem.

 

Absent a meaningful treatment for the withdrawal emergent symptoms, proper informed consent before starting OR stopping the SSRIs is critical.  Nobody should take SSRI antidepressants unless they know exactly what they are getting into. Informed consent for the SSRIs must necessarily include information concerning the difficulties related to stopping the drugs as well as the symptoms that occur when starting the drugs.  Also, patients who are considering stopping the drugs must also have informed consent concerning possible difficulties.

 

For this reason, I recently published an eBook, “Dr. Shipko’s Informed Consent for SSRI Antidepressants.”  It is the first book that gives warnings for patients who are considering stopping SSRIs as well as those who are considering starting SSRIs.  The book is short and readable and does mention that the drugs can be very helpful for some patients.  Most books on the topic are completely negative about using these drugs, and the bias is off-putting for patients who are trying to make their own decision about taking SSRIs.  I would hope that patients find the eBook palatable and reasonably objective.  Patients in my practice find the book helpful, and when a patient is still interested in an SSRI even after reading the book, I take this as a serious indication of how much they are suffering, and may find that the risk/benefit ratio tilts in favor of trying an SSRI.

 

If you know of someone who is thinking about starting or stopping a SSRI, please consider sending them a copy of ‘Informed Consent.’


#2 fishinghat

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Posted 09 January 2014 - 12:37 PM

Thismoment - I can't agree more with EVERY statement you made. I look forward to reading your ebook. Yes there are those who come off with little or no serious problems but given the severity of a lot of the withdrawasl I agree the inform consent should be a must. In addition it almost is identical to the comments made by my own psychiatrist. Great work!!!


#3 thismoment

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Posted 09 January 2014 - 01:02 PM

Hi fishinghat.

I didn't write this material, but I agree with your assessment!

The document is the work of Dr. Stuart Shipko M.D.

I hope you are well my friend.

#4 fishinghat

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Posted 09 January 2014 - 01:14 PM

It sounds like something you would right!! You are certainly smart enough.

 

I am doing so so. I am now coming off the lorazepam they put me on after the cymbalta withdrawal got too bad. Taking it slow, a 5% drop every 2 weeks. Going to take some time.

 

Take are of yourself sir.


#5 Donnaprashad

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Posted 09 January 2014 - 01:23 PM

@thismoment.  Thank you for sharing this.  I'm going to read this book as soon as I get home tonight.  I see my doctor on the 15th and I want to be able to convince him to take care when prescribing this drug.  Doctors should have a meaningful conversation with their patients when considering prescribing this drug to them.  I did not get that.  Just the warning from the pharmacy.  As a lawyer, I would argue that does not constitute "informed consent" and leaves the doctor open to a lawsuit.


#6 thismoment

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Posted 09 January 2014 - 02:51 PM

Donna, I agree. And regarding the pharmacy, I always get great advice from the pharmacist who takes the time to discuss the prescription- however innocuous the medication.

 

In my doctor's defence, initially, he was reluctant to prescribe antidepressants, but I guess I was in pretty rough shape. He said, "Take these once a day at the same time each day." which doesn't really constitute Informed Consent. But he did include the enigmatic caveat, "And just so you know, you could be on these for the rest of your life!" To me I had no life, so the warning went over my poached head.

 

I read there's 1 in 10 adults on antidepressants in the US, and I wonder if this might affect the national psyche, or domestic and foreign policy in the next 100 years. Did some of the heavyweights in the financial sector have their brains in psychopharmacological neutral post-2008?

 

Regarding Informed Consent- is there a legal definition of the term in this context?


#7 Wagtail

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Posted 09 January 2014 - 04:15 PM

Wow ..... Wow wow , very scary stuff .. The thought of NEVER recovering from these w/d effects blows me away .
Thank you ' this moment ' I need to have my nearest & dearest read this book as well .
Is it available world wide ?... I guess I just google it !.
Before Cymbalta I wouldn't have asked such a dumb question but now I think my brain has packed it's bags & gone walk about ..:-(
I don't know how I would cope if I didn't have you all to talk to , I've just woken up here in Australia & the first thing I do is grab my iPad & log in to check on you all & to get strength in the knowledge that I am still somewhat NORMAL !.
My love to you all. X

#8 thismoment

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Posted 09 January 2014 - 04:33 PM

Wagtail

Just click on the blue script and it will come up; it's an e-book and you can download it onto your computer.


#9 Clara

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Posted 09 January 2014 - 06:18 PM

Thismoment, thanks! I am going to try to read the book! Fear and anxiety seem to be the biggest thing for me right now! My doc did liver and pancreas test today! HHHMMMM, wonder how that's gonna turn out! She rather dismissed my remarks on how hellish wds are!!!!!!!!!!! Said Effexor is rough too! Well duh!!!!!!!!!!! I'm just pissed off, scared, tired, achy, anxiety ridden, and sick to my very soul of this garbage! I again am so grateful for all of you for your support and your willingness to share your wisdom and knowledge and "your stories". What a lifesaver!!!! Hugs all! clara :unsure:


#10 Donnaprashad

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Posted 09 January 2014 - 06:28 PM

I just finished this book. I am so so angry at not being advised of the danger of this drug and the damage this drug causes. I honestly feel I like my brain has been violated as has my human rights. This is very serious stuff. I would think that the majority if us were put on this drug at a time when we were most vulnerable. And I'm not manic angry right now. I'm just calmly dead seriously angry.

#11 Donnaprashad

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Posted 09 January 2014 - 06:30 PM

Thismoment. There is a definition of "informed consent." When I am back at the office and have a free moment I will look it up and post it. And I will explain what it means legally.

#12 thismoment

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Posted 09 January 2014 - 09:44 PM

Donna- you are in command today!


#13 Donnaprashad

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Posted 09 January 2014 - 10:32 PM

@thismoment. I do think there is logical basis to the idea that there is the real threat that national psyche is totally screwed up and most definitely could be the underpinnings of much of our governmental issues. It's very scary. I'm horrified that our society as a whole and individually is this gullible and easily manipulated into making an "easy fix" for our mental health a societal norm. I'm doubly horrified that I was so easily taken in myself.

#14 Wagtail

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Posted 10 January 2014 - 12:08 AM

Just read the book , I'm gobsmacked & upset that the doctors treat us like mushrooms " kept in the dark & fed bullshit ."
Also relieved that my symptoms are real & not a figment of my imagination. I'm going to get my children & husband read it as well .
Thank you so much for posting it Thismoment .. I'm indebted to you ..x

#15 thismoment

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Posted 10 January 2014 - 12:20 AM

Donna

 

Quick-fix meets Easy-money. 

 

I must say that I was sold long before I walked into the doctor's office; it's in the culture, and culture is the showcase of values.

 

I truly believed that antidepressants would stop depression, and after a period of time the learned physician, psychiatrist, and psychologist would have a little tete-a-tete-a-tete and one of them would lean back and take a long thoughtful drag on his Fat Havana Cigar, pull at his thick grey moustache and opine through a smokescreen of blue, "Y'know fellas, I think it's time Jimmy came off the drugs- surely he's cured by now! Of course we'll follow up with our First Line Monitoring protocol to ensure he continues to withdraw safely- and finally, he will gently be guided through our Long-Term Followup Program!"

 

But alas, there is no such plan, they're all just playing Symptom Whack-a-Mole in the Pharmaceutical Fun House . The plan ends amid the drooling, and the swooning sound of "Ka-ching!!" And it fits in perfectly with the Speed-Dating atmosphere at the local medical clinic where urine samples are gathered so fast you'd swear there's a hotshot running a Tequila Bar!  It oozes commerce.

 

So do your research kids; it didn't come up on my menu of choices.


#16 thismoment

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Posted 10 January 2014 - 01:03 AM

Wagtail

 

Glad you got to read the book. Ultimately I think most of us want to know the truth. The part I find so appalling is the fact that there's no plan beyond the transaction at the pharmacy.

 

I love your verb- gobsmack! It's built of what it describes: "I was shocked- I was gobsmacked!" It's alive- I love living words; all you have to do is let them run.


#17 thismoment

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Posted 10 January 2014 - 07:56 AM

Good morning Donna. I hope you have a great day! TGIF


#18 Clara

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Posted 10 January 2014 - 09:31 AM

Good morning dear friends!!!! Seems all I have done here lately is whine and complain and for that I apologize! I am glad to be here and grateful for all my friends here! My dear husband went to the doc w/ me yesterday for moral support! I'm waiting on results on liver and pancreas testing, whatever that means!!!! What happens if levels are high or I have disease? Frightening thoughts!! Oh well! Try to stay positive, I tell myself! Doc saw my level of anxiety and suggested I go back for counseling and start Buspar! After looking at Buspar s'effects, THAT will not be the answer!!!!!!!!!!!! So, my plan of action for this moment, (could change according to the mood, pun intended, searching for a little humor),is to get off the coffee...possibly go back to counselor, and try as best as I can to stay positive and have an attitude of gratitude! I believe for myself and others here, we will be able to look back at this crappy time in our life and truly be grateful we came through it and learned many great lessons, and found some wonderful friends along the way! Prayers, cyberhugs, and best wishes to all!!!    clara :)  :hug:





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