Healthy Skepticism International News

May 2008

Helping patients stop SSRIs

My involvement with GPs dramatically rose with the introduction of Medicare rebates for psychologists introduced in November 2006. Suddenly, more than half of my private practice case load were GP referrals, as GPs are the ‘gate-keepers’ to these rebates via mental health care plans. Prior to this, most of my clients were either self-referred, or referred by Employee Assistance Programs as part of employee entitlements. This increase in GP referrals has given me more experience in what appears to be conventional medical responses to such issues as depression and anxiety. It has also given me the opportunity to work more closely with many GPs and to see that for the most part, these are caring professionals who are genuinely well intentioned. This has created something of a dilemma for me in that it would be easier to take a critical stance of medical responses to mental health issues were I able to disregard the motives of physicians as being paternalistic power plays- my experiences have helped me to sincerely believe that this is not the case. What, then is going on?

While not maintaining any statistics on the issue, my estimate is that around 75% of people referred to me by GPs come already having been placed on antidepressants, usually SSRIs, and often benzodiazepines or mood stabilizers in addition. The overwhelming majority of these people present with symptoms which clearly suggest negative side effects. Naturally, I am aware that I see a biased sample, i.e those whose distress is resistant enough to medical treatment to justify a psychology referral. My assumption, based on the occasional client that I see as well as figures presented by David Healy, Professor of Psychiatry at Cardiff University, is that a portion of the population either appear to do well on SSRIs, or at least they are doing no worse. For the most part, I do not get to meet these people. Around 60% of people placed on antidepressants find the side effects so intolerable that they do not continue on them beyond the initial few weeks (Healy 2004). The other 40% are no worse, or they continue with the medications even though their lives are spiraling downwards. It is common for me to see this latter group of people in my practice. They typically present with many of the following symptoms:. worsening depression; anxiety and panic attacks; increases in suicidal ideation, and sometimes self-harming behaviour; psychological as well as physical agitation, and often increases in substance use to counter this; mania and hypomania, reflected in reports of ‘out of control’ behavour that ‘just isn’t me’; sexual dysfunctions; insomnia as well as lethargy; nightmares and terrors; electric shock like sensations in the head, as well as a myriad of other odd physical sensations, including new chronic pains (medically inexplicable); nausea; dizziness; headaches; tinnitus; bowel and digestive system abnormalities.

The people that I meet who have been suffering symptoms from this list, sometimes for years, generally lack the confidence to defy their physicians recommendations and withdraw. This lack of confidence is usually the bolstered by experiences of failed attempts to withdraw themselves, often ‘cold turkey’ or at least too quickly, resulting in terrifying withdrawal effects. To compound the problem for these sufferers, they tend often to respond to medical cues and invitations to view the symptoms as resulting from a worsening of their condition, eg. depression, rather than attribute the symptoms to the drugs. When a sincere and respected physician authoritatively tells a patient that the drugs cant be creating these symptoms, a significant part of the population are prone to believe them. People who are suffering tend to be vulnerable to the influence of those in credible positions of authority, even just out of sheer desperation. The greater the suffering, the greater the vulnerability to this influence As such, the sense of despair and hopelessness deepens and a vicious downward spiral can be created.

If this is all so apparent to me as a psychologist, why is it not so apparent to intelligent and conscientious GP’s? This question has puzzled me greatly. To date, I have settled on the explanation that when many of the current crop of mid-career physicians were embarking on their careers in medicine, the SSRIs were being heralded as the new ‘wonder drug’. Commencing my own career in psychology during the same era, I remember wondering if I had not just been made redundant by this advance in pharmaceuticals. This concern was only stemmed by my reading of Peter Breggin’s (1983) critical book on psychiatric drugs. The marketing of the SSRIs drugs in the late 1980s was so effective that few members of the public could have remained ignorant of them, and they had not yet been around for long enough for the industry claims of ‘no SSRI side-effects’ to have been proven false. The promise of relief from emotional suffering was now as close as the doctor’s prescription pad. Due to the effective marketing and the plethora of ‘good news stories’ in popular media, the placebo effect (most recently demonstrated yet again by Kirsch et al, 2008) was in full force. This merely reinforced everyone’s confidence, especially the prescribing doctors confidence, that the ultimate answer had been found in a pill.

Placebo effects are one matter, with the evidence in regards to the SSRIs calling into question the legitimacy of the very term antidepressant. Were the SSRI story to end there, merely with the placebo findings, one may conclude that they were relatively harmless. The issue of psychological and physiological damage is quite another matter however. It can take years for reports of adverse reactions to filter through to authorities in such numbers that demand attention. On a clinical level, it appears that many physicians (even those who both I and their patients view as being the most caring and attentive) are more attached to the promise of SSRI safety and effectiveness than they are to an open minded receptiveness to their patients reports of deterioration of their condition. This appears to be a psychological need of the physician. It is an anomaly that I can only understand in relation to the marketing successes of pharmaceutical companies and the construction of depression as a medical illness. My view is that depression and anxiety are not illnesses requiring medical attention. Our culture used to have a term which covered most of these experiences- it was called life. Some experiences in life can be entirely problematic - Thomas Szasz wisely referred to them as ‘problems in living’. Fortunately, most of the problems in living which are currently being treated with SSRIs and other antidepressants tend to be resolvable with: genuine care, concern and support from professionals or friends; problem solving strategies (perhaps involving legal, economic, social and interpersonal solutions); and with brains that are not being further compromised with introduced neurotoxins in the form of drugs, either illicit or medically prescribed. And this is perhaps the most tragic part of the situation to me- that so much of the apparent damage being caused to people with the mass prescribing of such substances is unnecessary. Viable alternatives exist, and are now financially accessible via Medicare rebates.

I have found Professor Healy’s (2008) SSRI withdrawal protocol to be an extremely effective approach to helping people restore some balance and sanity in their lives; however I would prefer to be spending my time helping people with problems that were not iatragenic in nature. The public maintains a healthy skepticism towards such wonder drugs. My observation is that there seems to be as many psychologists, nurses and social workers duped by the myth of antidepressants as there are physicians. When will health professionals of all types catch up with the inherent sense of the general public who we are meant to be serving? Surely, listening to people when they report adverse side effects or worsening of their problems post-drugging is a sensible starting point.

James Alexander.
PhD (Health Psych); Grad Dip in Counselling Psych; BA (psych/soc)
Registered Psychologist in Clinical Private Practice
Lismore, NSW

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