Farewell Marchino

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April 30, 2021 | 44 Comments

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  1. Sadly yet another tragedy is heartbreaking but not shocking. Regulators are careful to respond in the gentile veneer which hides their true colours but is worse than a contemptuous spit in the face They have the power to scew the truth churning out the same deceit decade after decade including by using the media When journalist such as The Herald in Scotland are taught that it is good practice to get a ‘balanced’ view spokespeople from medical colleges paradoxically are able to undermine the truth with the same lies and obfication decade after decade – The Herald has been flagging up concerns about anti depressants since 2013 including about suicide https://www.heraldscotland.com/news/16285833.antidepressants-found-drug-death-post-mortems-methadone-amid-record-fatal-overdoses-scotland/
    People feel betrayed by medicine when all avenues of help close up in defence of what has obviously caused harm ,the final cry when yet another denies what they often must know is the truth, is more an e tu Brutus. What a terrible way to die. ( the youngsters who are next in line for the vaccines in UK are only now being warned by the contemptible MHRA that they are at risk of blood clots – they are the group who will most want to go out and meet up with new friends and potential partners – they are being labelled as potentially in need of mental health serices after horrors of covid ease up – let’s hope they will get properly informed about prescription drugs.

  2. I think its not ok to go only behind the back of regulators. Let’s be brutally honest : the prescribers of these chemicals could stop this whole show if they only wanted to do it and had the true backbone for it. Would it stop psychiatry as it is now? Yes it would but that’s exactly what we need, no talking around the point. Every doctor that knows the risk here vs. the poor and unpredictable benefit should simply stop letting anyone take the risk – because they could.

    • This is not the case. For some people the drugs can help a lot. The RCTs are just a mechanism to get them on the market and give little indication of what happens on treatment. A person going on treatment needs to know the risks but even knowing this risk the seduction of going on the drug may be hard to resist. The key thing is when on treatment am i getting a benefit – if there is a very clear benefit then people might decide to continue with the risk. But if there is no hint of a benefit and clear hints of a problem, this is when getting people off quickly could make a big difference and where the warnings may have an effect – but it depends on people listening to each other and having a relationship. The idea of dishing out a poison where there isn’t a decent relationship between the poisoner and poisoned is a recipe for disaster.

      D

      • Is there not an argument though, that with psychiatric drugs, and especially SSRI’s; that until the risks are fully transparent, and “all of the cards are on the table”; then by default, the risks of prescribing, should automatically outweigh the potential benefits; because the prescriber does not know of the full risks, and is therefore not in a position to make an informed decision; about whether the benefits could outweigh the risks?

        Therefore I think until doctors have access to all the data/facts, on the true risk to benefit ratio, and are not in the dark about them; there is an argument they should refuse to prescribe them; apart from perhaps in certain severe cases of depression, that seem particularly resistant to non pharmacological treatments, or which doesn’t resolve on its own, over time ( as a lot of cases of depression eventually resolve on their own, even without any form of treatment).

        • Spruce

          I mostly agree with this. If doctors insisted on access to trial data and if they refused to prescribe without both them and you and the rest of us able to see this data in full – and this means if need be being able to interview some of the people who were in the clinical trials – we would all be in a better position.

          In the absence of this, there is a real onus on docs to say to patients this is a poison and both you and I need to keep a hawk eye on what is going on and if you aren’t getting much benefit and definitely if there are harms we need to stop it asap. But this is something else doctors are failing badly at.

          Would we be better placed if these were all over the counter drugs?

          D

      • Sorry but this is once again an answer dodging the point. The fact is : many of the adverse cases are abrupt and there is no way predicting and avoiding unless you simply don’t eat these pills. The only way to achieve this is that they are not prescribed, because the risks are known . Period. Everything else is bla bla bla and beating the bullet because psychiatry does not have the backbone to stop this all.

        • Its not dodging the point. I agree this approach won’t solve all cases. But at present most docs don’t believe these drugs cause sexual dysfunction or dependence or suicide or any other problems – so your first problem is to persuade them or you have no hope of getting anywhere.

          Your second problem is persuading all the people who want their acne cleared up (and their dermatologists who don’t think..) or the young men distraught at their hair loss (no one believes finasteride causes problems…) and the people who want an SSRI who have heard about all the amazing things that SSRIs can do for them not to ask for them. As things stand if people ask for accutane or finasteride or SSRIs and I say no you don’t really want them – I get fired.

          The only people who can change this are the pharmaceutical industry who when they spot a way to make money out of something else will persuade you and your doctor that SSRIs are not the right thing to do.

          If you think psychiatrists can make a difference to this or family doctors who do most of the SSRI prescribing, emotionally semi-correct though your view is, you are part of the problem rather than part of any solution.

          DH

          • Defence defence….

            I am talking of all doctors across the board should have enough backbone to simply not prescribe these things. Doctor getting fired is the problem? Then that segment of medicine is useless and harmful and living from it as a profession is not justified anyway. Family doctors have much more to do than psychiatric meds, accutane and finasteride. Drug industry the only culprit? Nobody forces a high moral doctor to prescribe anything. You make me a part of the problem? I think you are, and all you do is defend your position because you as one are not man enough to start really doing a practical paradigm shift here. Dont just talk and blame all the other instances. Be a man and show the way to other doctors on how to start finally running down this madness. Your repeating excuse of “because the patients want it” is total dodging of responsibility. You know what can happen and you have the means to change this. Don’t ride on multiple horses. It’s really something that eats the credibility. Be a man like Breggin and act up to what you talk. Nothing will change enough otherwise.

          • You could start by having the courage not to be anonymous. If you were not anonymous and a doctor and refused to give people SSRIs or ADHD meds or Medically Assisted Dying, or terminations of pregnancy or gender reassignment here in Canada you’d be fired and told by the Supreme Court that if you won’t do these things or refer people on doctors who will you should not be medicine.

            Having been fired twice and referred to disciplinary bodies on many occasion for taking the positions you seem to want doctors to take I can tell you the horse has bolted on this one. Whatever chance doctors had of doing this once when they exerted some real power, that moment has passed. Doctors may well pay for it when people start asking why should be pay these guys so much money – for what – what do we get from it.

            But if you weren’t anonymous and were to say this in front of a bunch of people interested to get treatments, you’d be torn limb from limb. You can say things like this in an echo chamber that is getting smaller and smaller and less and less influential the whole time and if that gives you a warm glow good luck to you

            DH

  3. Practically speaking is there a kind of data base which could provide doctors and individuals with the information needed for all permutations of harms versus benefits of each different eg anti depressant ,for each individual. One person has a different physiology from another; and/or a different profile of symptoms which would react differently to a specific drug from somebody else. It seems the data can still only ,however important it is that it should be available to everybody, be a guide .If there was an imperative for one named medic only to be responsible for prescribing to an individual there would be an opportunity for carefull watching and monitoring – and create research in action rather than rely only on trials data . (The push from NHS is for more tele medicine , GPs are presently being told to provide more video and phone consultations which cannot offer the same sort of nuanced discussion and investigation as face to face .just as being bounced around from one medic to another cannot provide proper careful/care.) If the trial data was available , as it should be ,would it though get watered down or dumbed down and possibly corrupted by a claim of making it more accessible In the same way as adverse effects are put into categories ,in scales of seriousness. Someone told there is only a 1 in 1500 likelihood of a serious adverse effect can understand that as a risk worth taking or another would say no thanks. The data can only provide a guide which is relevantly useless unless warnings to be watchful are given by prescribers and they carry out all the tests for symptoms indicated as being caused by a drug – and which cause a deterioration in physical health . I n short if people wish to become prescribers their practice needs to be a much tighter , more skilful and responsible practice -not left to doctors who are practicing in an amateur way relying on guidelines but without enough real knowledge of what they are handling.. As much as I think we should have the right to Acess data bases I cynically believe it will only have limited benefits unless the way prescribers, practice changes..and would they want to share that control openly with everyone..

    • Why do we need a database like this? Why not just trust people – believe what they say – make it possible for them to say things they are currently scared to tell us?

      Why are we treated like Nora in the Doll’s House?

      D

      • I i think we need it to have some level of protection against lack of info to make as much as possible informed decisions and that all health workers are not knowledgeable enough without some reference materials – wjhich i guess needn’t be just on data bases.

  4. RIP Marchino!

    I long for the day when the world finally acknowledges the existence of conditions caused and/or created by psychotropic drugs. Unfortunately for us, the “chemical imbalance” story concocted by the boys in marketing has been repeated so many darn times since the 80’s, the global consciousness has largely eaten it up as true already and wouldn’t dare question the firmly cemented “scientific” orthodoxy.

    It is so sad and frustrating. I don’t deny some of these drugs may be able to help certain folks in perhaps more extreme situations, however, it has been shown that the nature of SSRI drugs are even more addictive and more difficult to get off of than heroin, cigarettes, or any other hard drug for that matter. When were any of us told about this? Never…

  5. These very (self )important GPs are more keen to throw as many as possible Out of the dolls house Here is a prime example if anyone has the stamina to read it, of what it is like to try to have a real discussion with still too many opinionated doctors who still believe they should not be disagreed with – honestly- scroll down- I think this lot should self refer to Clare Gerada’s Distressed doctors service Their own servce is so fragmented it is hardly likely they will have an actual encounter with most registered with them or therefore understand the problems real people are experiencing The tone is frankly quite nasty , they talk at and about people rather than with them I wouldn’t trust my own healthcare to a group which sends such a letter out of the blue to people registered with them.
    https://www.pulsetoday.co.uk/views/in-full-gp-practices-16-page-letter-to-patientsre GP practice, Ivy Grove Surgery, has penned an open letter to patients explaining how demand for services has doubled in recent months as services have been This site is intended for health professionals only
    GP practice’s 16-page letter to patients
    In full: GP practice’s 16-page letter to patients
    GP workload
    30 April 2021
    A Derbyshire GP practice, Ivy Grove Surgery, has penned an open letter to patients explaining how demand for services has doubled in recent months as services have been used inappropriately. The full letter is as follows:
    April 26, 2021
    AN OPEN LETTER TO OUR PATIENTS ABOUT DEMAND
    April 26, 2021

  6. You know the saying – ‘we are given two ears but only one mouth, for a purpose’, meaning that LISTENING is twice as important as SPEAKING! How often is this true? In the medical world and especially in mental health terms, it seems that “speaking” is the role for the professional and “listening” is the only option for the patient. This HAS TO STOP. It will only stop if we, patients and their families, REFUSE to let it carry on. It seems as if doctors, when faced with pharma reps., take on the ‘listener’ role and let the reps. give them all sorts of information but never the full story. If we started to question a prescription given to us, started to phone in with any side-effects that we encounter and refuse to continue to take their magic, ‘happy pills’ and, in the meantime, keep notes of everything that we’ve noticed and shared, then many doctors might begin to wonder what is going wrong.
    Whilst so many of us accept whatever is recommended for us to take, continue to take it however it makes us feel, take monthly trips to our pharmacies for our repeated supplies – why should our doctors change their ways? If we make life so comfortable for them that they can simply press a button to supply us with whatever they please, is it really any wonder that we are in this mess?
    For those who are already in that vicious circle of ‘repeat the dose, increase the dose, change the meds – repeat as necessary’ it is too much to ask. Their needs are way beyond the expectations mentioned above. The rest of us, apparently queuing up for “support” due to lockdown restrictions etc., are the ones who can push for these changes. We can speak up for family members who are already in the hamster wheel – easier said than done, I know, but it is possible to get an outcome to change the speed of the turning wheel even if not to get the patient completely out of it. It takes guts and a resolve to continue pushing forwards but is well worth the effort when you see your family member’s life improving at last.
    We cannot stand by and expect someone else somewhere to wave a magic wand that will change the picture – we are part of it and have to make a stand against the situations that disturb us. Nothing will change whilst we sit back and let it continue.

    • Mary

      It sounds like we should protest against doctor-splaining. Something about the comment you’ve written, maybe combined with the mood I’m in left me hearing man-splaining. You know – men the creatures who have very active mouths but no ears.

      Of course its women’s love of men as boys – giving them space to talk and building confidence in them by treating everything they say as wonderful that perhaps helps create the problem – so it will need women more than anyone to think about how to makes sure that brittle male confidence isn’t crushed completely while they are learning to listen. See the post on DH.org today.

      The idea that a clinical encounter should involved anything less than 90% listening by a medic is weird – there are quotes going back over a century like ‘listen to your patients they are telling you the problem’.

      David

      • What compounds this, I believe, is the air of the medical profession itself and how the title of “Doctor” in the Western world has now become associated with status and prestige. Was it always like this?

        Example as a type of attitude: “I studied over 10 years to get where I’m at, I know better than you.”

        Nothing can be more harmful, in medicine or in any other field in life. This kind of closed-mindedness prevents the kind of meaningful discourse many patients are longing to have with their doctors.

        • I’d like to see a video made of a ‘good’ consultation. Not the sort medical students are engaged in , or just more lectures but by a qualified GP and by a psychiatrist with a real person with a real current problem in real time without any props or rehearsing..That could be useful in boosting confidence to people before going in to a meeting – the make a check list advice may be useful but a conversation brings out a lot more and it would benefit practitioners who aren’t taught how to treat individuals with guenuine respect on an equal basis of exchanging knowlege learned and knowledge gained from real experience to come to a way forward .They end up just repeating and teaching formulaic disempowering and unhelpful consultations a lot of the time

  7. This all needs a television documentary I think. I can see how I would edit it and put the pieces together to get the message across clearly. I don’t know why popular channels wouldn’t broadcast one. Has the documentary Medicating Normal been on popular channels ? I have no idea I don’t watch television. I see there is this Crime of the Century one coming down the pipeline soon. We want something like this to get doctors to start asking questions and raise the bar for ssri prescriptions, encouraging some herbal anxiolytics rather than ssris all the time might be wise.

    https://youtu.be/SkU75sBdjdU

    • Medicating normal is ok but to be honest : it pretty much leaves the picture that everyone heals slowly and withdrawal is the biggest problem. That’s not good, cases of permanent harm should be presented, cases leading to suicide like this one. Sexual dysfunction is not even present in the movie. I think it missed a good chance to be rough as reality is. Too bad. It seems to be made with the Alto Strata attitude : “everone recovers” – which is far from the truth. It’s false hope.

  8. I watch the Professor Simon channel sometimes as he makes some very good quality Science/History videos. I like his style he has set himself up to generate his own electricity using a waterwheel next to his house with battery storage. I like the idea of doing things myself and being as self reliant as possible, not being beholden to anyone would be nice. Professor Simon probably wouldn’t dare do a series of videos on ssris as his channel would be sunk forever. His series on the Boeing 737 Max 8 is very good.

    https://youtube.com/playlist?list=PLMs-DCi6qWoIz1IvGuU3BkEOHdV8-nb_-

    • Really enjoyed this Professor Simon and the set of 14, particularly The Real Problem on the wider economic problem and the problem with the Challenger Shuttle disaster – very good.

      https://www.youtube.com/watch?v=VeX4FnZS79Q&list=PLMs-DCi6qWoIz1IvGuU3BkEOHdV8-nb_-&index=6

      On Medicating Normal viewings

      Miranda Levy @mirandalevycopy

      Delighted to appear on the panel discussion after this film on 13th May, on the harm that can be caused by psych meds. Alongside heroes @DrDavidHealy @markhoro @StevieLewis83 . See @UkSobriety
      for more details.

      Sobriety Films UK @UkSobriety

      SFUK is holding an exclusive and virtual screening of award winning MEDICATING NORMAL with
      @GenesisCinema
      13th May 18.30. Tickets available on 4.5.20.. Live Q&A panel with
      @DrDavidHealy
      @mirandalevycopy
      @markhoro
      and Stevie Lewis.. Celebrating #MentalHealthAwarenessWeek

      About the Film

      https://medicatingnormal.com/

      • as I say in another comment, as ok as Medicating Normal is, it still gives a softened version of what these drugs can do (permanent damage). The people in the film suffered and to some extent suffer from the drugs but the really nasty cases that exists in large numbers are not present. The awareness and alerting value of the movie could be much better , if it covered cases like the unlucky one here in question in this thread. Now it’s more like a surviving antidepressants theme movie “everyone will recover”, and that’s not true.

  9. Would creating a PSSD website with an intro to each sufferer, their first name and when they protracted the condition help. of course sufferers will be hesitant to put themselves on the website but wouldn’t this be a clear view of who has it and and to push the boundaries of being anonymous which is the first step, showing our faces ? I will be more than glad to create the website I just want to get insight on if this might be beneficial. This is a very rare condition and to have all the sufferers laid out on a map with their faces be a huge difference.

    • I think this might be beneficial. There are a group of women in particular who are willing to be known. There are people who are dead who are known. It makes it a lot harder to ignore you.

      DH

  10. In other words a short 60 second video of each sufferer where there from and how long they’ve had it all layed out in one website. This will shed more light to the condition.

  11. On 3rd June 2013, I obtained 690 signatures.
    It was successfully tabled in the House Of Representatives.
    The petition submitted for the consideration of the Standing Committee on Petitions regarding legislation to improve consumer safety by requiring warnings and results of all clinical trials to be included in pharmaceutical labelling and information.
    As you know, the petition was presented in the House on 3 June 2013 and referred to the then Minister for Health.
    A response from the former Minister for Health was presented in the House on 12 December 2013.
    Sadly, the response is not robust.
    I remained anonymous.
    Tap on the link and look at the 3rd of June 2013 with 690 signatures.
    I did this whilst I was very ill but was passionate to get my concerns out to the people.
    Please open out file to see petition and response.
    I am creating an awareness about consumer safety because all clinical data pertaining to medicines is not out there.
    Even the consumer information pamphlet does not disclose everything.
    Many pharmaceutical companies keep their information vaulted so that the public don’t see it.
    It is important that you create an awareness about this to your loved ones and all you come in contact with.
    We need to educate ourselves about these issues because there is a lot of clinical data pertaining to medicines that is not fully out there for consumers to see.

    https://www.aph.gov.au/Parliamentary_Business/Committees/House_of_Representatives_Committees?url=petitions/petitions_43/health.htm

    Over prescribing and mixing a cocktail of medications with a combination of other medicines is not only dangerous but deleterious to ones health. It is like putting a loaded gun in someones hands. If only changes were implemented back then when I submitted a petition, unnecessary deaths, like Issac’s would have been avoided.

    I am sure the statistics of deaths due to unsafe medicines and over prescribing is not accurately captured.
    This is most often likely reported as overdoses or suicides.

    https://www.abc.net.au/news/2021-05-05/isaac-died-taking-prescribed-medications/100043708

    How many deaths will it take before people listen?

  12. Amy Pearlman is inviting people to get in touch – e mail below

    Amy Pearlman, MD
    Urologist, Sexual Health Specialist
    https://medicine.uiowa.edu/urology/profile/amy-pearlman

    June 15, 2020
    To Whom This May Concern,

    My name is Amy Pearlman and I am a urologist specializing in sexual health at a large academic institution. I have helped care for several young men with a history of selective serotonin reuptake inhibitor (SSRI) use who are suffering from long-term genital anesthesia and erectile dysfunction that started after taking an SSRI(s). Though impossible to say for certain whether these side effects are a direct result of prior SSRI use, the timeline of SSRI treatment and subsequent sexual health symptoms, despite cessation of SSRI medication, suggests that the medication is, at least, associated with these symptoms.

    Despite normal hormone levels and penile doppler ultrasounds, in addition to medical management with oral phosphodiesterase inhibitors and alpha blockers, and pelvic floor muscle therapy, I have been unsuccessful in finding a reliable treatment for these men. I absolutely believe, based on my training and experience seeing these patients, that long-term sexual side effects despite cessation of the SSRI(s) is a real phenomenon, even though we haven’t yet figured out the reason.

    I’ve discussed my concerns with mental health providers and my patients who regularly follow with mental health providers, and I worry that the sexual health conversation is not routinely part of the mental health discussion, thus, I have no doubt that post-SSRI sexual dysfunction is more common that we currently appreciate.

    In the recent weeks, I have had several men and women from across the country reach out to me with their concerns about suffering long-term sexual side effects related to prior SSRI use and, inspired by their stories, I have built a multi-institutional team of sexual health experts to help me study this underrecognized and under-appreciated disease.

    As someone who has built her career treating people with sexual dysfunction, these men and women with whom I have talked are suffering from this life-altering condition. As a result, I feel strongly that additional research, resources, and medical attention are of utmost importance.
    Amy Pearlman, MDAmy Pearlaman
    Contact us at pssdcanada@gmail.com

  13. I have to get through another day which will be alot harder work than it should be with the relentless withdrawal symptoms taking up most of my avaliable resources. It’s grim and for some reason still always worse in the mornings, the supplements I take do help they make days feel like less of an unplesant endurance test. I have to schedule my activities around the periods when I feel better which are unpredictable. It’s rather exhausting and frustrating. If you see a fella shuffling along the pavement with a thousand yard stare in Harlow that might be me.

  14. DH

    your answer still is just defence and dodging away from how to change this all from the point of view of doctors.

    Just keep on talking and riding many horses. As said a true man would do something else more straightforward if he really wanted to change something . Realizing this seems to be triggering you.

    • Faceless

      You are good at sneering. Is there anything else you’ve done to help anyone affected by these conditions?
      You made a good point about medicating normal dealing in recovery stories only when they should have added in more about the permanent damage for many – and then you sneered at Altostrata.

      You’ve never seen anything here that suggests doctors are anything other than a bunch of wimps. They ended up in 1951 being the people through which the poisons come – because it suited the bureaucrats in FDA and the pharmaceutical industry realised it would also suit them. And making a comfortable living out of this doctors aren’t likely to change any time soon and have made things more comfortable by forgetting they are dealing in poisons.

      The reality now is that a lot of the prescribing gets driven by people like you seeking out the poisons – and not doing your own due diligence on what you are taking. By people like you being taken in by the idea that these are sacraments. More fool you.

      At the end of the day, you and others depend on the courage of some of the people linked to what we are doing here (not mine) to go public in their efforts to raise awareness of the profile of the problems and the courage to try some poisons – because this remains the likeliest way we are going to find an answer to what has happened and how to put it right.

      And when we do, you’ll benefit without ever having the courage to do anything that requires courage.

      DH

  15. I think this fella probably makes some sense about the dissociative states I get at the moment. Alot of people in withdrawal conditions probably get dissociation along with all the other ‘fun’ symptoms like mood swings, anxiety and excessive sweating. It’s hardly surprising people dissociate when experiencing symptoms there is nowhere else to go.

    https://youtu.be/dbi5gJFQi6Q

  16. This has been flagged up before but it’s worth pointing out that the guidelines would never have been changed without the efforts of campaigners which vitally include medics . Hardly surprising there will be points of friction and dispute but it’s doubtful if much progress would have been made and won’t be made for ‘sufferers’ of sexual dysfunction caused by prescription drugs ,without their committment, encouragement and support.

    Lack of evidence on safe methods to stop antidepressants, study finds
    Lack of evidence on safe methods to stop antidepressants, study finds
    Beth Gault
    05 May 2021
    There is little evidence that the current approaches to stop antidepressants in long-term users are safe and effective in people with recurrent depression, researchers have warned.
    The recently published Cochrane review looked at 33 studies with 4,995 adult participants, which recorded different methods of antidepressant withdrawal, including stopping abruptly and stopping gradually over several weeks – or tapering.
    Guidelines currently recommend that an antidepressant should be continued for at least six months after patients start feeling better, and for at least two years if they have had two or more periods of depression.
    The review concluded that the evidence in this area was ‘very problematic’ and it was uncertain whether the methods studied to date are effective and safe in people with recurrent depression.
    In a blog on the review, co-author Ellen Van Leeuwen, said: ‘The rise in long term antidepressant use is a major concern. For example, in the UK nearly half of people using antidepressants (8% of the total population, approximately 3.7 million people) have been taking them for more than two years.
    ‘Antidepressants that, despite initially being appropriate, are not discontinued after the recommended duration can lead to unnecessary harm and costs.’
    She added: ‘Honestly, the evidence in this area is very problematic. It is not possible to make any firm conclusions about the effects and safety of the approaches for discontinuation studied to date. There were only a few studies with a focus on successful antidepressant discontinuation rate.
    ‘The main problem is that studies did not distinguish between symptoms of relapse of depression and symptoms of withdrawal after discontinuation.’
    Withdrawal symptoms can include insomnia, low mood, anxiety and changes to appetite, but they are also recorded on the depression scales used to detect relapse. This could ‘inflate’ the rate of relapse in groups that stop antidepressants, according to co-author Mark Horowitz.

    He added: ‘Additionally, most tapering regimes were limited to four weeks or less, in contrast to NICE guidelines recommending tapering over four weeks or more. In fact, there is now increasing recognition that antidepressants might need to be tapered over months or longer than a year to very low doses for long-term users.’
    The authors said, despite the inconclusive data, the study would enable clinicians to openly discuss options with their patients, with the potential benefits or harms of continuing or stopping antidepressant use, but that more research was urgently needed.

    Ms Van Leeuwen said: ‘This review reinforces the call for more research in the primary care setting, particularly for people with low risk of relapse and those for whom there is uncertainty about the benefit of antidepressant treatment.’
    The review comes after NICE was forced to delay the release of an updated guideline for treating depression in adults after it came under scrutiny for ‘out-of-date’ advice on antidepressant withdrawal.
    The original guidance had advised that symptoms are generally mild and self-limiting over the course of a week, while the updated guideline warns of ‘severe’ and lengthy antidepressant withdrawal symptoms.

  17. I tend to make mind analogies with what happens with a computer as I like to think simple. If you flood a micro with too many interrupts external or internal the operating system will begin to cancel tasks as there is has not the capacity to process the demands being placed on it. That happened with the Apollo 11 LM module when it was trying to land on the Moon the processor was swamped which caused its performance to degrade. You don’t have to be an expert on data structures and algorithms or have read the entire set of Donald Knuths books to deduce something analogous to an interrupt storm occurs during withdrawals. The poor old brain becomes overwhelmed by the storm of spurious interruptions and is distractable, can’t focus, executive function and mental flow is impaired which makes one feel ones mind is going such a condition evokes fear and the amygdala getting triggered rather more often than one would like. I tend to think of what happens when I am trying to navigate the outside world in a withdrawals state using the swamped by spurious interrupts analogy. The irritability threshold iis lowered then more easily triggered by loud noises and dealing with daily events, a swamped brain has alot more trouble dealing with normal life so to escape it dissociates.

    • This makes a good deal of sense. Serotonin is one of the most primitive neurotransmitters. When we interfere with it we affect gut, muscle, skin, eyes, bone, blood and pretty well everything. Stopping interfering doesn’t restore things to normal. There are going to be signals overloading the brain for ages afterwards.

      The good news is that while people feel their brain is badly affected, there may be very little brain damage. The problem is an overload one as Justin suggests

      D

  18. Maybe going against the grain again but I find the use of algorithms intersting if used with the cautions in the summary It is all too obvious that all practitioners don;t know enough about what they prescribe — this would reassure me somewhat if the clinician -individual and some use of decision aids was available

    Respiratory Medicine CME Elsevier
    Volume 2, Issue 2, 2009, Pages 63-67
    CME Article
    Algorithms for assessing the probability of an Adverse Drug Reaction
    Author links open overlay panelMartin J.Doherty
    https://doi.org/10.1016/j.rmedc.2009.01.004Get rights and content
    Under an Elsevier user licenseopen archive
    Abstract
    Adverse Drug Reactions (ADRs) are common and are associated with significant risk of morbidity, mortality and admission to hospital. Deciding if a clinical event is an Adverse Drug Reaction, or not, can be difficult. The decision is often based on clinical judgment alone, yet studies have shown that decisions based on clinical judgment often vary greatly between raters.

    Therefore a number of decision aids or Algorithms have been developed to try and improve this variability. Studies have shown that the use of algorithms does improve the between and within rater agreement significantly, and gives a semi-quantitative measure of the likelihood of causality. There are variations between these algorithms but none of them can in themselves prove or disprove causality. These algorithms, their benefits and their problems will be discussed in this article.

    every 1000 hospital admissions die as a result of an ADR.5 The economic impact of ADRs is massive; they increase hospital stays by almost two days on average, with its intending costs. The total cost of ADRs in the USA has been estimated to exceed the cost of all diabetes treatment.

    Recognition of ADRs
    The ADRs produced by a certain new drug are often recognized when the medication is undergoing its phase three randomized controlled trials. Both in the USA and in the UK there is post marketing surveillance of ADRs. In the UK this involves reporting suspected ADRs to the Commission on Human Medicine using the yellow card system. In this system new or intensively monitored medicines should have all suspected ADRs reported and other medicines should have any suspected serious ADR reported. In spite of these mechanisms ADRs are vastly under reported6 and initial reports of adverse reactions to drugs have taken up to seven years for trends to begin to appear in the literature.

    Under reporting of ADRs is likely to be due to a number of reasons. Reporting is not mandatory to clinicians in the UK and so is likely to be forgotten about amongst the many other work pressures. A clinician may have problems recognizing the scenario as an ADR, because of the background symptoms of the patient’s original illness. Clinicians might also be wary of reporting an ADR, because of worries of inducing a complaint, even in this no blame culture NHS. It should be pointed out that the yellow card clearly states you do not need to be sure if it is or is not an ADR before you report it.

    In recognizing an ADR there are a number of important factors. One is identifying those individuals in whom ADRs are most likely to occur. This includes the aged and the premature, those with liver and renal dysfunction, those on polypharmacy and patients with certain individual conditions, such as Human Immunodeficiency Virus infection (HIV).

    Assessment of causality
    It is often difficult to decide if an adverse clinical event is an ADR or due to deterioration in the primary condition. Furthermore, if it is an ADR, which medicine caused it, as many patients are on multiple new medications when ill, particularly if admitted to hospital.

    In spite of these problems, the decision that a particular drug caused an ADR is usually based on clinical judgment alone. Studies have shown that there is a lot of variation in between rater and within rater decisions on causality of ADRs; this applies both to pharmacologists and physicians.7, 8 In one study two physicians and four pharmacists were asked to decide about 63 possible cases, they showed a between rater agreement of 38% to 63%.9 Another previously published study showed a 50% agreement between two raters with a Kw value of 0.3.10 These problems with using individual clinical decision making in allotting causality for a change in clinical condition to a medication led to the development of a number of decision aids.

    The benefits of algorithms
    Decision aids or algorithms were developed in the 70s and 80s, they tend to consist of yes/no questions, which can be used to categorise causality. For instance the Jones’ algorithm11 will categorise the causality into remote, possible, probable or highly probable. Other algorithms consist of yes/no questions, the answers to which correspond to a set score. So by answering all the questions in the algorithm you end up with a total score, this numerical score then corresponds to a given category of causality.

    There are benefits in the use of such algorithms; including standardization of methods. Algorithms being structured systems specifically designed for the identification of an ADR, should theoretically make a more objective decision on causality. As such algorithms should have a better between and within rater agreement than clinical judgment. Indeed this has been shown to be the case.9 In this study the between rater agreement of a panel of experts, using clinical judgment ranged from 41% to 57% (kappa = 0.21–0.37, R(est) = 0.49). When the same individuals used the Naranjo Algorithm it rose to between 83% and 92% (kappa = 0.69–0.86, r = 0.92), this rise being statistically significant. The within rater agreement was also high using the algorithm, being between 80% and 97% (kappa = 0.64–0.95, r = 0.95).

    Comparing the algorithms
    A number of algorithms or decision aids have been published including the Jones’ algorithm,11 the Naranjo algorithm,9 the Yale algorithm,12 the Karch algorithm,13 the Begaud algorithm,14 the ADRAC,15 the WHO-UMC16 and a newer quantitative approach algorithm.17 Each of these algorithms has similarities and differences. An example of one of the more commonly used algorithms; the Naranjo algorithm (Fig. 1) is shown below. The consistency of three of these algorithms was directly compared in a study in 1986.18 In this study 28 ADRs were assessed using the Jones’, the Yale and the Naranjo algorithms. There was 67% agreement between the Yale and the Naranjo algorithm (Kw = 0.43), similarly there was 67% agreement (Kw = 0.48) between the Yale and the Jones’ algorithm. Agreement between the Naranjo and the Jones’ algorithms was 64% but the Kw value was only 0.28.These levels of agreement are better than those that have previously been reported when two raters have compared the same ADRs using clinical judgment.

    Download : Download full-size image
    Fig. 1. Naranjo algorithm.

    They concluded that the Naranjo algorithm compared well with the Yale in scoring ADRs but had the advantage of being less time consuming. The Yale algorithm containing 57 questions compared to the 10 questions in the Naranjo algorithm. They were less supportive of the use of the Jones’ algorithm in view of its lesser agreement with the Naranjo algorithm. To reduce the ambiguity in the assessment of potential ADRs these algorithm have been introduced at pharmacovigilence centres in many countries.

    Problems with algorithms
    Although algorithms have better reproducibility than clinical judgment in rating ADRs, clinical judgment with its low inter- and intra-rater agreement still plays a big part in the identification and rating of potential ADRs by an algorithm. This is because the answers to some of the questions in the algorithm may be affected by clinical judgment. More importantly the first step in ADR identification depends on a clinical judgment, i.e. the decision that this might be an ADR and so deserves further assessment using an algorithm.

    Further problems include that the questions in an algorithm are often weighted, these weights are arbitrarily assigned based on their perceived importance and vary between algorithms. This qualitative assigning of weights means that algorithms are unable to truly determine the probability of the ADR causality.

    Even though algorithms have been shown to be more reproducible than clinical judgment alone, the validity of the measure must also be considered. The fact that the algorithms agree well with each other does not mean that they are right. Studies have looked at the validity of algorithms, by comparing the category of causality that they produce to the decision on causality decided by a group of experts in the field. This is not a true test of the validity of an assessment system, as this testing cannot work as for as the majority of ADRs, no true “Gold Standard” exists.

    Further problems include the idea that most include questions on dechallenge/rechallenge, and the rechallenge often does not occur in the “real world” of clinical practice. This might not occur for a number of reasons, for many serious ADRs rechallenge might be considered unethical, since it may pose a considerable risk to the patient. Also for many lesser potential ADRs using a different drug rather than undergoing the rechallenge may well be deemed an easier and simpler option by the clinician. Even if the clinician is willing to consider rechallenge to strengthen the probability of causality for an ADR, the patients themselves will often refuse such a rechallenge. Without a rechallenge it is difficult with most of these algorithms for causality to be graded more than “possible”.

    Algorithms depend on a YES/NO answer to individual questions, this is not always easy, sometimes a “maybe” might be more appropriate. So in a way algorithms may simply replace honesty with pragmatism. Lastly there are a great number of ADRs in a number of different body systems, so a single standardized assessment tool may not be ideal for such a diversity of possible presentations. More recent work has tried to develop assessment schemes for individual problems e.g. liver disease, interstitial lung disease, and renal failure.19

    Summary
    In summary algorithms are useful in assessing causality in possible ADRs, as they decrease the disagreement between assessors and can classify uncertainty in a semi-quantitative way. They are often used by journals and national pharmacovigilence organizations to mark individual case reports. They improve the scientific basis of causality assessment and are useful in education about causality assessment. However they cannot prove or disprove causality, nor give an accurate quantitative measurement of the likelihood of a relationship.

    • Suzanne

      Listening or being able to listen is the key. Not an algorithm. We have the Naranjo algorithm built into the RxISK report but if people are too scared to bring it to their doctor because they don’t think it will be listened to and if doctors don’t know the basics of working out if a drug causes a problem, an algorithm is not going to help

      D

  19. As serotonin effects so much of our bodies it is sad that those many of us who trust what used to be called ‘alternative’ practioners, now slightly more respectfully ‘ complementary’ pratitioners are treated as though we have one foot in la la land. MAssage treats the skin, herbs the gut and eyes and other parts of the body as well as help with sleep… and so on They can have serious adverse effects but no more than pharma drugs Plus there are some which are used for sexual problems Maybe there could be some research on using them to find a cure and claim the Rxisk prize

  20. A total overload then means that ‘death can be a welcome result’…

    The ‘agitation’ predisposes some to take radical action.

    I was thinking about the three days from when I left the mental hospital having restarted Seroxat and spent six days with diazapam and three days later ‘death was a welcome result’.

    Driving home, after about ten minutes all sorts of thoughts came in to my head. As I drove my mind was fantasising about ‘death’. I carried on as these thoughts grew and grew. When I was home I stood in our sitting room totally displaced. No thoughts at all. It was a dream, a trance-like state, I was looking at my little girl and her father as if I was trying to see through a wall-of-water. This feeling persisted through Saturday and early on Sunday I jumped out of bed in the dark and at 100 mph set about using gas, knives and ropes and finally overdosing on 28 Propanolol.

    This calmed me down and I was sick. I phoned a friend and she came and I was taken from local A&E to a large mainland hospital where the spree continued.

    I was incapable of telling anyone what was going on. Whatever was inhabiting my body, it took all of my normal communication with it. I implored a doctor to get me Seroxat and with this pill in my system I woke up to see a familiar face doing his rounds. It was my orthopaedic surgeon and I told the nurse that I had an appointment with him that very day. He came over and checked on my foot.
    God knows what he thought with bloody bandages on my wrists. The ward was a geriatric one and I asked the sister if she had a private room as it was so noisy. As luck would have it there was one.

    I didn’t tell anyone what had happened because I was incapable of doing so.
    I don’t know what you would call it. Acting out a nightmare, going through an out-of-body experience, overtaken by aliens…

    What I do know is that drugs like Seroxat cause a massive malfunction which is why I understand how people like Stewart acted so out of character in this huge state of agitation which takes over body and soul. There are no 24-hour guards when the world of ‘akathisia’ takes over…

    My second withdrawal was an improvement on the first with the liquid but it fell at the last hurdle and although I desperately wanted to restart the Seroxat, how could I possibly do that….
    Flat on my back again for months, I gradually came back to life.

    Apollo and ‘dissociates’ and ‘interrupt storm’ is a nice touch…

    • has anybody had the agitation recorded as paranoia on medical notes? When the restlessness begins it can seem like a running away from something unknown and fear of even people known let alone strangers. This incorrect ‘diagnosis’on a record can lead to all sorts of further confusion and harmful treatments even incarceration

  21. If your interrupt service routines are overloaded you might have difficulty working in the service industry your performance may drop. I can imagine some places I would really not like to work right now, working in an Amazon warehouse has to be quite high on my list of jobs I would immediately resign from. I’m overestimated and crippled with decision paralysis just shopping in the grocery store so it’s best to leave Justin alone with his peace and quiet at the moment. I’m a bit of a Melvin Udall type personality.

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