Lonesome Heroes can work Miracles

Yesterday, the BBC reported that following inquests where older drivers with compromised eyesight have killed pedestrians, and what, possibly thanks to the work of the BBC’s Hazel Martin (SSRIs and Alcohol), the British government has called “a catastrophic rise” in deaths linked to alcohol, it has been announced that there will be a tightening of regulations for eye-testing over the age of 70 and a lowering of drink driving limits – Over-70s face driving ban for failing eye tests

Yesterdays BBC also reported an Australian man’s death after being hit by an over the alcohol limit e-scooter driver – British backpacker pleads guilty to killing man while drunk on e-scooter

Will any of this get to grips with what we can all agree are a growing set of problems? Could the inquests or pending Australian e-scooter court case have missed any tricks?

I’d Like To Tell My Story

This line comes from Leonard Cohen’s A Bunch of Lonesome Heroes.

Several years ago in my forties I was put on sertraline. The background was an episode of depression in my teenage years for which I was given an antidepressant, but there were no further episodes, and the antidepressant had been stopped 25 years previously.

I did well in university and ended up in a creative job that involved some social drinking as part of the business, occasionally heavy, which I was aware of and worried about. I had a seizure several days after a heavy drinking bout. This was investigated thoroughly, and I was told I was not epileptic but I had a low seizure threshold. A link to alcohol was dismissed.

Years later I may have made a mistake taking on the challenge of moving from a secure job to much the same job in a riskier setting, and this led to a prescription of sertraline 100mg, which I was told would be more effective and safer than most of those older drugs.

The information that came with my sertraline made it look good.

At the time I was teetotal, keen to ensure the new job worked out well. I am someone for whom boundaries and focus have always been important. It took hard work to get to where I’d got – there was no silver spoon in my mouth. The new job meant it was possible to work from home a good deal and having my family around helped my boundary setting.

Covid and lockdowns also came along and helped keep me anyway on the straight and narrow, although a year later, I began drinking when the family were away. This slowly extended. I began losing my boundaries. My drinking crept into family time. My work focus began to weaken, and I lost my job.

I increased my sertraline from 100mg to 200mg. Within a few weeks I noticed two new problems. One was with my vision. I could no longer focus on a computer screen without reading glasses.  I rapidly moved from no need for glasses to 3.5 strength readers.

The other problem was with my balance. I’m fit. I run and work out in the gym. Balance had never been an issue. But now I could trip even walking up steps if I didn’t pay heed. Preventing myself from falling over required much more attention, more cognitive input than before.

Then a few days after another session of heavy drinking, I had a sequence of several seizures in a row – at home and then in the ambulance en route to the hospital. I know seizures can come with alcohol withdrawal, but I had no other features of alcohol withdrawal at the time.

The investigations the hospital undertook revealed a small amount of brain demyelination. They told me they did not think this was multiple sclerosis.

There were other changes. One day I was standing at a restaurant looking at the menu with a relative, having a normal conversation when I dropped to the ground. I had had several drinks, but this was not a seizure. It happened more than once. In a strange way it seemed as though I had become drunk without being aware of it until I blacked out. There were no hints of the kind of changes that normally tell us we have more and more alcohol on board. If you asked me was I drunk or the relative who was with me, the answer would be no.

The relative with me outside the restaurant later told me: “I think this is linked to your sertraline. There are posts on the web of people whose drinking gets out of control on sertraline.” This relative has no medical training or background in healthcare.

Four years after starting sertraline, I stopped it.

My problematic alcohol intake stopped. There have been no seizures or blackouts since. Over a short period of time my need for reading glasses reduced from 3.5 to 1.0. My balance improved. Recent brain scans show that the area of demyelination has shrunk.

I am not saying that sertraline alone caused my alcohol use disorder. I think I drank more than I should before starting it, but it definitely got worse on sertraline. I do not think I craved alcohol, but I lost my boundaries. Once I started to drink it was difficult to stop and there were no signs of drunkenness to inhibit me continuing nor any care for the consequences.

Leonard’s Heroes

Leonard didn’t know much about Sertraline’s story before he told his story. The original licensing of sertraline was held up by concerns it can cause seizures. Regulators have since had lots of reports from doctors linking sertraline to seizures and convulsions.

He didn’t know that sertraline and other SSRIs can cause osmotic demyelination. See Could your Antidepressants Cause Dementia. This likely happens following disturbances to our water-sodium balance.  A fall in sodium levels can be dangerous. When first reported, doctors rushed to replace our sodium rapidly and in doing so they triggered osmotic demyelination. Something similar can happen when we drink.  Leonard fortunately caught this early at what looks like a reversible stage.

There are also vision and balance problems. The Tables below come from RxISK.org’s Drug Search tool, which can give us counts for the number of reports specific to sertraline and also for all SSRI/SNRIs.

The counts also allow us to calculate the Proportional Reporting Rates and other disproportionality metrics for any events. Any PRR value greater than 1.0 points to a link to the drug.  Any value greater than 2.0 points to a substantial link.  The values below all have confidence intervals that confirm them as likely the correct or close to correct value.

The two problems Leonard reported besides alcohol and seizures were vision and balance problems.

Sertraline and Vision

While on sertraline Leonard had accommodation and focusing difficulties one explanation for which may be linked to a paralysis of his mydriasis reflex. Just the opposite to opioids his pupils were likely not constricting – for some of us on sertraline, there may be almost no iris visible. The problem can be worse at night when the lights of cars become more blinding than usual.

Accommodation and focussing problems may be reported to regulators, or coded by them, under a varied set of heading such as mydriasis, accommodation problems or under a series of other headings as listed in this table.

The problem can get worse at night or in low light and lead to dangerous driving even if our pupils are okay. People with Visual Snow Syndrome (VSS) typically have nyctalopia, also called night blindness.  Nyctalopia is a more complex condition than mydriasis. It appears linked to a set of cells called bipolar cells, which lie in the retina and have a serotonergic input. See Vision Weird, Vision Blurred, Visual Snow.

SSRIs are among the most common treatments reported to regulators as causing these visual problems.

These findings are clearly significant for the BBC reports above – both in older folk in respect of their vision, younger folk on e-scooters and all the rest of us taking SSRIs.

Sertraline and Balance

Dizziness is among the most common problems reported on SSRI medicines both starting and stopping. This might sound like a mild problem until you take the alternate headings under which the problem may be reported into account – vertigo, ataxia, balance disorder.

Balance problems lead to falls and disturbances of gait which can be very serious. But unlike vision problems above, which are reflex behaviours, they can be managed to some extent with a cognitive effort and extra attention.

Our visual systems can help us compensate – unless of course they too are compromised.  Visual systems typically are also compromised.  Balance is complex.  It needs input from proprioceptor receptors in our muscles, joints and bones, from the vestibules of our inner ears, as well as our eyes – all of which have serotonergic input.

Losing our balance can give us debilitating panic attacks – for which we will be told the best treatment is an SSRI. See:

• Persistent Postural Perceptual Dizziness – PPPD
• Balancing our Bodies and our Selves
• Juggling our Selves and our Bodies

Sertraline and Alcohol

The vision and balance problems and how these might affect driving were all reported in a 1983 healthy volunteer study that Pfizer ran, from which they concluded Sertraline can cause all these problems.  But no regulators or medical journals or anyone got to see or hear about this over 40-year old study.

Tricky and problematic as these visual and balance difficulties can be and were for him, Leonard’s undoing lay in a sertraline induced alcohol use disorder.  He is likely right, when he says he got used to drinking more than he should before Sertraline, but he gives very clear descriptions of a change in both the character and quantity of his drinking after he started and while on Sertraline.

Legal systems in general and Governments don’t understand what is going on here or how to manage the situation that a Lunch of Lonesome Heroes like Leonard have taught us – that:

• Sertraline can cause Alcohol Use Disorder
• Canadian Guidelines advise stopping SSRIs if used in alcohol use disorders and not starting SSRIs if there is any hint of an alcohol use disorder – A Medical Triumph SSRIs and Alcohol.
• Alcohol can relieve the agitation/akathisia sertraline causes and this is a potent trigger to drinking – Antidepressant Dysregulation.
• Sertraline can cause a doubling of blood alcohol levels beyond normal – Every Drink Spiked – an Australian discovery.
• These elevated alcohol levels can remain elevated for extended periods beyond normal

Above all Leonard comes very close to the reporting that others on an SSRIs offer about the lead up to events that can turn out to have even more catastrophic consequences than his:

I was thinking I wanted to stop, that I didn’t want to do it, but I had to. Asked why did you have to the answer will often be: Because I had started it – I can’t explain it. 

This is close to the heart of what SSRIs do.  They inhibit the sensations, feelings, that in Leonard’s case might have alerted him to the fact he was getting drunk.

SSRIs have minimal effects on the brain.  They act on sensory receptors in our body to mute sensory input – just the opposite to LSD which opens the gates to sensory input.  The most obvious and immediate effect of SSRIs like sertraline is to cause genital numbness within 30 minutes of a first pill at very low doses compared to the doses used clinically.

The same happens to touch around our bodies which we describe not as muted touch but as emotional numbness – by which we mean our feelings are numbed.

On SSRIs many report not getting drunk or being aware of the signs of being affected by alcohol until they blackout. If told the following day they were drunk the night before, they will often deny it.

The many people who have Post-SSRI Sexual Dysfunction (PSSD), which involves a genital and sensory numbness enduring long after treatment stops, similarly report a sense of not getting drunk when they take alcohol that was not there before they began the treatment.

Justice

These are problems for a Ministry of Justice and legal systems.  A reduction in sensory input leads to reduced imagery and the action reflexes linked to imagery that we call emotions or sometimes hunches or what Daniel Kahneman called Fast Thinking.

Overwhelm our sensory input by taking LSD and we can have significant problems. Restrict the input, as in a sensory deprivation tank or with an SSRI and we can one image coming to dominate.

If one image dominates it eliminates the free will, and choice, and Slow Thinking that is called into play when we have competing sensory inputs and emotions.  Instead, we can end up with automatic behaviour and only come back to ourselves when the trance is broken.

There are profound issues here for justice systems to deal with.

On a more mundane level, what about the millions of us who are driving with compromised eyesight, especially at night, whose problems might not be picked up on optometry screening done by day.  What about those of, increasingly young and riding e-scooters, who can’t focus on road or pavement signs properly?

What about blood alcohol levels over the legal limit in someone who does not feel remotely drunk and may be driving competently, who is on an SSRI.

Is it really justice to ban them from driving when the labels of SSRIs don’t give anyone any hint this could happen?

Everything we know about the treatment related effects in this post has come from people like Anne-Marie, Leonard and other Lonesome Heroes – left abandoned by those who give the orders to struggle beneath an extraordinary load.

Leonard Cohen’s heroes were struggling beneath an ordinary load. This sounds like the kind of ‘wisdom’ I heard as a child but we don’t hear these days – everyone has to carry their own cross but God (we were told) doesn’t ask us to bear more than we are capable of. In response much more recently, a Xtian pastor exposed to the horrors of SSRIs remarked that Xt never had to endure the horrors SSRIs can visit on folk.

You, occasionally helped by doctors, have been the people doing the Science that SSRIs and other drugs open the door to. You are increasingly likely to be left on your own to do real Science – See The Miracle of Artificial Intelligence.