Restoring the Magic to Healthcare

The Serotonin Reuptake Inhibitor (SRI) story starts in 1969 with Arvid Carlsson (above) who created Zelmid, the first SRI, after listening to people on antidepressants. He linked an anxiolytic effect some older drugs have to the serotonin system.  The SRIs aimed at exploring that effect – Normality and Antidepressant Dysregulation.

Fluoxetine (Prozac). sertraline (Zoloft). paroxetine (Paxil). citalopram (Celexa). escitalopram (Lexapro), vortioxetine (Brintellix), venlafazine (Efexor) & duloxetine (Cymbalta) are SRIs.

This post aims at giving you a basis for a conversation with your doctor. The so-called patient-information-leaflets (PILs) or even smaller print 40 + pages doctors get are a weapon that is all too often used against you.  Give this ‘medicine label’ to your doctor to read, gauge their response and act accordingly – Challenging My Doctor to Disclose.

SRIs

Serotonin Reuptake Inhibitors were created to make you serene – to damp down your reactions – a chill pill.  This can be useful for managing stress or anxiety.  But no more than half of us who take an SRI become more serene. Some of us become serene but find it unhelpful  – just not us.  For many of us, nicotine can be better than an SRI.

People who are stressed or ‘depressed’ have normal serotonin systems. If an SRI doesn’t give you a clear and helpful effect within days, you risk a bad trip and should stop. This is particularly true if you feel worse on the treatment.

These drugs are not selective to serotonin. They are not SSRIs. Selective here is a marketing trick designed to fool you.  Ditto with SNRIs. These are marketing soundbites not science. SRIs act on multiple systems, producing effects that can add to your stress levels.

The conditions that lead to us being offered an SRI, or told we should have one, on average clear up naturally in 12 to 14 weeks – without treatment. SRIs can help by making things more comfortable while you wait on recovery, but depending on your reaction to different medicines they may be no more helpful for you than nicotine.

SRIs supposedly take up to 6 weeks to work. Stopping treatment earlier, you will hear, would be a mistake. This is a myth. Within days of the first dose, you can notice a numbing of your genitals and emotions – among the good effects – or problem effects like agitation or disinhibition.

Within 2-3 days, people who know you can spot the good and bad changes from the outside, so it is worth letting them know what is going on and paying heed to their input.

If you know you are feeling worse, and your doctor doesn’t listen to you, or suggests this is your depression and needs time or a higher dose, unless s/he is very convincing, you need to change doctor.

Apart from adverse effects, one serious problem is that the help some of us get can mislead us into thinking we would not have recovered without treatment. Even if the drug helps you, your serotonin system will be more abnormal after a few days on an SRI than before and will get more abnormal as time goes on. You will be more resilient if you get well without meds.

Unlike older antidepressants, SRIs can’t help severe depression, melancholia, a condition that affects older people. Melancholia also recovers spontaneously but can take 5-6 months.

SRIs can cause a severe Treatment Resistant Depression (TRD) for which we have no treatments. TRD is not a mood disorder. It is a drug-induced toxic state in which several bodily systems end up badly dysregulated, some of which may never recover.

For some of us, however, SRIs can be more helpful than critics suggest, but neither good nor bad effects are all in our minds – SRIs are no more placebos than LSD is.

Standard SRI doses, the doses most people start on, are close to toxically high. This is because companies had problems showing these drugs worked and couldn’t take a risk on low doses in their clinical trials.

Lower than conventional doses are a safer bet, especially when starting. Fluoxetine 5 mg or perhaps St John’s wort to see if you get the serenic effect and if it suits you. If do not feel anything useful and especially if you feel worse after starting, you should not agree to an increase in dose.

Why keep mentioning nicotine?  Arvid Carlsson said for some of us nicotine is better than SRIs. Most of us recognize that nicotine is a poison. If it helps, this is exactly what medicine is about – bringing good out of the use of a poison. We should have the same attitude to SRIs.

You who are taking an SRI are the only person able to decide if the benefits you can detect are worth the risks. SRI risks at the moment look at least as bad as nicotine.

The Drug Label

Company lawyers write Drug Labels/PILs supposedly based on company studies. Regulators like FDA or EMA ‘approve’ what companies write. The regulators do not have the study data. They go along with company efforts to get you on a product that will keep the company healthy, rather than getting you thinking twice about something that may not be right for you.

Companies shape treatment guidelines – standards of care – by ghostwriting the articles on which they are based. The articles often claim a drug worked well and was safe when it didn’t work and was hazardous. Scared of lawsuits, medical journals, guideline makers and lay media won’t hint that a drug might cause problems.

Companies, regulators, medical journals, lay media and increasingly doctors have an allergy to the word cause, unless you are saying a drug caused you to get better.

Companies downplay treatment hazards in ways few doctors know about. The result is a story that puts you at risk from Good Doctors who keep to the Drug Labels and Guidelines written by companies – not by FDA, MHRA, EMA, NICE etc

See Who Will Make Medicine Great Again.

Two mantras help companies eliminate hazards. They claim their randomized controlled trials (RCTs) offer a science of cause and effect. They have branded our views and our doctor’s views as anecdotal. Companies accept RCTs miss some rare or later developing hazards, implying we are told about everything that is common or significant.  The best example, perhaps in all of medicine, of how wrong this is lies with SRI induced genital changes that everyone is likely to have within an hour of their first pill.  Company trials missed this completely – because investigators were told not to ask about sex.

There is another important feature to RCTs. Even if done by angels, they give average effects. You are not, and no-one is average. You can decide what a drug is doing to or is not doing for you better than anyone else.

Any Magic there might be in Healthcare lies in the relationship between you and your doctor – not in a chemical.

Hazards

SRIs cause the hazards listed here in healthy volunteers. Companies and regulators try to link these hazards to ‘depression’. Mood disorders do not cause these problems.

Sex and Love

SRIs numb genitals and mute orgasms within hours of a first pill, and later diminish libido, in far more people than treatment helps. These problems may recover after stopping but can instead get worse and last decades – this is called post-SSRI sexual dysfunction (PSSD).

SRIs reduce sperm counts in men and hormones critical to embryo implantation in women in addition to causing birth defects. They compromise your fertility. They put any baby you conceive at risk of neurodevelopmental problems. You and your partner should be told this, but we are all kept in the dark and it is no surprise we have falling birth rates.

See RxISK posts on PSSD

Emotional Blunting

SRIs aim at making you less reactive. At just the right dose, this can be helpful, but the dose is invariably too high leading to emotional blunting. You may not be able to cry at the funeral of someone you love.

Caring less about consequences may disinhibit some of us. Family and friends may notice personality changes. Other people who have been on these drugs can often spot when you have started an SRI in a way healthcare staff can’t.

See Zen and the Art of Psychopharmacology

Agitation

SRIs can make us malignantly anxious, agitated, irritable or restless and generate out of character thoughts that can usually be distinguished from feelings linked to depression or anxiety. These include impulses to harm ourselves or others, which can lead to suicidal, homicidal, or other criminal behaviour, especially if combined with emotionally blunted disinhibition.

Claims that suicidal effects only happen in young people are incorrect. The treatments can trigger suicidality or homicidality in young or old.

As with sexual effects, family and friends should be made aware of these hazards.

Anyone mentioning anxiety or agitation after starting an SRI may be put on another drug to damp things down or may have their SRI dose doubled. This is dangerous. Stopping treatment should be the first option.

Antidepressants and Homicide

Suicide

SRIs cause suicide, suicidal acts, and suicidal thoughts (suicidality), along with homicide, homicidal, violent or aggressive acts and violent or homicidal thoughts in healthy volunteers or anyone who takes them – whatever age. Forget the idea that it’s your difficult illness that is causing the problems and the answer is to increase the dose.  This is possible but less likely than it is the drug causing the problem.

Many of us can distinguish drug induced thoughts like these from anything we might ever have had before.  They can begin within hours of a first dose, after a dose change or can be linked to stopping the drug – which can be very tricky.

500 Drugs That Can Cause Suicide

Alcohol

SRIs can increase your alcohol intake whatever its original level was.  For some, alcohol damps down the agitation SRIs cause.  For others, even pregnant women, drinking becomes compulsive and can cause fetal alcohol syndrome. The combination of an SRI and alcohol increases the risk of other hazards.

Alcohol use often returns to normal almost immediately on stopping the SRI.

It looks increasing likely that SRIs and other prescription meds may lead to increased intake of non-prescribed drugs. Gen Rx increasingly seem to blur these boundaries.

Conventional drug information tells you nothing about this  – Antidepressants and Alcohol

Sensory Problems

Where psychedelic drugs open up the senses, SRIs mute them. Visual Snow is a dramatic visual effect, but SRIs can also cause blurred vision, night blindness, after-images, glaucoma and other problems.  Visual Weird Vision Blurred.

SRIs can badly affect balance giving rise not just to dizziness but to a disabling vertigo that leads to a form of panic attacks.  None of these conditions show abnormalities on scans and you will be told your problems are all in your mind – and told to take an SRI.

See Balancing Our Selves

Emotional numbing is closely linked to a literal numbing of touch and other sensations. Too high a dose of treatment or too long on treatment can damage sensory nerve endings and cause pain – for which you will be offered SRIs. This damage is called peripheral neuropathy or sensory neuropathy – as in the image just below.

Dysregulation and Withdrawal

Companies knew from 1980s healthy volunteer studies that SRIs cause serious problems on stopping. Serotonin is more primitive than estrogen and the dysregulation of all our senses SRIs cause trigger a wide range of long-lasting symptoms on stopping equaled only by stopping estrogen in the menopause.

If you have symptoms of anxiety or depression on stopping, your doctor may insist these are part of your depression and you need to go back on treatment or need other meds. This is wrong. Even healthy volunteers get depressed and anxious after 2 weeks exposure, along with nightmares and disturbed sleep.

For some of us, it just takes a few weeks to produce problems stopping an SRI that many people taking opioids find worse that stopping heroin. Stopping can take months or years. Gradual Tapering may help but it may be impossible to stop and take years to get back to normal after stopping.

The withdrawal period has the highest rate of suicidal acts. This leads some to claim SRIs are life-saving. Sexual, vision, balance and other difficulties may get worse in this period.  Persistent genital arousal disorder (PGAD) can develop especially in women on stopping and can be bad enough to lead to clitoridectomy.

Acetazolamide or low potency SRIs may make things easier – see RxISK – Antidotes.

Therapists and doctors can make things worse by linking your problems to unresolved trauma. There are an increasing number of people claiming to be able to get you off meds and charging a fortune to do so. No one can reliably get you off at the moment – if you got off without too much trouble you were lucky..

Polypharmacy

SRIs are a gateway drug to benzos, antipsychotics, stimulants, statins, anti-diabetic and other drugs, which may all increase the difficulty in getting drug free and the risk of serious hazards.  Company drug labels assume you will only be on one drug. If your doctor has seen fit to put you on an SRI, they are highly likely to want to add other medicines. Every drug they add likely makes the company label for each of these drugs irrelevant.

An SRI in its own right is likely to shorten your life through cardiac or other effects, but a premature death or dementia is even more likely if you are on 3 or more drugs.

SRIs cause muscle wasting as will statins, and weight gain, which along with apathy are liable to make you ever less likely to engage in options that take motivation.  Taking a pill will seem easier.

They also seem to be a gateway drug as in the image above to cannabis, adderall etc – Go to the Gym, Eat Vegan and Take Zoloft.

Quality of Life

Back in the 1990s, when SRIs launched, companies, knowing they were less effective than older drugs, pushed a Quality of Life argument instead.  Believing their own propaganda, companies made Quality of Life scales and put them into studies,

The data was never published.  Why not?  You not your doctor complete QoL scales.  Those of you on SRIs in company studies reported a poorer quality of life, lower levels of wellbeing, than those not on them.

Other Hazards

RxISK’s Drug Search Tool shows other hazards reported for SRIs. These include weight gain and diabetes, cardiac problems, strokes, bone thinning and fractures, muscle wasting, gut problems, bladder problems, fatigue, sleep problems – on and off the medicines.  The list goes on and on. Many of the problems can fool your doctors and you. The urinary tract or prostate infection they think you have may not be an infection and putting you on antibiotics can add to your problems.

You can’t depend on your doctor to get the diagnosis of a side effect right. They are quite likely to put you on other mental health, gut, antibiotic or other drugs for problems that would clear if you stopped your antidepressant.

If a partner or family member is being put on one of these pills you might want to ask them or their doctor to inform your consent.  If you are liable to have your love-life wiped out or to be killed or injured by a drug they are put on, should you not be alerted to this?  But if you live with someone whose personality changes on a medicine, you might find them resistant to stopping it and their doctor unwilling to listen to you.

Older women used to be the main takers of antidepressants.  While there are still many older folk hooked to them, likely forever, older women seem to have gotten the message and are less likely to start them. The number of younger women taking them, however, is rising strikingly. Antidepressants are fast becoming a young woman’s drug.

This is not down to company marketing.  These are old drugs from which pharma makes no money now.   They also haven’t been shown to work in this age group. What is going on?

We would like to hear from you. Tell us what would make a treatment label work for you and we will write similar labels for other drugs.  RxISK wrote Guides to some of these drugs a decade ago and we will update these based on what you tell us you need.

All Illustrations above are by Billiam James

Note:

This post was prepared ahead of a two meetings. First, Washington State’s Congress is exploring consent issues with antidepressants and other drugs in younger people. Britain’s Medicines’ Regulator, also, has been asked to take stock of their risk communications for antidepressants – which at present are very different to those offered here.

Medical Regulatory/Certification Bodies can strike doctors off for using their position as a doctor to promote ‘opinions’ on health matters rather than ‘facts’. Very much aware of this, I am confident this post offers facts rather than opinions.

Finally, this post is the first RxISK post to meet Tik-Tok. There are some great descriptions of the side effects above from Tik-Tokers.

• Lilly describes Emotional and Libido Numbing
• Georgia describes A Bad Trip  and is given tricky/scary advice