Sex, No Sex, Sex, No Sex….

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April 21, 2021 | 19 Comments

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  1. Author interview: Stopping long-term antidepressants in people with depression or anxiety
    a black woman sits on a couch and talks with another black woman therapist
    Antidepressants are widely used for depression and anxiety. Guidelines recommend that an antidepressant should be continued for at least six months after people start to feel better, and for at least two years if they have had two or more periods of depression. Many people take antidepressants for much longer. Ellen Van Leeuwen and Mark Horowitz, authors of a recently published Cochrane review on approaches for discontinuing antidepressant use, answer some questions about the findings of the review.

    Tell us about this Cochrane Review, why did you think it was important to do it?

    Ellen: The rise in long-term antidepressant use is a major concern. For example, in the UK, nearly half of people using antidepressant (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.

    Mark: Antidepressants can put people at risk of adverse events such as sleep disturbance, weight gain, sexual dysfunction and gastrointestinal bleeding, as well as feeling emotionally numb and what they described as feeling “addicted,” because they cannot easily stop the medication. This is because people’s brains physically adapt to antidepressants after long-term use (called physical dependence). They may also impair patients’ autonomy to deal with problems in their life without medication. Guidelines recommend that antidepressants should be taken up to 6 to 12 months after improvement and 2 years after improvement in people at risk for relapse.

    Ellen: As a GP I see many patients struggling with coming off antidepressants that they have been taking long-term. However, I was surprised that there wasn’t a Cochrane review on discontinuing long-term antidepressants, so I started this review. We included all studies comparing approaches for discontinuation with continuation of antidepressants (or usual care) for people who are prescribed antidepressants for depression or anxiety for at least six months.

    What can people learn about discontinuation from antidepressants from this evidence?

    Ellen: 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.
    Mark: Yes, withdrawal symptoms can include insomnia, low mood, anxiety, changes to appetite, and these symptoms will be recorded on the depression scales used to detect relapse, so they might inflate the rate of relapse recorded in groups that stop antidepressants.

    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.
    Ellen: For me, it was disappointing that the large group of people taking antidepressants in the community (i.e. those with only one or no prior episode of depression) have been under-researched. Most published studies focus on people with recurrent depression. Another finding was that we found very low certainty evidence that high intensity psychotherapy such as mindfulness based cognitive therapy (MB-CT) and cognitive behavioural therapy (CBT) may support people to come off antidepressants. But none of the studies included more scalable and accessible psychological approaches such as online support.

    And what can people learn about continuation of long-term antidepressant use?

    Ellen: Based on the limitations we have mentioned, we cannot make any conclusion about this, as we were not confident in the evidence we found. We certainly need more de-prescribing studies investigating the harms and the benefits of discontinuation before we can make any conclusion.

    Mark: Yes, it is very difficult to interpret existing studies that suggest continuation of antidepressants because they are based on discontinuation studies in which half of the patients are stopped – often abruptly or in a few days – compared to a group that continues their antidepressants. This means we can’t be sure whether the group who stopped got worse because of withdrawal symptoms or genuine relapse. To provide clearer evidence on this, future studies should distinguish carefully between relapse and withdrawal symptoms and follow emerging guidance to use taper schemes of many weeks or months (or longer for long-term users) down to very low doses before stopping. Such studies would give us a clearer idea of the ability of antidepressants to prevent relapse.

    Ellen: Additionally, there is an urgent need to include wider representation of patient populations. For example, those people with one or no prior episodes of depression, those with anxiety disorders, and older people including those who take multiple medications (polypharmacy) and those who are frail. Most antidepressants are prescribed by GPs. 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.

    What is the core message for clinician’s and patients?

    Ellen: Overall there remain many uncertainties. However, this review aids clinicians in openly discussing with their patient and with family/carers (as appropriate) the potential benefits and harms of continuing or discontinuing antidepressants including withdrawal.

    Mark: Doctors and patients should be aware that withdrawal symptoms from antidepressants are common and can be mistaken for relapse of the underlying condition. Although evidence found in this review is sparse, experiencing withdrawal symptoms is not a sign that the patient needs the antidepressant, but rather a sign that they might need to taper more gradually and down to lower doses before stopping.

    What will happen next? Are you planning an update or any subsequent reviews on a linked topic?
    Ellen: Celebrating with my team that we made it! No, I am currently working on a PhD of which the review is part of it which I want to defend in 2021. However, I’m continuing further research in the field of long-term antidepressants. One of the recommendations of our review is a further review comparing different discontinuation strategies.

    Mark: At the moment there are a few studies happening around the world looking at discontinuing antidepressants, such as the REDUCE trial in the UK, some including somewhat slower tapers than the studies found in this review, going down to lower doses, and so an update to this review may be necessary in the future.

    Read this review on the Cochrane Library
    Visit the Cochrane Common Mental Disorders Group website
    Thursday, April 22, 2021

  2. Though it seems to me that cognitive symptoms and anhedonia are even worse than sexual impairment (which is very bad).
    Last year you made a post called “gateway to the soul” describing other non sexual symptoms from ssri’s. I could not find litterature documenting persistent non-sexual symptoms, is there? I believe that it would be helpful to ssri damaged people to have that to legitimize their symptoms in a way that cannot be dismissed as psychiatric illness symptoms. Also It feels to me like serious ssri risks like these wont become recognized by the medical establishment or public if they are conceptualized/or only being described in the litterature, as always being related to sexual dysfunction which is embarrasing/humiliating to go public about. If i dont understand it incorrectly you want more of us to come forward publicly?

    • There isn’t a literature on persistent non-sexual symptoms. We are trying to remedy this. Keep an eye on RxISK. Having made that point, there is a literature on persistent withdrawal problems and some of these are almost certainly enduring effects just as PSSD is or Tardive Dyskinesia is rather than classic discontinuation symptoms as happen after opioids or alcohol, which clear.

      DH

      • In this aspect it is great that in her book Generation Zombie, Ariane Denoyel pays attention to the persisting emotional numbing that some persons experience after stopping SSRI medication. This emotional numbing can be more devastating than the loss of libido or other sexual problems. It wipes out a persons personality. Perhaps you even can’t call emotional numbing an adverse effect, as it is used by psychiatrists as a wanted effect of SSRI’s in anxiety and OCD problems. Just numb the emotions of a patient and the anxiety or OCD is reduced. The name Post SSRI syndrome would be more appropriate than PSSD and more in line with the names Post Finasteride Syndrome and Post Accutane Syndrome. Though I realise quite well that it is a real challenge to convince psychiatrists that the persisting emotional numbing is due to their prescribed medication and not due to the formerly psychiatric problems. It would be great if the book of Ariane Denoyel could be translated in English in order to get more attention and recognition to all the Post SSRI problems. We need more publications on the persisting mental problems after SSRI-use.

        • Elra

          What you say about emotional numbing is absolutely true. The reason to focus on genital numbing is not a denial of this but primarily because this is much easier to tackle than emotional numbing. Finding the answer to what has happened in a few testable centimetres of skin has to be easier than finding an answer to what and where – there is no agreement on what emotions are or even where they are located

          David

        • Elra

          I should have also said – everyone should get Ariane’s book – she is really putting these things on the map in a way no-one else has done up till this

          D

  3. Opiods 2x30mgs caused shaking immediately after taking a dose for the first time for pain – ie not withdrawal – is it similar to how symptoms of akathisia begin?

    • S

      This is interesting – it does look like opioids can help some cases of akathisia and restless legs syndrome. One of those situations where if akathisia is bad, its not clear that being dependent on opioids would be worse

      D

  4. ‘No good evidence’ for long-term use of antidepressants

    https://www.heraldscotland.com/news/19256645.no-good-evidence-long-term-use-antidepressants/

    THERE is “probably no good evidence” for long-term use of antidepressants but very little research into how patients can discontinue treatment safely, according to one of the academics behind a major new review into the drugs.

    Dr Mark Horowitz, a research fellow and psychiatrist-in-training at University College London who has studied the neurobiology of antidepressants said studies have consistently failed to distinguish between disease relapse and withdrawal symptoms, adding that it was “absolutely incredible” that millions of people are being left on the drugs for years.

    VIVID and MUST READ article expunged from The Herald today :

    This exclusive ‘Health Investigation’ appears in the Herald on Sunday 25 April 2021:

    By Helen McArdle

    https://holeousia.com/in-the-world/a-sunshine-act-for-scotland/pe01651-prescribed-drug-dependence-and-withdrawal/no-good-evidence-for-long-term-use/

    Aye Peter …

  5. I’m thinking about getting myself a few sprouting jars to produce broccoli sprouts, the supplements are a bit of a tip off. Here is a bit more detail on trials done on Sulforaphane in Autistic individuals. It can’t do any harm in to try it out for ssri protracted withdrawals. It is probably better is you can grow your own sprouts at home.

    https://www.pnas.org/content/111/43/15550.long

    If you want something safe to help you sleep well I’ve had great results using lemon balm, hops, rosemary and chamomile a bit before bed time.

  6. Rapid Response:

    Re: Chronic pain – New NICE Guideline Summary: Antidepressants and chronic pain – chicken or egg?

    25 April 2021

    Marion Brown
    Psychotherapist and Mediator (retired)
    none
    Helensburgh, Scotland
    @recover2renew

    https://www.bmj.com/content/373/bmj.n895/rr

    Dear Editor

    Chronic pain is debilitating and depressing. The new NICE guideline says “Chronic primary pain has no clear underlying condition or the pain (or its impact) appears to be out of proportion to any observable injury or disease” (1). This description or definition of chronic pain is deeply troubling, especially when taken together with the Guideline’s confident recommendation under “management” for pharmacological treatment with antidepressants, “even in the absence of depression”.

    We are hearing from many people who have developed ‘unexplained’ chronic pain conditions after taking antidepressants, as prescribed on- or off-label, and sometimes over many years – and this has often led on to polypharmacy with other drugs added ‘for symptoms’ along the way, most likely including benzodiazepines, z-drugs, opioids and/or gabapentinoids. These are the five classes of drugs that were included in the PHE Review of “Dependence and Withdrawal associated with some prescribed medicines” which reported in September 2019 (2). Of course, all of these drugs add more layers of dependency and other side-effects and adverse-effects – as well as (now slightly better recognised) complex withdrawal problems.

    Building on the work of others, who had already been raising concerns over many years, we have ourselves been campaigning about the issues of adverse effects of commonly prescribed antidepressants (especially) and benzodiazepines since 2014, as summarised in our BMJ response April 2018 “Is the BMJ – and the medical profession that it represents – really listening to patients and the public?” (3).

    Following this, our own systemic research with the All Party Parliamentary Group for Prescribed Drug Dependence, drawing on the detailed written evidence submitted for our 2017 Scottish and Welsh Public Petitions (4), was analysed (together with further patient experience evidence) within the National Guideline Centre 2019 “Patient experience: review of evidence” publication (5) and was included in section 4 on “Patient experiences of harms” in the PHE Review Report 2019 (2).

    In 2020 an expanded version of our work was published by Therapeutic Advances in Psychopharmacology (6), with a specific focus on how antidepressant effects and withdrawal effects are frequently missed or misdiagnosed, and this aspect has been further explored in our article for The Journal of Critical Psychology, Counselling and Psychotherapy “The Patient Voice: Antidepressant Withdrawal, Medically Unexplained Symptoms, and Functional Neurological Disorders” (7).

    In this context, we were stunned to read the statement on 7 April 2021 by NICE (1) that “The antidepressants amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine, or sertraline are the only drug treatments that should be offered to patients with chronic primary pain because evidence shows these may improve quality of life, pain, sleep, and psychological distress, even in the absence of depression” and that “For many commonly prescribed drugs, including paracetamol, non-steroidal anti-inflammatory drugs, benzodiazepines, or opioids there is little or no evidence that they make any difference to people’s quality of life, pain, or psychological distress, but they can cause harm, including possible addiction.”

    So … what the new NICE guideline apparently suggests is that people will be called for review of their medications and recommended to be withdrawn from the ‘addictive’ medicines – and that ‘non-addictive’ antidepressants will be the only pharmacological option ‘recommended’. This scenario is fraught with problems.

    Deprescribing of polypharmacy is complex – and in any case the same people will very likely already be taking prescribed antidepressants, and already be suffering from various adverse effects of these … which (effects) may indeed have led on to the chronic pain conditions which resulted in polypharmacy.

    There have been many concerns raised about antidepressants, which (concerns) seem in this new primary chronic pain guidance (1) to be completely overlooked by NICE, once again. Could it be that the antidepressants are the problem, as detailed by John Warren 2020 “The trouble with antidepressants: why the evidence overplays benefits and unplays risks”? (8).

    The Cochrane Collaboration evidence on “Approaches for discontinuation versus continuation of long-term antidepressant use…”, just published (9), confirms beyond doubt the very issues around the longer-term safety of antidepressants that we have been flagging ourselves – and especially the problems which arise around ‘discontinuation’. In many cases of chronic pain, antidepressants may actually have been the ‘gateway’ drug.

    Herald Scotland has now reported this Cochrane review within the current (April 2021) Scottish context. This makes for alarming reading, certainly rising important questions about antidepressants – and chronic pain – chicken or egg? (10). This Herald report includes information about the Scottish Government Short Life Working Group’s online Public Consultation on ‘prescription medicine dependence and withdrawal’, currently open for public input until 4 June 2021 (11).

    (1) Chronic pain (primary and secondary) in over 16s: summary of NICE guidance. BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n895 (Published 21 April 2021)

    (2) Taylor S, Annand F, Burkinshaw P, Greaves F, Kelleher M, Knight J, Perkins C, Tran A, White M, Marsden J. Dependence and withdrawal associated with some prescribed medicines: an evidence review. Public Health England, London. 2019. Dependence and withdrawal associated with some prescribed medicines: an evidence review (publishing.service.gov.uk)

    (3) Brown M et al. BMJ rapid Response April 2018 Is the BMJ – and the medical profession that it represents – really ‘listening to patients’ and the public? | The BMJ

    (4) Guy A, Brown M, Lewis S, Reid S, Espley K, Cope D, et al. The Patient Voice: an analysis of personal accounts of prescribed drug dependence and withdrawal submitted to petitions in Scotland and Wales. : All Party Parliamentary Group for Prescribed Drug Dependence; 2018 Voice-of-the-Patient-Petition-Analysis-Report-for-publication-081018.pdf (prescribeddrug.org)

    (5) National Guideline Centre. RCP: Carville, S, Ashmore, K, Cuyàs, A, et al Patients’ experience: review of the evidence on dependence, short term discontinuation and longer term withdrawal symptoms associated with prescribed medicines 2019. https://www.rcplondon.ac.uk/file/13705/download?token=F3JJ3PKJ.

    (6) Guy A, Brown M, Lewis S, Horowitz M. The ‘patient voice’: patients who experience antidepressant withdrawal symptoms are often dismissed, or misdiagnosed with relapse, or a new medical condition. Therapeutic Advances in Psychopharmacology. January 2020. doi:10.1177/2045125320967183

    (7) Brown, M. Lewis, S. (2021). The Patient Voice: Antidepressant Withdrawal, Medically Unexplained Symptoms, and Functional Neurological Disorders. Journal of Critical Psychology, Counselling, and Psychotherapy, 20 (4), 14-20 (1) (PDF) JCPCP v20 i04 Brown&Lewis (researchgate.net) Contents – JCPCP, Vol. 20, No. 4, Winter 2020 (egalitarianpublishing.com)

    (8) Warren J B. The trouble with antidepressants: why the evidence overplays benefits and underplays risks. BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3200

    (9) Van Leeuwen E, Driel ML, Horowitz MA, Kendrick T, Donald M, De Sutter AIM, Robertson L, Christiaens T. Approaches for discontinuation versus continuation of long‐term antidepressant use for depressive and anxiety disorders in adults. Cochrane Database of Systematic Reviews 2021, Issue 4. Art. No.: CD013495. DOI: 10.1002/14651858.CD013495.pub2. Accessed 24 April 2021.

    (10) McArdle H, ‘No good evidence’ for long-term use of antidepressants. Herald Scotland 25 April 2021 ‘No good evidence’ for long-term use of antidepressants | HeraldScotland

    (11) Short Life Working Group on Prescription Medicine Dependence and Withdrawal – Consultation on Draft Recommendations – Scottish Government – Citizen Space

    Top-Notch…

    • ‘The antidepressants amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine, or sertraline are the only drug treatments that should be offered to patients with chronic primary pain because evidence shows these may improve the quality of life —-‘.

      More evidence debased medicine? Marketing masquerading as medicine?

      PSSD. PGAD. AKATHISIA + DISINHIBITION —-> Suicidal ideation.
      Changes in emotions, feelings and behaviours misdiagnosed as S.M.I. —-> multiple psychotropic drugging —-> Cascade Iatrogenesis and intolerable withdrawal syndromes must be assumed to be acceptable collateral damage?

      Are the risks of all these dreadful ADRs going to be explained to each of these these patients as would appear to be advised in the 9th November 2020 GMC Guidelines on ‘Decision Making and Consent’?

      I am appalled.

      • MISSD @MISSDFoundation
        ·
        3h

        “I would like people to know the signs of akathisia and that, despite the innocuously worded description in the #patient information leaflet, akathisia can be very dangerous.”
        #Akathisia can cause #drug-induced #suicide

        https://www.youtube.com/watch?v=ibCOhnmM608&t=7s

        MISSD Foundation

        SUBSCRIBE

        This educational video features firsthand experiences of people who suffered akathisia and family members who witnessed akathisia before their loved one’s death. MISSD is grateful to all who help increase akathisia awareness. We present this video in memory of those who have suffered the pain and loss precipitated by akathisia.

        Akathisia is a disorder, induced by medications, including drugs prescribed as antidepressants, that can cause self-harm, suicidality, suicide, and violence. However, few prescribers know about akathisia, and consumers are often left uninformed.

        Visit MISSD.co to learn more.

        For a woman whose husband threw himself in front of a train in Chicago in the throes of Akathisia from a generic version of Paroxetine should have been a final nail in the coffin for GlaxoSmithKline and Paxil, Seroxat but instead the UK Government are heralding those individuals upon whose watch it happened – they are not invisible, yet they are shielded…

        Tim, we are appalled…

  7. In the programme from Germany the reporter meets with Celine Luning- the lady writing her thesis on PSSD and there’s a discussion about why doctors prescribing antidepressants don’t mention possible sexual problems. She says that some doctors may feel its best not to warn patients of possible sexual effects because if they have an awareness of this prior to treatment it may mean these adverse effects are more likely to occur, citing the nocebo effect as a possible reason for withholding this kind of information. This is just crazy as any suggestion patients may somehow induce their own sexual dysfunction is misinterpreting the true nature of PSSD and viewing it as some sort of psychological manifestation rather than the drug induced horror that it really is. I’m pretty sure you can’t think your way to a complete lack of sensation in your vulva and nipples (which Andrea describes)

    When Dr Jorg Signerski-Krieger then asks Andrea about the reasons behind her originally being prescribed antidepressants, I found myself feeling a bit uneasy. Im sure thats a reasonable question to ask someone but he asked this first and I had a sense this exploration of her past history was already being primed towards this being concluded as a mood based issue rather than an iatrogenic one. Its interesting that the lady interviewed on Skype had received a PSSD diagnosis from him but Andrea didnt. It made me wonder how we’re deciding who has it and who doesn’t and whether time on treatment is considered a factor as the lady on Skype had only been on treatment for 3 days before running into problems. The doctor mentioned therapy for Andrea which I interpreted to be some sort of cognitive or talking therapy that presumably would involve going back to Andreas childhood and past pain- yet again focusing the attention in the wrong direction and away from where it should be- on the drug.

    (Andrea herself does appear to comment underneath the video and says she hasn’t as yet received a therapy place and her sexual difficulties have not improved. She says the PSSD association have helped her a lot)

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