Stopping Antidepressants

Fran, a 36-year-old teacher, initially presented with symptoms of major depression with anxiety. She responded well to an antidepressant and I saw her twice a year for medication management. Nine years later, we discussed stopping the medication. I gave my usual spiel, recommending a one month long taper period.
Fran called a few weeks later on the emergency number. She was sobbing – feeling terrified and anxious. She was nauseated and fuzzy. Her body felt sick, like electrical shocks were zapping her brain and limbs. She was terrified she might have MS.

These were symptoms of withdrawal. We devised an immediate plan for a slower taper. By the end, she was taking small thumbnail “chips” of the pill. It took months until she was comfortable without the medication.

While some can stop antidepressants no problem or with minimal discomfort, more than half of the patients experience withdrawal effects similar to Fran’s.

Psychiatrists knew antidepressants could not be stopped “cold turkey”. We just didn’t know how to stop them. If patients were really miserable, we simply restarted the medication, misinterpreting symptoms as a sign of relapse. Patients hated it so much they wanted the medication back, thinking this was a sign of true need. Discontinuation horror stories are all over the Internet.

Guidelines state that withdrawal reactions are self-limited and last one to two weeks. Simply untrue. Recent studies show that withdrawal reactions can be longer and more severe than initially thought. Restarting medications has lead to a dramatic increase in the length of time patients are on these drugs. How much do we know about long-term risks?

This is not unique to antidepressants. How many of you have tried to stop proton-pump inhibitors (PPIs) for acid reflux? After a few days of heartburn you reach desperately for that omeprazole without giving the body time to adjust. Furthermore, long term use of both PPIs and antidepressants are associated with neurologic diseases like dementia.

Finally doctors are paying attention. There has been a new focus on withdrawal from antidepressants which will hopefully be generalized to other drugs. Research is surfacing about how to manage a safe discontinuation.

When I prescribe antidepressants we discuss withdrawal risks from the beginning. The taper must be super slow – it can take months or years. Dr. Mark Horowitz at University College London says many people “have to pull apart their capsules and reduce the dosage bead by bead”.

I was involved in the first clinical trials for SSRIs. Those were exciting times! Finally we had safer and better tolerated weapons to beat depression. These medications have saved lives. Now we need to be just as skilled at de-prescribing as we are at prescribing them.

CELEBRATE INDEPENDENCE

On the 4th of July Milwaukee is like Pleasantville, USA. This becomes a place where people are “swell and perky.” American flags fly proudly. Kids decorate their bikes in festive red, white and blue. There is a parade with floats, clowns, animals and classic cars. You can win a stuffed animal at the carnival. Roasted sweet corn, snow cones and cotton candy are standard fare, along with plenty of beer.

I love a holiday with no religion.

Family travels in and the walls of our house expand to fit whoever can stand the chaos. My famous American flag cake is expected. I don’t formally invite friends; it’s an open annual event by now. The barbecue grill is fired up for hours. We skip the carnival and the parade and spend the day in the water.

When darkness sets in, we move to the deck, leaning on the railing in anticipation. Local fireworks are launched from a nearby park and we can see them from our backyard. The colors light up the night sky and reflect off the lake. The deep booms and short pops are magnified and echoed in the bowl of the lake. Only after our dog Marley lost her hearing in her later years could she finally relax during the show.

Who can resist the glory of fireworks? Those brilliant, loud, flashes of light mesmerize even the cynics. Scientists say we like them because they scare us. I say they are a part of our collective unconscious. They bring us back to a time we believed in magic. Even when experienced in a group, the experience is paradoxically internal and personal: fireworks stir up a sense of nostalgia, wonder, and possibility.

EAT A PEACH!

Let’s start the weekend thinking about the peach. The vibrant mix of fiery orange and red sweeping its surface. How sexy is that shape – with the round, fuzzy curvature and visible crack? It baits you to take a big messy bite, juice running down your chin. The sweet flesh a wake up call to recruit your sense of taste, smell and touch. When perfectly ripe on a summer day it is 100 percentage fruit – sheer delight.

I brought one to a friend in the hospital. That peach stood out like a beacon in the dull room full of grey machinery, tubes and the monochromatic hospital lunch tray. I’ll never forget the expression when he tasted it.

Where I live, finding fresh fruit can mean waiting for a truck to come in every month. The truck is packed with Georgia peaches and pecans in early summer and gorgeous Michigan blueberries added later in the season. By august thankfully I have my own home-grown cherries and raspberries.

Everything has its time, it’s season. Being knowledgable and active in seeking out fresh, local produce grounds us.
I play with metaphor here as the peach, at the right time, can be a remarkably sensual experience.

Every day life conveniences – fluorescent light, air conditioning, TV, cars, – can distance us from the earth. Savoring a peach pulls us back in.

Ask Dr. Annie K: How Mental Health Can Affect Relationships

 

I’ve (34M) been with my girlfriend (40F) for 3.5 years and very much do still love her. I suffer from severe anxiety and PTSD but have been active in therapy for well over 15 years. My girlfriend suffers from BPD or bipolar (hasn’t been fully diagnosed yet) and unlike myself, is just starting to go through therapy and seeing a psychiatrist as well. I love her to absolute death but she’s become a very difficult person to be in a relationship with and have it not be a miserable ride.

She’ll pin me down for 2+ hours trying to explain and get me to side with some of her destructive relationship behavior. It’s very exhausting and it’s hurting our relationship. I try to give advice, but it usually doesn’t get absorbed or even listened to at all. I don’t look forward to seeing her anymore and I hate that feeling but I’m not sure how or if I can get back to the excitement of being around her again.

What do I do? Establish that we need to take a break? Break up completely? Toughen the heck up and quit being a wuss? I’m at a complete loss because even though we love each other, being her boyfriend while she’s in this state is bringing the most unhappiness I’ve ever felt in my life…

Sincerely,
A guy stuck between a rock and a hard place.

Love+Medicine

Dear Guy,

Thank you for consulting me. It is always difficult to assess the entire picture when having only one side of the story but I will offer my observations.

I am sincerely happy to hear about your own personal progress with your anxiety. You are clearly invested in treating your illness and realize how valuable it is to stay in therapy. You do not want your illness to prevent you from having a healthy, loving relationship.

If you read your letter to yourself again, you will see that the answers are there. You are clearly in love with this woman. Yet you describe yourself as experiencing “the most unhappiness I’ve ever felt in my life.”

This is understandable. Anyone who has a relationship with someone suffering from bipolar disorder knows the challenges. Your girlfriend is just now starting the healing process. It can take time to reach stability.

In the meantime, you are unhappy and this can impact your own mental stability. Giving the relationship a break may be the way to go for both sides. Your partner needs time to get healthy.

You would not be splitting because she has mental health issues. You would do it because you are miserable right now and appropriately concerned about the future.

After a period apart, you can both reassess how you are feeling. A couples counselor can be helpful particularly when confronting painful emotions – especially when facing the possibility of an end of your relationship.

Ask Dr. Annie K: B12 Injections

Love+Medicine Vitamin B12
 

Should I get a B12 shot weekly @ 65 years old?

Love+Medicine

B12 injections have been popular for decades. This is the most fun part of my job as a writer – I learn new things. While researching for this article, I have learned that I am borderline B12 deficient. Enough about me (more later). Let’s get to the facts.

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