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Doctors are finally learning to manage antidepressant withdrawal

newscientist.com

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Re: Doctors are finally learning to manage antidepressant withdrawal

#71

Post by MrDrMcCoy »

jaggederest wrote: post #68
Aurornis wrote: post #66

Earlier quoted context omitted.

> After a few weeks I was tapered off them. > I felt no different before, during or after them. SSRI onset is slow, which is one of the common problems with treatment. In studies where they survey both the patient and their family members, the family members actually start noticing improvements before the patient. Onset is slow and it takes a long time for patients to realize the positive effects. Ideally they’re pre…

The other problem with SSRI treatment is that individually they are only barely better than placebo. They're among the worst classes of drugs as far as NNT, effect size or remission rate (individually! STAR-D treatment algorithm works for the vast majority of people) Especially in acute cases, I think they should be replaced or augmented by something stylistically in the direction of esketamine. 6-8 weeks per medicat…

+1 on therapeutic ketamine. Got me out of a bad spot, and felt better long after it was over. You can get it by mail in the US from Mindbloom, who offered excellent care despite being remote in my case.

Re: Doctors are finally learning to manage antidepressant withdrawal

#72

Post by keepupnow »

D-Machine wrote: post #17
burnte wrote: post #11

Earlier quoted context omitted.

> Best way to manage the withdrawal would be to dramatically reduce them being prescribed in the first place. No, that will just hurt more people up front for longer. The truth is antidepressants have a larger effect on mental health than actually gets reported because of how improvements are measured. If you look at a patient who doesn't get out of bed, is in trouble at work/school for performance, doesn't spend soc…

> The truth is antidepressants have a larger effect on mental health than actually gets reported because of how improvements are measured. The truth is actually exactly the opposite, and I provided very high-quality evidence demonstrating this to be the case. You have nothing but bald assertions.

[dead]

Re: Doctors are finally learning to manage antidepressant withdrawal

#73

Post by Aurornis »

jaggederest wrote: post #68
Aurornis wrote: post #66

Earlier quoted context omitted.

> After a few weeks I was tapered off them. > I felt no different before, during or after them. SSRI onset is slow, which is one of the common problems with treatment. In studies where they survey both the patient and their family members, the family members actually start noticing improvements before the patient. Onset is slow and it takes a long time for patients to realize the positive effects. Ideally they’re pre…

The other problem with SSRI treatment is that individually they are only barely better than placebo. They're among the worst classes of drugs as far as NNT, effect size or remission rate (individually! STAR-D treatment algorithm works for the vast majority of people) Especially in acute cases, I think they should be replaced or augmented by something stylistically in the direction of esketamine. 6-8 weeks per medicat…

> The other problem with SSRI treatment is that individually they are only barely better than placebo. They're among the worst classes of drugs as far as NNT,

These numbers are really misunderstood when taken out of context.

SSRIs have an NNT around 7, depending on the study you look at (random Google result https://pubmed.ncbi.nlm.nih.gov/19588448/ as an example )

Which sounds terrible if you know nothing about NNT. But when you learn that Tylenol has an NNT of almost 5 and even a powerful drug like Xanax has an NNT of 4, you realize that NNT is a difficult measure of drug efficacy.

> Especially in acute cases, I think they should be replaced or augmented by something stylistically in the direction of esketamine. 6-8 weeks per medication trial is an absolute eternity

Ketamine and esketamine are used a lot to begin therapy. They’re not good long-term options though, so they’re best used to start treatment as a bridge to SSRI efficacy.

Re: Doctors are finally learning to manage antidepressant withdrawal

#74

Post by jaggederest »

Aurornis wrote: post #73
jaggederest wrote: post #68

Earlier quoted context omitted.

The other problem with SSRI treatment is that individually they are only barely better than placebo. They're among the worst classes of drugs as far as NNT, effect size or remission rate (individually! STAR-D treatment algorithm works for the vast majority of people) Especially in acute cases, I think they should be replaced or augmented by something stylistically in the direction of esketamine. 6-8 weeks per medicat…

> The other problem with SSRI treatment is that individually they are only barely better than placebo. They're among the worst classes of drugs as far as NNT, These numbers are really misunderstood when taken out of context. SSRIs have an NNT around 7, depending on the study you look at (random Google result https://pubmed.ncbi.nlm.nih.gov/19588448/ as an example ) Which sounds terrible if you know nothing about NNT.…

Okay, so we set aside NNT, even though their NNH is also quite low, and that's highly relevant, what about effect size and remission rate? This feels a bit like cherrypicking. And you'll note I said "augmented", as well, if somebody is going through the treatment algorithm with SSRIs, by all means, that's the bridge to stability for somebody on a longer term course.

But many people don't need anything more than acute treatment, so what about them?

Re: Doctors are finally learning to manage antidepressant withdrawal

#75

Post by Xortl »

D-Machine wrote: post #3

Best way to manage the withdrawal would be to dramatically reduce them being prescribed in the first place. The linked article says they have "small to moderate effectiveness", but this is being far too generous. The correct way to measure drug effectiveness is if the treatment meets the standard of a minimal important difference. I.e. you measure depression on various rating scales, like the 17-point HAM-D, and rese…

What's your opinion of the claim that antidepressants have small impact on people with mild to moderate depression, but significantly more impact on people with severe depression [1]?

I ask as a nonexpert because this is a view I've read a few times from people I trust more than most, and I know two people who suffered from severe depression who credited SSRIs for getting them through.

[1] https://pubmed.ncbi.nlm.nih.gov/20051569/

Re: Doctors are finally learning to manage antidepressant withdrawal

#76

Post by Aurornis »

jaggederest wrote: post #74
Aurornis wrote: post #73

Earlier quoted context omitted.

> The other problem with SSRI treatment is that individually they are only barely better than placebo. They're among the worst classes of drugs as far as NNT, These numbers are really misunderstood when taken out of context. SSRIs have an NNT around 7, depending on the study you look at (random Google result https://pubmed.ncbi.nlm.nih.gov/19588448/ as an example ) Which sounds terrible if you know nothing about NNT.…

Okay, so we set aside NNT, even though their NNH is also quite low, and that's highly relevant, what about effect size and remission rate? This feels a bit like cherrypicking. And you'll note I said "augmented", as well, if somebody is going through the treatment algorithm with SSRIs, by all means, that's the bridge to stability for somebody on a longer term course. But many people don't need anything more than acute…

> what about effect size and remission rate? This feels a bit like cherrypicking

Trying to pull out NNT feels like cherry picking because it sounds really bad to people who don’t know how other drugs look on this measure.

If your point is that it would be better if we had better drugs then I agree.

I think trying to imply that SSRIs are barely a step above useless is not helpful, though. Statistics like NNT and remission rates do not capture incremental improvements that these medications can make for people who need all the help they can get. Even if it doesn’t cause complete remission by itself it can be very helpful.

Re: Doctors are finally learning to manage antidepressant withdrawal

#77

Post by OptionOfT »

sandcat_ wrote: post #7

To provide one additional anecdote: I came off escitalopram with no taper after taking it for about five years (10mg). I got brain zaps for a while, got very irritated at times, but largely was fine after a few weeks. Not downplaying the withdrawal effects for some people, but they’re not as catastrophic as this article suggests for many (perhaps most). And overall I’m very glad I took it! It got me through a rough p…

I tried to come off Trintellix. 4 weeks was fine. 5th week immense thoughts of doom. Had to take Xanax to bridge it kicking in again.

Re: Doctors are finally learning to manage antidepressant withdrawal

#78

Post by Rendello »

sneezychl wrote: post #40
Rendello wrote: post #15

Earlier quoted context omitted.

See also: The Serotonin Theory of Depression: a Systematic Umbrella Review of the Evidence (2022). It's worth reading the introduction and results in full, but here are two important quotes (footnote markers removed): > Our comprehensive review of the major strands of research on serotonin shows there is no convincing evidence that depression is associated with, or caused by, lower serotonin concentrations or activit…

The "chemical imbalance" theory is objectively wrong, but still useful in that it conveys the fact that mental disorders have physical causes. It's a purposeful simplification.

Many people take SSRIs and other medications because they believe the serotonin imbalance theory to be the modern scientific consensus. A doctor would be fired and ostracized for using the four humours, but can prescribe life-altering medication after five minutes to correct chemical imbalance, a theory which has never had much support within the scientific community.

Indeed, a rebuttal [1] to that paper starts with:

> Moncrieff et al. report in a review of reviews that depression is not generally linked with serotonin deficiency. This is hardly news to neuropharmacologists, which Moncrieff et al. tacitly admits, as they justify their review by citing examples of laity and general practitioners believing depression is caused by a “chemical imbalance”, i.e., in serotonin. For instance, already in 1986 did Depue and Spoont point out that serotonin deficiency may not be a general cause of depression or other psychiatric illness. Further, that increasing extracellular serotonin—e.g., with selective serotonin reuptake inhibitors (SSRIs)—treats depression does not mean decreased serotonin causes depression.

I have a lot of trust in the science of medicine, but almost none in healthcare. It seems like the research is totally divorced from the medieval treatments I see doctors give all the time. "This is hardly news to neuropharmacologists" vs "laity and general practitioners believe ..." indeed.

1. https://www.nature.com/articles/s41380-023-02090-3

Re: Doctors are finally learning to manage antidepressant withdrawal

#79

Post by D-Machine »

Xortl wrote: post #75
D-Machine wrote: post #3

Best way to manage the withdrawal would be to dramatically reduce them being prescribed in the first place. The linked article says they have "small to moderate effectiveness", but this is being far too generous. The correct way to measure drug effectiveness is if the treatment meets the standard of a minimal important difference. I.e. you measure depression on various rating scales, like the 17-point HAM-D, and rese…

What's your opinion of the claim that antidepressants have small impact on people with mild to moderate depression, but significantly more impact on people with severe depression [1]? I ask as a nonexpert because this is a view I've read a few times from people I trust more than most, and I know two people who suffered from severe depression who credited SSRIs for getting them through. [1] https://pubmed.ncbi.nlm.nih…

Honestly, every time I look into if the "treatment by severity effect" is clearly established, I feel I come away only able to shrug. It is at least plausible, but hasn't been clearly established or refuted.

What does seem clear to me is that the whole cost-benefit considerations change in favor of anti-depressants when the depression is severe. I wouldn't say anti-depressants should be first-line treatments for ordinary depression, but for severe depression, I think they are a very reasonable first-line option.

Sure, they still might not help, but the costs / harms don't seem so bad compared to the potential costs / harms of leaving the severe major depression untreated, and the other options look all pretty terrible here too.

Re: Doctors are finally learning to manage antidepressant withdrawal

#80

Post by ritcgab »

sandcat_ wrote: post #7

To provide one additional anecdote: I came off escitalopram with no taper after taking it for about five years (10mg). I got brain zaps for a while, got very irritated at times, but largely was fine after a few weeks. Not downplaying the withdrawal effects for some people, but they’re not as catastrophic as this article suggests for many (perhaps most). And overall I’m very glad I took it! It got me through a rough p…

Same experience early this year but I did halve the dosage to 5mg for a month, which was of near zero difference. But the full withdrawal? Oh man it is no joke.
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