Dec. 15, 2004 -- Dr. Joseph Glenmullen, a clinical instructor in psychiatry at Harvard Medical School, appeared on "Primetime Live" to discuss the often-unrecognized side effects of antidepressant drugs. Here is a sampling of his answers to your questions on the subject.
Norma asks: Are there currently any class action lawsuits against the makers of Paxil?
Dr. Glenmullen: There is a large group of lawsuits against GlaxoSmithKline, the maker of Paxil, involving patients who experienced Paxil withdrawal. It's not exactly a "class action" but it's similar and called an MDL for multi district litigation.
Annette in Massachusetts writes: Is there a safe way to stop taking Paxil? Any help would be greatly appreciated.
Dr. Glenmullen: There is a safe way: Tapering carefully off the drug. This is true for all 32 antidepressants currently on the market in the United States. One of the most difficult aspects of tapering antidepressants is how widely patients vary in their susceptibility to withdrawal reactions. While one patient may be able to taper off an antidepressant in two months, the next patient may need to take eight months to taper off the same dose of the same antidepressant. So, an antidepressant tapering program has to provide standard dosage reductions for each antidepressant and at the same instruct doctors and patients on how to customize the dosage reductions when patients have moderate to severe withdrawal reactions that require slowing the taper down to keep patients safe and comfortable. In The Antidepressant Solution I present a 5-Step Antidepressant Tapering Program. The five steps are: 1) evaluating whether your are ready to try tapering off your antidepressant; 2) making the initial dosage reduction based on standard tapering schedules for each of the 32 antidepressant on the market; 3) monitoring withdrawal symptoms after dosage reductions; 4) customizing the size of additional dosage reductions if necessary; and 5) safely completing the taper.
Alex in Minneapolis asks: What are the symptoms of antidepressant withdrawal?
Dr. Glenmullen: The symptoms of antidepressant withdrawal can include suicidality, impulsivity, aggression, anxiety, depression, crying spells, insomnia, dizziness, vertigo, nausea, vomiting, headaches, tremors, and electric "zap" sensations in the brain. When patients stop antidepressants cold turkey the symptoms can be so severe that they are debilitating: the patients cannot get out of bed or work. In fact, there are more than 50 symptoms of antidepressant withdrawal. Be sure to educate yourself about all of them before you make your first dosage reduction. If the dosage reduction is reasonable in size, you may not have any withdrawal symptoms at all. On the other hand, if the dosage reduction is too large, you may have severe, debilitating withdrawal symptoms that require you to go back up on the dose and slow the taper down.
Tominell in Texas asks: What tests should a 15-year-old girl take before she is diagnosed bipolar and depressed, other than a verbal interview?
Dr. Glenmullen: There are no medical tests to diagnose bipolar disorder, depression, or any other psychiatric condition: no blood tests, X-rays, brain scans, or any other objective tests. Medical tests should be used to rule out other conditions that can look like depression such as thyroid conditions. But all psychiatric diagnoses are subjective and based on the patient's personal history rather than on objective medical tests. This is what makes psychiatric diagnoses susceptible to being abused at times. In recent years, many patients who have toxic reactions to antidepressants are misdiagnosed as bipolar and put on powerful anti-manic drugs because the pharmaceutical industry has not adequately educated doctors on how to recognize antidepressant toxicity. For years the pharmaceutical industry denied antidepressant-induced suicidality, saying it was the patients' underlying depression. In effect, this was blaming the victims. Now that the FDA has officially warned that antidepressants may make patients suicidal, the pressure to diagnose patients who do poorly on antidepressants as bipolar is the latest variation on this theme of blaming patients rather than the drugs.
Karen in Tulsa wants to know: If antidepressants can make patients suicidal and cause withdrawal reactions, do you prescribe them at all?
Dr. Glenmullen: Yes. I am a moderate in the debate about antidepressants. I prescribe antidepressants to many patients who report how helpful they are. At the same time, I am a critic of over-prescribing antidepressants to patients with mild, even trivial conditions. I advise patients that if they are depressed enough to need medication, they should use other forms of treatment to address the underlying problem and hopefully ultimately wean off the drug. I also argue that many patients are not adequately warned of the side effects and dangers of antidepressants, especially when treated in managed care settings where doctors barely have enough time to write a prescription let alone do a thorough evaluation and educate patients about side effects. With antidepressant-induced suicidality, the most dangerous scenario is when patients are not warned. Under these circumstances, they mistake the drug side effect for a worsening of their condition and are at serious risk to harm themselves. When patients are warned, no matter how badly they may begin to feel, they can remember "This might be the drug, not me. I need to call the doctor right away." Under these circumstance, patients can almost always be kept safe. When antidepressants make patients suicidal it looks very different in most instances from depression making patients suicidal. But doctors and patients need to be educated about how to recognize the difference and how to treat antidepressant-induced suicidality. With regard to antidepressant withdrawal, so far I have been able to get patients off the drugs with a careful taper. Some patients can be off in two months or less while others may take eight months to get off the same dose of the same antidepressant because they have severe withdrawal reactions.
Daisy in Alabama writes: I am 17 years old and after it was suspected that Lexapro was the reason I slashed my entire body with a razor blade on more than one occasion, I was told to just stop taking it. Now I have perpetual headaches, nausea, dizziness, weakness, agitation, muscle pains, hallucinations, cold chills, and problems with my balance. I wonder if, like Paxil, Lexapro is not very effective in adolescents? What percentages of people have reported problems?
Dr. Glenmullen: The only antidepressant that the FDA has approved as effective for depression in children and adolescents is Prozac. Other antidepressants that have been tested for depression in patients under 18 years of age have failed the tests; they were no better than sugar pills. Lexapro is one of the 32 antidepressants that the FDA has warned may make patients suicidal or more prone to self-harm, which is apparently what happened to you. And, like the other antidepressants, Lexapro can cause all the withdrawal symptoms you report if stopped cold turkey. If one restarts the antidepressant and uses a program to taper off slowly, these symptoms can usually be reduced or eliminated so that one remains safe and comfortable. Examples from studies of the percentages of patients affected by antidepressant withdrawal reactions if they stop the drugs cold turkey are: 78 percent of patients stopping Effexor, 66 percent of patients stopping Paxil, 60 percent of patients stopping Zoloft, and 14 percent of patients stopping Prozac. The withdrawal reactions vary from mild to severe. Why do antidepressants vary in the percentages of patients who experience withdrawal reactions? Because this depends in large part on how quickly they wash out of the body when stopped cold turkey; the faster an antidepressant washes out of the body, the more likely it is to cause withdrawal reactions. The brain needs time to adjust to slowly lowering the dose of antidepressants. You shouldn't stop them cold turkey because of the potential for severe withdrawal reactions.
Teddie in California asks: My daughter has been having recent and frequent emotional breaks -- just graduated 18 years old. I have her in therapy and the therapist has prescribed Zoloft -- I am very leery of any antidepressants … but I have a strong family history of emotional/mental illness. Can you point me to further information about Zoloft -- or would you have any advice for me?
Dr. Glenmullen: The FDA has not approved Zoloft for depression in patients 18 years old or younger. Zoloft failed in two studies of patients under 18 because the drug was no more effective than a sugar pill. Yet it is the most widely prescribed antidepressant for this age group. So, be sure to get your daughter a thorough evaluation and good, reliable information on what drugs, if any, the FDA has approved for children with that diagnosis. As many as 89 percent of prescriptions for antidepressants for children and adolescents are for drugs and conditions not approved by the FDA for this age group. This is a serious problem now that the FDA has warned that the drugs can make children and adolescents suicidal.
Angie in Georgia asks: Are you finding similar (adverse) side effects with regards to SSRI's in adults AND adolescents?
Dr. Glenmullen: Yes. The same side effects that occur in children and adolescents also occur in adults. It may be that children are even more vulnerable to some of the side effects. For example, young children are more vulnerable to withdrawal reactions if antidepressants are stopped cold turkey because they have faster rates of metabolism that cause the drugs to wash out of the body even more quickly than in adults.
Sheri in Grand Rapids, Mich., asks: What are the long range side effects after discontinuation? I have trouble with sequential tasks, comprehension, staying focused and complete gaps in memory, which I did not have before … Is there anything I can do to help restore some of the lost skills?
Dr. Glenmullen: This is an important question for which we need more research. Many patients on antidepressants report memory problems. And memory problems are a recognized withdrawal symptom in patients who go off antidepressants cold turkey. But exactly how long-lasting memory problems are has not been adequately studied. The most common reasons why patients don't want to stay on antidepressants indefinitely if they no longer need them are weight gain and sexual side effects. But memory problems are another reason why patients want to go off. But, whereas we know quite a lot about weight gain and sexual side effects, we know little about memory problems and other cognitive difficulties.
Deb in Atlanta asks: Are suicidal thoughts associated with the use of the antidepressants, or more with the withdrawal? Have similar occurrences shown up in adult users?
Dr. Glenmullen: Suicidal thoughts and behavior are associated with both the use of antidepressants and with antidepressant withdrawal. The new FDA warnings that antidepressants may make patients suicidal specifically cite both going up on the dose and going down on the dose as the most risky periods. In other words, one needs to be the most concerned about this side effect whenever the dose changes: when one starts an antidepressant, increases the dose to get more of a therapeutic effect, decreases the dose because of side effects, or tapers off the drugs when they are no longer needed. This is true for adults as well as children and adolescents. The most dangerous period is the first month or two after changing the dose up or down. The FDA warnings list a number of antidepressant side effects that can contribute to new or worsening suicidality including "anxiety, agitation, panic attacks, insomnia, irritability, hostility, akathisia (severe restlessness), hypomania, and mania." Unfortunately, the FDA warnings provide little information beyond listing these side effects. This has created a lot of confusion among doctors and patients. In The Antidepressant Solution, I take each one of these side effects and discuss how they can exacerbate or cause suicidality, how to distinguish antidepressant-induced suicidality from the suicidality of depression, and how to treat antidepressant-induced suicidality. Akathisia is the antidepressant side effect most linked to suicidality and the one that many doctors know the least about. Akathisia is a form of toxic, drug-induced agitation that has long been reported to cause suicide and violence. In light of the FDA warnings, no one should change the dose of their antidepressant, up or down, without knowing how to do so safely and comfortably.
Patricia in Little Rock, Ark., asks: I have serious side effects from using the antidepressant Effexor XR. When I question my doctor, I am given a stronger dosage. Is it safe to reduce the dosage on my own, or do I need doctor supervision?
Dr. Glenmullen: You need a doctor's supervision. Antidepressant withdrawal reactions can be severe, debilitating, and even include suicidal thoughts and behavior. Effexor is one of the worst antidepressants in terms of causing lightning-fast withdrawal reactions that can be severe. Patients who miss their morning dose of Effexor can be in withdrawal by mid-day. If your doctor does not know much about antidepressant withdrawal and tapering the drugs, then educate yourself and get a second opinion.
Ali in California asks: I would like to stop taking Paxil for a healthier alternative, what do you suggest?
Dr. Glenmullen: First, you need to discuss with your doctor whether or not this is a good time for you to taper off your antidepressant. There are a whole series of questions you should consider with your doctor including: Are you no longer depressed? Is this a relatively stable, calm period in you life in which to consider lowering the dose of your antidepressant or are you in the midst of a stressful transition? Are you having side effects that contribute to your wanting to try going off the drug? Are you concerned about the long-term, largely unknown risks of staying on an antidepressant indefinitely if it is no longer needed? If you and your doctor together decide that this is an appropriate time for you to try lowering the dose of your antidepressant, be sure to use a tapering program to do so safely and comfortably. Don't stop the antidepressant cold turkey. There are many alternatives to antidepressants depending on what your original problem was that include psychotherapy, cognitive-behavioral therapy, couples therapy, 12-step programs, and exercise.
Robert in Iowa writes: I have chronic and severe PTSD and have been on Paxil and clonanazepam (Klonopin) for about 8 years now. I can attest to the withdrawal symptoms of Paxil as I tried to wean myself off the drug about 6 years ago. Is there a newer better SSRI or other anti-depression drug that might actually let me feel good? Are there questions I should be asking?
Dr. Glenmullen: If you tried to stop your antidepressant and couldn't because of withdrawal symptoms, a good question to ask is: Are you caught in what I call the "antidepressant catch 22"? Antidepressant withdrawal symptoms like anxiety, depression, insomnia, and crying spells can mimic a patient's original psychiatric condition. Countless patients have tried to lower the dose of their antidepressants and mistook these withdrawal symptoms for depressive relapse. Their doctors make the same mistake if they are not well informed about antidepressant withdrawal. When this happens, patients are needlessly put back on the drugs, often for years and despite severe side effects. In this "antidepressant catch-22," patients are unaware that they were undergoing withdrawal rather than a return of their original psychiatric condition. The antidepressant catch-22 can be avoided by learning how to distinguish withdrawal symptoms from depressive relapse. The distinction is easy to make once one is well informed about the difference between the two. All of the SSRIs can cause withdrawal reactions to varying degrees. In fact, this is true for all 32 antidepressants currently on the market in the United States. There are many other antidepressants you could try besides Paxil. And there also are many other forms of treatment for PTSD that you could consider including psychotherapy and cognitive-behavioral therapy. If you've been on the same medications for eight years and don't feel they are helping, I would definitely talk to your doctor about making a change in your treatment.
Jeff in Houston asks: I have heard of others also having success using marijuana to combat side effects of the antidepressant withdrawal. Is there any movement to look into the use of THC to help people who are having difficulties stopping the meds?
Dr. Glenmullen: The symptoms of antidepressant withdrawal include nausea and vomiting that can be severe. Some patients self-medicate the nausea with marijuana like cancer patients getting chemotherapy use marijuana for the nausea caused by chemotherapy. Of course, marijuana is not approved for antidepressant withdrawal and is not something a doctor can recommend. And, using marijuana runs a number of risks including lung problems, addiction, apathy. So, I advise patients to instead slow down their taper of the antidepressant until they no longer have any nausea or the nausea is tolerable without using any kind of drug (prescription, over-the-counter, or illicit) to "treat" the nausea. The same principle applies to the other symptoms of antidepressant withdrawal like dizziness, flu-like aches and pains, or headaches: Use a program that instructs you how to slow the taper down so your withdrawal symptoms become tolerable instead of trying to treat, or mask, the withdrawal symptoms with additional drugs.