Dr. Mark Horowitz (7:25)

Thanks very much for having me on. I'm very happy to talk about this topic.

Dr. Stephanie (7:29)

So let's start potentially with a salacious question. I want to talk about maybe a misdiagnosis crisis that I see in my community. And I've heard you say women in midlife are being medicated for menopause, not necessarily depression. So help us understand the difference. What are some of the symptoms that overlap between menopause and or maybe even perimenopause and depression? And why do you think doctors are very or like a classic GP or even a psychiatrist? Why do you think that they're so quick to run for the prescription pad for a prescription for an antidepressant So

Dr. Mark Horowitz (8:10)

I won't pretend to be an expert in menopause or perimenopause, but, you know, medication is widely used in America and around the world. We know that one in six people are on an antidepressant in America, in the uk, Australia, other countries. We know that it is used more in middle aged women. In the UK, there's good data. One in three women between the ages of 40 and 60 are on an antidepressant. We know that. You know, part of what explains this is that being depressed and anxious is a very common thing. It happens to most of us in our lives. So I'm not sure I would separate clinical depression, that is a mental illness, and menopause. There is just, we all experience moods, we all have downs and ups in our lives. We know by the age of 45, 70% of us will meet criteria for clinical depression or clinical anxiety. So it is an extremely common thing. It occurs in response to life stresses, things, divorce, job loss, death of loved ones. All the things that are inevitable for most of us lead to low mood. We also know that there are physical causes of low mood and anxiety. And some of those include hormonal changes. And I guess menopause is one of them. And because psychiatry and general practice have taken a very, you know, someone meets the criteria for depression or anxiety according to a checklist, you know, do you have these five out of nine symptoms, have they occurred for more than two weeks? You meet the criteria for clinical depression or clinical anxiety. The next step in many doctors minds is to use an antidepressant because that has been, it's ubiquitous now in education, in practice, and so it is an almost automatic response. It would be preferable if doctors would take a step back and think about what is the life context of this person, what's happening in their lives with their relationships with work, with finance, with all the other aspects of our social lives. And also what are the physical things that are happening in this person's life? Is there another reason for them to be depressed? And I guess with your audience you're thinking about, are there hormonal changes that are explaining people's ups and downs with mood? And you're right, all sorts of hormonal changes can cause anxiety or depression. And it's unfortunate that doctors have taken this one size fits all approach to treating any sort of mood issue that walks in through their door.

Dr. Stephanie (10:47)

I like the life context angle because I think that in midlife, I mean, a lot of things happen in midlife, as you mentioned. Hormones. But divorce is very common. We see death of loved ones. And redirect me here if I'm wrong, because I'm not a psychiatrist, but I would think that being depressed or meeting some of those clinical conditions for depression after a mother passes away, a father passes away, a love beloved Peter, or divorce, that you would be depressed. And that is a normal response to the stimulus that you're being presented. And potentially the drugs can help as a crutch, let's say, or a safety net during that time if the person doesn't have, or in addition to, you know, social networks, maybe speaking to a therapist, cognitive behavioral therapy, et cetera. But, but I feel, and maybe I'm wrong here, so this is why I'm asking this question, that maybe the prescription pad is whipped out a little bit too quickly for these medications, when in fact what might be happening is a normal response to this person's life event.

Dr. Mark Horowitz (12:03)

You're totally right. And I'll take it a bit further. I think that low mood, anxiety, all the kind of unpleasant emotions that we experience, have been highly pathologized and medicalized in our modern society. So exactly everything you've just mentioned, divorce, relationship fracture, conflict, work issues, death of loved ones, you know, have caused people to feel sad, grief stricken, depressed throughout history. But what has happened that's new in the modern world is that drug companies and the sort of medical establishment has pathologized these things as abnormal. So I said that most of us get depressed or anxious by the age of 45. It's very clear, it's in response to life events. The more things that go wrong in a given year, the more likely people are to be depressed. The relationship is incredibly tight. If everything goes wrong in your life, if you have 10 stressful life events, your risk of being depressed is very high. If everything goes pretty well, very low risk. I always say if you asked your grandmother what causes depression or low mood, they'd say, life is hard, it makes you depressed. But the modern generations have been kind of suffused with this information that, no, it's all about illness, brain chemistry, serotonin. That is really a narrative that has changed the way we perceive ourselves as human beings. So this is illustrated really well in the uk, and I'm sure it's the same in the us. In the uk there was a campaign run called Defeat Depression, which explained to the public that if you felt low, anxious, hopeless, it was an illness called major depressive disorder. And you should go see your doctor to receive help. They did research on why this campaign was not taken up very well at the beginning and there was two reasons. One, the public thought that low mood meant that you were responding to the events in your life, divorce, et cetera, and that it wasn't an illness. And number two, that if you went to your doctor and received a medication, the medication would be dependence forming and hard to stop. So the campaign, which was run by psychiatrists and GPs, tried to counter these two ideas by saying, no, mental health problems are illnesses just like any other illness, like diabetes or heart disease. And number two, no, the drugs will not be dependence forming. They will be easy to stop when people want to stop them. Now that was very successful. It ran for 15 years, it was fronted by GPs and psychiatrists, it was funded by drug companies and it led to an eight fold increase in the use of antidepressants over 15 years in the UK. And there's been very similar trends in America, in Australia. And so what this campaign and the equivalent of it around the world has done has transformed people's intuitive, sensible ideas about their emotions being readout on what's happening in their lives to thinking about these as diseases, illnesses, chemicals of which there is no proof. You know, the reason why you don't get a brain scan or a blood test when you go to your doctor to diagnose depression is because there are no findings of any biological changes in depression because it is such a normal thing. It cannot be that 70% of us have something wrong with our brains. That is not possible. What is possible is that we respond when we are overwhelmed with stress, with demands on ourselves that we can't cope with, that we become depressed and anxious. It's a very normal response. And so you're right, these things have become medicalized and pathologized. And what do antidepressants do? Let's just bend one minute thinking about that because it'll inform the rest of what we talk about. You know, antidepressants have been sold to the public, especially to Americans, because they've got advertising direct from companies, that antidepressants will fix an underlying chemical imbalance, that depression is caused by something like low serotonin. The drug will restore it, a bit like insulin restores diabetes. It's a wonderful story and it sold millions and millions of drugs. The problem with this story is if you look at the science, there is no robust evidence showing that people with depression have lower serotonin or any other chemical compared to normal people. When you start to realize, well, it's 70% of us, it would be pretty strange if 70% of us had something, you know, abnormal going on. So if there's not this sort of chemical imbalance in depression, then what are antidepressants doing? And there's all sorts of theories out there about inflammation, stress hormones, none of which have been robustly proved in humans. But what we do know is that most people who take antidepressants feel emotionally numbed. And what that means is their normal range of emotions, from very positive to very negative, get squeezed into the middle. And that can be a great relief if you're very anxious, very depressed, or very panicked. But it is not a targeted bullet that gets rid of just negative emotions. It gets rid of the entire range of human emotions. And so people also say they can't cry, they can't feel joy, they lose interest in things, it affects intimacy, relationships. So I think that's a very important reframe to understand what these drugs are doing. It might be a great relief in the short term for the drugs to give people this dampening of their emotions. But it's the number one people. It's the number one reason people come to see me in the long term, because emotional numbing affects people's sense of self, their relationships, their joy. And so I think people should really understand that. And I'll just say, because we'll get there. I think the numbing effect is part of why it might be useful in pain syndromes and things like menopause with unpleasant symptoms. And I think that's worth sort of figuring into people's calculations when they're thinking about is this drug worth it or not for me.

Dr. Stephanie (18:12)

Okay, I love that. So let's walk through somebody who's prescribed an antidepressant. Let's say she's a 45 year old woman, she's walking in, she's telling the doctor that she's not sleeping well, she's feeling more anxious, she doesn't feel like herself, she doesn't want to go out anymore, she has more antisocial tendencies, she walks out with a prescription, let's say for an SSRI or, you know, any, any, you know, an antidepressant. What are the impacts on her physiology systemically. But maybe we can talk about it from a brain first perspective, five, ten years down the line. And I would love to lead this into our, maybe a conversation around dependence on the drug. Like what happens when our system just sort of gets used to or habituates to having this chemical in the body all the time. What happens there?

Dr. Mark Horowitz (19:05)

So I think a few things to say is, number one, there is very little research into the answer to your question. That might be shocking. And it should be shocking because in america There are 25 million people who are on antidepressants for more than five years. And there is more and more people who are on these drugs for decades. And that's becoming increasingly true in Canada, Australia and Europe. Most of the research on these drugs goes for eight to 12 weeks because that is the length of time that the drug companies need to perform a study to have it approved for use by the national drug regulators like the fda. And so there is very little evidence about what goes on in the long term. There are some observational studies. They're not as good as randomized controlled trials that give us a sense of what's going on. So, number one, there are lots of long term side effects. There is a story out there that side effects go away soon after starting, but the evidence doesn't bear that out. People can become tolerant to some of the side effects, which is a sign you're becoming dependent on the drug. But the side effects in long term studies are very common. Most people have side effects from these drugs, and I should also say most people don't attribute it to the drug, their side effects. So, for example, if you take an antibiotic for a week and you start vomiting and having diarrhea, everyone knows that's the antibiotic. When you take a drug for several years and it has subtle effects that build up like emotional numbing, like nausea, like trouble with sleep, it's quite hard to pin it to the drug if it takes months to come on. So what I often see in my clinic is I will sit someone down and pull out the information sheet that's stuck inside the drug packet and say, go through this and circle any of the symptoms that you have. Now, a lot of patients have been told by their doctors, this is a list of possible side effects written by the lawyers. Don't worry about it. I say this is a list of side effects written by the lawyers. You should really worry about it. If it wasn't serious, they wouldn't be putting it in these documents. Most people will circle 10 different symptoms that they have. I'll give you some examples of what people experience. We know that between 50 and 80% of people who take antidepressants long term will have treatment caused sexual side effects. That means less desire, less ability to become aroused, less ability to have an orgasm. We also know that when people stop taking their antidepressants, for some of them, we don't know how many quite yet. Those issues will persist. It's called post SSRI sexual dysfunction, PSSD. Some studies say it happens to one in 200 people that take an antidepressant. Some say it's one in seven, which is really concerning. So there's a sexual issue. There is weight gain. In the short term studies, most of these drugs don't produce particularly big changes in weight to any of the participants. But in six to 12 weeks, there's very little time for that to occur. In longer term studies where they have tried to isolate the effects of antidepressants, 30% of people become overweight and 30% of people go from being overweight to being obese. And so there's several kilograms of weight put on to translate that into American. That means 20 to 30 pounds of weight over several years of use of antidepressants. They also cause impairments in memory and concentration. And I think this is where it's worth thinking about what I said before. When you have a drug that you believe is normalizing normal function. So if the drug was rebalancing out chemicals, that sounds very safe. You know, when I hear about insulin being used for diabetes, it doesn't worry me that much because it's replacing the lack of a normal chemical that you have. But when you understand that there is no abnormality in the chemistry of people that are depressed when we're given antidepressant, we are changing the normal chemistry of the brain. And you can predict from that you're going to have some kind of disruption to normal function. So in healthy volunteers, antidepressants impair memory. They impair the ability to concentrate and to attend to information, and they impair sleep at nighttime. And so all of those things occur in people taking antidepressants. One of the ironies is the people are often given antidepressants for insomnia. But study after study shows that these drugs disrupt normal sleep rhythms. They disrupt REM sleep, which is why people often dream less. They disrupt slow wave sleep, which is why people feel less restored by their sleep and often wake up tired. And it's also, I think, probably why people have impaired concentration and memory on these drugs. Other issues are there's a whole long list. Nausea, headaches, dizziness, postural hypotension, where people stand up, they can feel dizzy. And then the emotional numbing that I've mentioned, which, whether you see it as a side effect or the intended effect of the drug, people find that concerning after years of use, I'll say one More thing issues with their gut because there's a lot of serotonin receptors in the gut. People can develop things like diarrhea, constipation, bloating. I have seen many people on antidepressants being given a diagnosis of ibs, irritable bowel syndrome. And I've also seen it disappear when people stop antidepressants. And that's the last point I'll make here is people, when they come off their antidepressants, then realize in retrospect how many different effects they were having on them whilst they were taking them. That's one thing that becomes clear.

Dr. Stephanie (24:59)

So there's two things that came to mind when you were talking. One I think it's worth talking about. You've mentioned it a couple times, but often people will say, Well, a type 1 diabetic has an insulin deficiency and therefore they need insulin in order because they're not creating insulin. So we need to give that patient insulin.

Dr. Mark Horowitz (25:20)

Yep.

Dr. Stephanie (25:21)

The monoamine hypothesis, which is what I think you're referring to, is this fundamental hypothesis that. And again, you can, you can say this better than I can, that your depressive symptoms are coming from a lack of serotonin. They're coming from a lack of certain neurotransmitters that have, you know, impacts on the brain, like feel good, like that helps to augment and improve your mood. I would love for you to just talk about whether or not we have ever validated this idea that someone who is depressed doesn't have enough serotonin. And then the second piece to this, when you're listing out some of the symptoms, which are horrendous, by the way, and I agree with you, if these are, these are. If it's a slow creep, it's going to be next to impossible to chronologically pinpoint that to something that you started taking two years ago or three years ago with the weight gain. I mean, 30. I wrote this down here, 30% overweight. And then. So 30% of individuals become overweight and then 30% of individuals who are overweight become obese. And I think that there's a lot of discussion today around medications addressing obesity. And there is a. And I know that you're not an endocrinologist, but I know that there's a, there's a lot of, we'll say, hi, hypothetical proposals for this idea that obesity is genetic. Now, there are genetic tendencies, right. There are different reward cascades in the brain. There's different responses to the brain to certain things. But I also wonder if we are looking back to some of These stats, like 1 in 3 women in the UK are on an antidepressant. 25 million in the States are on some type of antidepressant. If that is not a big driver of the weight issue that so many. If you are a woman, you're 45, you've been on an antidepressant since you were 35 and now you're saying, oh, my waist is disappearing in midlife, I need to get on a GLP1, like, I wonder. And not to say like, you know, again, again, use the medication as it, you know, to create an opportunity for you, if that is the right decision for you. And you under. You're informed, you have. You understand side, you understand risks. But I wonder if that also could be driving a lot of the obesity issues, as there's so many women who are not ascribing the antidepressant to some of their weight challenges.

Dr. Mark Horowitz (27:47)

So, I mean, I won't pretend to be an expert in obesity, but it would be impossible if 30% of people who are taking these drugs long term are going to develop either becoming overweight or becoming obese. And there is. There's 56 million Americans on antidepressants, 25 million of whom are on them for more than five years. It would be impossible if that doesn't have some contribution to what is going on with weight. Of course, there's many, many factors. Yes, it's very unlikely to be just antidepressants, of course, but it would be very unlikely if that wasn't one factor, of course. And in relation to the serotonin, the monoamine hypothesis you brought up, I mean, I think it's pretty clear now that depression is not caused by a chemical imbalance. It's not caused by low serotonin. The American Psychiatric association has removed that from its website. Most major psychiatric institutions have said that is not the case. I can tell the story briefly about where that's come from and why it's so prevalent. In the 1950s and 1960s, there was a hypothesis. That's why I use the word hypothesis means a good guess, a clever guess, that depression might be caused by low serotonin, because they saw that drugs that increase serotonin make people feel better. Now, that itself is a fallacy of reasoning that has a name. It's called the Ex Juphantibus fallacy. Fancy Latin. It basically means, just because something makes something better doesn't mean the opposite of it made it go wrong. For example, aspirin improves headaches. It doesn't mean that headaches are caused by aspirin deficiency. But anyway, that was the hypothesis. There's been 60 years of research since that hypothesis. Different authors have summarized it. I happen to be involved in a group that summarized it about three years ago in quite few a. A paper that got a lot of attention, where we looked at all existing studies looking at serotonin in depressed people and healthy volunteers in their brains, in their urine, in their cerebral spinal fluid when they died in their autopsies. And the answers were quite clear. There was no difference between both groups, healthy volunteers and depressed people. There was no differences in any genetic, any level of serotonin between the two groups. The response to our paper, which was covered around the world because it was such a surprise to the public and to journalists who assumed that it had been proven that depression is caused by low serotonin. The response from psychiatric institutions was mostly, we already knew this. This isn't news. So there was sort of a disconnect between what researchers in psychiatry understood for years that this is not the case and what was communicated to the public. Psychiatrists have come out and said various different explanations for why that happened. Some of them have said it was a neat story to tell to summarize complex things. It was a way to encourage people to take their medication, you know, which I think is very unfair because if I was told that I had an electrical imbalance in my heart and this drug will fix it, and it turns out there is no electrical imbalance, then I feel that I've been misled to take a drug under false pretenses.

Dr. Stephanie (31:00)

100% shut up and take your drugs and be a good girl. That's what that sounds like. You're too dumb to understand what's going on, so just take the drug and be quiet.

Dr. Mark Horowitz (31:09)

And I think it was definitely spread by drug companies. There's a famous ad in America of a little kind of unhappy blob. This is by Zolt, the company that makes Zoloft Unhappy Blob. Blob sort of going along, crying. And it sort of zoomed in on its brain where it had low serotonin. Then they gave it soul loft and sort of the rainbows came out and the chemicals were back to being normal. And that was a very popular advertisement on TV for years. And so the public, if you ask the public now in America, 90% of them say that depression is caused by a chemical imbalance. So the advertising has been incredibly successful. It also was all way. All through medical textbooks. And so lots of doctors think the same thing. And so there is this. You know, people think that insulin for diabetes is the same as antidepressants for depression. And that is that is not the case.

Dr. Stephanie (32:00)

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Dr. Mark Horowitz (34:24)

Right, so it's a really interesting game that's being played. There was a famous documentary in the UK by the BBC called Panorama. It's the big expose. It's the equivalent of 60 minutes or I'm not sure in America what the equivalent is. And they had the executive of a drug company that makes a highly dependence forming antidepressant. And they, they said, tell us about this drug. And he said, it's not addictive. And that is probably true, but extremely misleading for the following reasons. So if a drug is addictive, it means you want more of it, you crave it, you become obsessed with it, you'll misuse it. If it's around, you use up all of it, you're going to go rob your neighbors to get more of it. That's addiction. And antidepressants do not do that because they don't get people high. They're not highly reinforcing, so they don't do that. But much more important than that is physical dependence. Physical dependence is what happens when you use a drug that affects the brain multiple times. Your brain gets used to it. So, you know, if you use a drug that increases serotonin, your brain gets used to high levels of serotonin and it adapts to that. It becomes less sensitive to serotonin. So I'll give an example. I'm going to assume maybe you're above average healthy, but that you and many of your listeners are using caffeine and are therefore dependent on it. Caffeine, you know, if you stop using caffeine, you'll get a withdrawal syndrome. That's a sign of dependence. I'm going to assume that nobody in your audience is snorting caffeine, stealing from their neighbors to get more caffeine, or selling their bodies, you know, on the street to get caffeine, because none of them are addicts. But they're all gonna be physically dependent because their brain and their body has gotten used to repeated exposure to the drug. And the same happens to antidepressants, actually to all psychiatric drugs, benzodiazepines, gabapentinoids, all of them. And now that means that if you've used it for a few weeks, often your body's become dependent on it. And now when you come to stop it, your body's gonna miss it. It's used to getting certain number of units of serotonin enhancement every day. And now it sees when you stop it as a deficit and that's why you go into withdrawal when you stop it. Now, doctors will often say only addicts get withdrawal, and that is completely false because that would mean that nobody that stops drinking caffeine should ever get withdrawal effects. The scientific necessity for withdrawal is to be physically dependent. Addiction is something else. So all you need is to have adapted to a drug for withdrawal. And we know that after long term use, most people will have withdrawal from antidepressants. It's not rare, it's not some person who's injecting it in their bedroom. It's to most people that are using these drugs for more than a few months, and especially those using it for more than a few years.

Dr. Stephanie (37:25)

Okay, so the mechanist in me wants to understand how the dependency. So it's not addiction, we understand that, but there's a physical dependency. So what is the mechanism that causes that dependency?

Dr. Mark Horowitz (37:37)

So again, like with so many things in this area, there isn't a lot of research, but this is what we know. So the overall explanation for dependence is any change that your brain makes to a drug while you take it will be reversed when you stop taking the drug. So if you look at people who are taking antidepressants, what you can see in their brains after just a few weeks is down regulation of serotonin receptors. So that's a fancy way of saying you're getting bombarded by serotonin. It's sort of like the body has put down the accelerator on serotonin and so now in response you're your body and brain puts on the brake. So serotonin is being knocked at your system. Your serotonin receptors become less sensitive and less numerous. So now it's like someone's screaming at you and your eardrum becomes less sensitive to sound. And now when you. And there's all sorts of things downstream, that's just the beginning of the cascade. Serotonin affects dopamine. That's one of the reasons, I think, that people become numbed on the drugs increase serotonin, you inhibit dopamine. Dopamine is supposed to give things salience and meaning. And that's one reason people think these drugs might be numbing. There's all sorts of effects on the way your brain works. And of course this is happening not just in your brain, but in your guts, in your hormonal system. Why are people putting on weight? Obviously because these drugs affect the hormonal system. So there's all sorts of effects happening throughout the body. The main thing is that the body is becoming adapted to this increased signal of serotonin, amongst other effects. And now when you stop the drug, the body is used to there being all this serotonin. It doesn't get it. And so the experience is of something like a low serotonin syndrome. That's what withdrawal is. So rather than it being in depression, which has never been found, actually withdrawal can create a legitimate low serotonin situation. I'll give you a quick analogy using the sound example. You go to a loud concert, your eardrum becomes less sensitive to sound. That's the adaptation or dependence to sound. When you walk out into the quiet street afterwards, your friends voices sound muffled for a while. It's actually a sound withdrawal syndrome because your eardrum is used to this very loud sound. It takes a minute or two for your friends voices to sound normal again because that's the time taken for your body to adapt to the drug not being there. The same sorts of things happen with antidepressants. You stop the drug, your body is sort of screaming out for serotonin. And rather than taking a minute or two, like leaving a loud concert, we know it can take people months or even years for their brain to go back to their normal level of serotonin sensitivity after stopping the drug. And that's why people can have long lasting withdrawal effects after stopping. People always think withdrawal means a few days, a week or two. They've seen train spotting, they think about that. But when it comes to coming off antidepressants, because they're taken every day, year after year, in lots of people, it can take months or years for the body and the brain to recover to how they were before the drug was there.

Dr. Stephanie (40:52)

Okay, so let's talk about withdrawal. When I was in clinical practice, I would be supporting patients with pain management. And while their, their pcp, their GP or their psychiatrist was, you know, maybe facilitating a taper and it's like, God bless these people because it, I mean I had so many patients that they literally felt like they were dying. And sometimes they would get to this like level of tapering where all of their symptoms would come back. They, and it almost felt like it was worse than before. And often the, the narrative was like, well we, we need to increase your dose again. So let's talk a little bit about maybe the difference between withdrawal and relapse and, and relapse and what, what is going on in the brain when somebody is saying, okay, so I've been taking Lexapro, I've been, you know, whatever I've been taking for a while and Now I would like to see if I can manage with a lower dose. What happens to the brain? How can we, how can we help? If someone chooses to. To taper or to reduce their, their reliance on it and what happened, there's that little. There's that moment where they reduce it to a certain level and then everything gets worse. And so they feel like, okay, maybe I just, maybe my symptoms are coming back. Maybe I really do need this drug now. And then they increase their, their dosage and they just have a hard time getting off that last sort of, you know, it's like they get to 80% of the way or 90% of the way, and then that last 10% just seems insurmountable.

Dr. Mark Horowitz (42:22)

Sure. So let me talk a bit about withdrawal first and then talk about ways to avoid it second. So, you know, why do you get withdrawal? Again, we don't know all the details, but your brain gets used to the drug. The entire system has adapted to these new levels of transmitters, and suddenly it's thrown into these lower levels and it is scrambling to catch up. In the same way as when you come off alcohol, you get a whole lot of withdrawal symptoms. It's the same for any drug around. I think that's a comparison worth making. When we think about antidepressants as being like insulin, that normalizes a bodily process that doesn't make sense to get withdrawal from insulin. But when you start to see that antidepressants are affecting our thoughts and feelings, numbing them, not that that differently from recreational drugs, you understand why when you get used to them and stop them, you get withdrawal effects as you do from amphetamines, benzodiazepines, or alcohol. We know that these drugs affect the central nervous system, the peripheral nervous system, the gut, and you get withdrawal effects in every one of those categories. So the most common withdrawal effects people get are actually psychological symptoms. Anxiety, low mood, irritability, panic, becoming suicidal, obsessive thinking. Now, you said people get afraid their symptoms are coming back or that they feel that they are. Now, it's possible, but I just spent a minute sort of unpacking that. Number one, we know from studies of people who are given antidepressants for reasons other than mental health problems, given it for pain, given it for the menopause sometimes, or given even to healthy volunteers when they stop the drug, they get low mood, anxiety, panic, irritability, suicidality. So you don't need any underlying condition to get those symptoms. So it's not necessarily a sign of things coming back. It could well Be completely new symptoms, withdrawal symptoms. But you're quite right, it's very confusing. You know, it can feel like your old condition coming back. There's a few clues. If it's more severe, that's a clue. It's withdrawal. If it's a novel symptom, something you haven't had before, that's a clue. The confusion comes. I'll give you another example, because if both you and I sat down and drank a liter of very strong coffee, we'd both get very anxious, but we'd both get anxious in different ways. You'd get anxious in whatever is typical of your way of thinking, and I'd worry about my hair. In other words, you know, the chemical cause is being filtered through our particular minds. And so we get quite kind of idiosyncratic symptoms. And that's why people can feel that it's very similar to relapse or a return of their underlying condition. But I'd just like to problematize the idea of relapse altogether. If you think about depression as being response to your mother dying to divorce, it would be very strange if five years later, when you come off the drug, you have a return of divorce or of your mother dying. The idea of relapse is all situated in this medical model that depression is about a chronic brain problem that's kicked off by certain events in your life that will come back if you don't medicate it, like diabetes. I think that entire frame is misleading. If you think about depression as being a response to our lives, the idea of relapse occurring when you're in a different situation, you know, it's possible people can still have the same stresses going on. But the assumption that relapse is very likely, I don't think is well supported. In my experience, most of the time, when people come off a drug and they have symptoms, it's most often withdrawal and not relapse. But doctors are very much trained in the medical model that if you stop these drugs, it'll come back. Patients are told that again and again. So people jump to conclusions. The second set of withdrawal symptoms are physical symptoms that make it easier to untangle. So I talked about the psychological ones, which are the most common and I think the most concerning. But there's also a whole set of physical symptoms because these drugs affect the gut, the hormones and the brain. There's headache, there's dizziness, there's something called brain zaps. These little shocks people get in their heads sometimes on moving their eyes. People can get shooting pains anywhere. In their body. In fact, they can have gut problems, nausea, vomiting, constipation, diarrhea. They can also develop quite severe symptoms like akathisia. It's a kind of jargon term. It's a Greek word meaning can't keep still. It's this kind of incredible agitation that makes people pace backwards and forwards. Those are the sickest people I see in my clinic and get. Get endless emails from. And inevitably what you're pointing to happens. A doctor concludes when someone turns up to their clinic or to the emergency department in a panic. I've just stopped my drug two weeks ago. I can't sleep. I'm having panic attacks. The doctor will stop you there after 30 seconds and say, you must need your drug. You must need to go back on it. No one explores. Is this a withdrawal effect? Do you need to come off more slowly? I'll just give you. Just to make it. Just to sort of bring out the absurdity of it. It's kind of like if someone said, I've just quit smoking and I feel so anxious and so irritable. And the doctor says, well, you better go back on your cigarettes to prevent this anxiety and irritability that's affecting you. We would never say that about cigarettes because we all know they cause withdrawal effects. But because knowledge about withdrawal effects from antidepressants has been so minimized and suppressed, most doctors are not aware of how common they are. And they're always thinking about relapse. And that leads to the exact misdiagnosis that you're talking about that you saw in your patients, where doctors are saying this withdrawal effects are a sign. You must need the drug. You better go back on it, maybe for the rest of your lives. And that leads to huge amounts of unnecessary medication for people who could have come off more slowly. And I can talk you through what that looks like, coming off more slowly and why. Why that's useful.

Dr. Stephanie (48:30)

Yeah, I think that's my next question. So let's say that we have identified that these are withdrawal symptoms. Maybe we have tapered too quickly. How can we manage the withdrawal symptoms while still honoring the desire of the patient, which is to eventually taper themselves off of these medications? So how can we. I don't know if treat is the right word. Care for the withdrawal symptoms of the patient. What do we do in that case?

Dr. Mark Horowitz (48:59)

So there are basically three main principles to coming off an antidepressant safely. The first one is that it takes longer than people think. The slower you do it, the easier it is. I'll give you an example. Altitude sickness is what occurs when you go up a mountain too quickly. The air pressure drops, your body can't adapt to it, you get all sorts of symptoms, dizziness, headache, joint pains. The way to avoid altitude sickness is you've got to go up more slowly. So it's not the hype that kills you or gets you, it's the rate at which you go up. It's the same and it's also a kind of withdrawal syndrome. It's a withdrawal from ground, sea level pressure. The same is true for coming off antidepressants. If you come off in four weeks, like most doctors suggest in America, around the world, because it's what guidelines say most people, most long term users will have a lot of trouble coming off. If you come off over several months or sometimes more than a year, the issues are much less. So the rate at which you come off plays a very big role. That's issue number one. Principle number two is we know there's a few risk factors for who gets trouble and who doesn't. One of the main risk factors is how long have you used the drug for. Another risk factor is which drug you're on. Drugs like Effexor, Venlafaxine, Cymbalta, Duloxetine, Desvenlafaxine, Pristique, Paroxetine, Paxil are much higher risk than other antidepressants. But all antidepressants carry with them some risk. I think that actually Effexor, Venlafaxine is one of the drugs most used for the symptoms of menopause. So that's probably particularly relevant to your listeners. We know that those drugs have many times the risk of withdrawal compared to other antidepressants. Dose plays a bit of a role. Past experience plays a bit of a role. The more you've been on and off drugs over time, probably makes things worse if you've been on and off drugs several times. People talk about a kindling effect where every attempt gets harder and harder. So people who had no trouble the first time, when they've come back on the fourth time for whatever reason, it seems to be a lot, a lot harder to come off.

Dr. Stephanie (51:11)

It's like a yo, yo dieting, something

Dr. Mark Horowitz (51:13)

like that, sort of. Yeah, yeah, yeah, yeah. And so I say this because we can guess a little bit who's going to have trouble, but we can't do it perfectly. And so the second principle is you've got to adjust the rate of taper to what you can tolerate. If you start to get Withdrawal symptoms. It's a sign that you need to pause, go back a step, and go more slowly. And the third principle is where I'm going to share a picture with, I hope a thousand words.

Dr. Stephanie (51:38)

So for those of you that are listening, we will put this. We will make this available on YouTube as well, so you can head over to the YouTube channel to see this as well.

Dr. Mark Horowitz (51:46)

Okay. So I apologize for. For this kind of. This onslaught of. Of neurobiology to your listeners or watchers, but I'll try to make it.

Dr. Stephanie (51:54)

Oh, they love it. They love it. They love it.

Dr. Mark Horowitz (51:56)

Okay.

Dr. Stephanie (51:56)

It's great. Yeah.

Dr. Mark Horowitz (51:57)

So this is a neuroimaging study of. Of people's brains who are taking antidepressants. And the antidepressant that I'm showing here is citalopram or Celexa, which is extremely commonly used in America and around the world. And on the Y axis, there's a very complicated term there, but just think about it as effect on the brain. And what I'm going to show you for Celexa is true for all antidepressants. I'm using this to illustrate what this graph is showing is that there's not a straight line relationship between dose of these antidepressants and effect on the brain. So the most commonly used doses around the world are 20 milligrams and 40 milligrams. The smallest tablet in lots of countries is 20 milligrams, and some countries have 10 milligrams. Now, you can see that increasing the dose from 20 to 40 doesn't double the effect on the brain. In fact, there's not that big a difference. And most importantly, a little tiny dose like 2 milligrams that most doctors would laugh at as being homeopathic actually has about half the effect as 60 milligrams, much bigger than you'd expect. The reason for this relationship is something called the law of mass action. What it means in simple terms is when there's not much drug in the system, in the brain, all the receptors for the drug, the bits of the brain where the drugs kind of click into, are open for business. And so every milligram of drug at low doses has a very large effect on the brain. A little bit like the game of musical chairs, when there's early in the game, there's lots of chairs to sit down, it's easy to find a chair. As there's more and more drug in the system, more and more of the receptors are filled up with drugs, more and more of the chairs are taken and it becomes harder and harder to find a spot. And so every extra milligram of drug at high levels has less and less incremental effect, and you get this sort of law of diminishing returns. And this graph happens to be a hyperbola, is the mathematical shape. Now, all of that is to explain what happens when people come off their antidepressants in the way that most doctors recommend. Most doctors say something like, why don't you halve your dose from 20 to 10, halve it again to 5 and then stop it? It's very easy for a doctor to recommend that. You can split tablets in half. It makes their life very easy. It's just very hard for the patient. Because when you go from 20 to 10, the change in effect on the brain is something some people already find that extremely unpleasant, but some people can handle that from 10 to 5 is a bigger change again, but when you go from five to zero, it's like jumping off a cliff. It actually has about 20 times the effects of reducing by 5 milligrams from 20. So the same size reduction has about 20 times the effect at lower doses. And this is exactly what patients describe. The first few milligrams are easier to come off and the last few milligrams are hellish to come off. And so the way to get around this trap is rather than coming off by fixed amounts of dose, so the 2010 5, it makes more sense to come off by even amounts of effect on the brain. Again, I'll make it a bit simpler. Imagine if this was a walking path. You could start off by walking down it pretty quickly, no big deal. As it gets steeper and steeper, you need to go slower and slower until you're basically climbing down a sheer mountain face and you have to go inch by inch. And that's the same approach for coming off these drugs. You need to go down by smaller and smaller amounts, down to extremely small doses before stopping, so that you're not jumping off that cliff in the last picture. And so these doses get down very small, much smaller than the most than the smallest commonly available tablet or capsule from a pharmacy. And this approach is called hyperbolic tapering, because this is a hyperbola. That's a bit of jargon. And so this is the best way to come off in these reducing doses.

Dr. Stephanie (56:22)

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Dr. Mark Horowitz (57:54)

And the next issue that brings up is how to make up those doses for people. And that's a kind of issue because you can't use tablets or capsules from the pharmacy for most drugs. Some drugs come as liquids made by their manufacturers, which doctors can prescribe. Once you have a liquid that's very easy, you can use a small syringe to make smaller doses. And there are also tricks of the trade where you can crush up tablets, open up capsules to count beads like Effexor or Venlafaxine, where people are sort of a little bit forced to become kitchen chemists. A bit like Walter White in Breaking Bad, unfortunately, in order to make those very small reductions that allow people to come off their drugs. And so to put it all together, coming off slowly over months and sometimes more than a year at a rate you can tolerate, using either a liquid or other ways of making small reductions over time is the best way to come off these drugs. And a good rule of thumb is to reduce by about 10% of your most recent dose every month. That's my spiel in two minutes.

Dr. Stephanie (59:05)

I love that. So with this hyperbolic tapering, what is the success rate? And can you compare that to, you know, a traditional tapering recommendation? Let's say that, you know, that you outlined before where someone says go from 20 to 1010 to five, five to none.

Dr. Mark Horowitz (59:21)

Great question. There are no randomized trials answering that. We're trying to do one right now. But there are lots of studies that get people who couldn't get off their antidepressants with their doctors in the usual way and give them the ability to do this tapering, either by giving them smaller tablets or some other way of doing it. And I've also seen that in the clinics that I've run, my experience is that people who are prepared to do it as slowly as it takes, which can be a year, can be two years after long term use, are prepared to stop when they get into trouble, go back, go down more slowly. I see success rates 90% plus. I think that the biggest, I think there's two major barriers there. One is accepting it'll take you several months, maybe more than a year, and two, that you've got to use these fiddly ways of doing things, liquids or other ways. Then I see extremely high success rates. In published studies, the success rates are a bit less, they're 70%. But in those studies I think the tapering rates are quite quick. So people come off in four months, which I think is quite quick. So even that most of those people were not able to come off with their doctors. So already that's a huge improvement. So I've seen if you can accept the slowness that it takes, that the vast majority of people can come off their drugs if they do it slowly enough and are sensible.

Dr. Stephanie (60:45)

So I have two questions that I've been thinking about as you've been talking. First is, I know that there are a lot of women who are listening to this who are on some type of antidepressant. How can they determine for themselves? How do they know when they're ready? Right, so maybe they've been on whatever it is for effects or for 10 years, 5 years, 2 years. How do they know that it's time to get off the drug? You know, we were saying at the beginning, maybe the numbing, if you're having a huge life event, maybe that numbing is actually beneficial. There's, it's a, it's a crutch, if you will, to help you through a very difficult time. Why would somebody say to themselves, okay, now is the time that I, that I want to get off the drug. And how do they know if they're ready? And I don't know if you can answer that for every woman or for everyone listening, but what are some of the questions that you might invite someone to answer for themselves around this, it's

Dr. Mark Horowitz (61:43)

a great, it's a great question and you're right, it's hard to answer for everybody or I'll give you some of the broad ideas to think through. Number one, these drugs were never designed to be used long term. The studies that have been done on them go for 8 to 12 weeks. Most guidelines around the world recommend that for an episode of depression or anxiety they are used for six to 12 months. If we have time, I can go into why even those guidelines are not based on good evidence. But let's take them at face value now and that longer term use of a couple of years or more should only be reserved for severe recurrent conditions. Most people given these drugs have mild or moderate symptoms. So most people around the world do not meet criteria for being on these drugs long term. You know, there is this culture of set and forget that happens in America and around the world. And so most, when they do analyses of people sitting in GP offices, they find that 50% at least just don't need to be on antidepressants anymore, according to what I would say are very overly conservative guidelines. And so this idea of open ended medication was never meant to be. It's just become, I think there's a few reasons why that's happened. Number one, doctors are asked, why don't you stop medications? They say, don't upset the boat, don't upset the apple cart. I'll wait for the patient to say something. Patients are saying, they're waiting for the doctor to say something. They, they're deferring to medical expertise. So people are sitting there for years. No one's bringing up the issue of should they be on this drug that has all of these side effects and very questionable benefits. The other issue is people are told that story about insulin and diabetes. People with diabetes don't stop insulin. So if they have this idea in their mind, we know from studies people who believe that are less likely to stop their drugs even when it's no longer needed. So I think we need to have a conversation about what is causing depression. Is it chemical? Is it about life circumstances? People need to be told this drug company line is not true. You don't need this to correct a chemical imbalance. The other issue is that you've talked about, people stop their drugs and they go through a nightmare and they think, I don't want to stop again. This proves that I need the drugs. In fact, to some of them it proves I've got a chemical imbalance. These kind of, these different ideas come together in this kind of Frankenstein. Whereas people should understand that if you stop a drug and you feel terrible, it's much more likely to be withdrawal effects than a return of your condition. What I see again and again is exactly 10 years after someone's mother died, they're still on antidepressants. They're on antidepressants for postpartum depression and their kids are at college, university, they're in their 20s. There's a lot of legacy prescribing for people who don't need to be on these drugs anymore for an individual. So I think they need to understand these things to make an informed decision. And I think you've also made a few good points. Just because the drug was useful 10 years ago doesn't mean it's still having a use. One, we know that the drugs wear off over time because of tolerance effects. All drugs wear off antidepressants as well. So that even if it was once useful for you, it may not be anymore. We also know, to be frank, that for most people these drugs don't work. So again, using even very drug company influenced data, they will say you need to treat seven people to get one positive response. That means six people are getting a response they would have got if they were given a sugar tablet. So we know that for the vast majority of people, these drugs are not having a positive impact. So those are all the things to think about. Were the drugs ever effective? If they were effective at the beginning, are they still effective? Do you meet criteria? That's what doctors should be thinking about. And then all the things that I've already talked about, all the side effects you list, emotional numbing, weight gain, cognitive impairments. We talked about a few different misdiagnoses here. You know, a lot of people being diagnosed with ADHD antidepressants cause cognitive impairments, memory and attentional issues. I wonder how much of the effects of antidepressants contribute to the increasing rates of ADHD diagnosis. The other thing that I didn't mention when I was talking about the effects of antidepressants, the negative effects, is a whole series of studies showing long term physical health consequences of antidepressants. So in antidepressant studies, in the long term, people who take antidepressants have an increased risk of stroke, falls, fractures, cataracts, osteoporosis, and even an early death. This is in people over the age of 65, so maybe it's slightly older than your audience. There's a debate about whether this is caused by the drug or by depression. But some of those things, it's ridiculous to say it's caused by depression. Depression doesn't cause cataracts, it doesn't cause falls, doesn't cause osteoporosis. So there are signals that these drugs are having an effect on a lot of different bodily systems in a negative way. And that's one reason to be off them sooner rather than later. The other issue to say is the longer you're on drugs, the more severe the withdrawal effects. So the sooner you come off, the easier the path is going to be. I think, of course, in people's lives they're thinking, when's a good moment to do it? And I, you know, some people have very stressful lives and they don't have the space to do it. I think that makes sense. You know, it is easier to choose a less stressful time. But I would also say if you do it really slowly in the background, you know, over a couple of years, people can find a way to live their lives with the ups and downs and come off slowly enough that it doesn't disrupt their lives. And again, I think people are all thinking coming off in a few weeks is so incredibly hard. I don't think I can tolerate that. But if you understand you can come off very slowly in a way that won't disrupt your life, it makes it much more acceptable to people.

Dr. Stephanie (67:51)

Would you say it's a fair categorization that your professional opinion is that everyone who gets on these drugs should have a plan to try and get off of them?

Dr. Mark Horowitz (68:02)

Absolutely. So in the UK you are almost getting into malpractice if you don't have that, that the guidelines now say everyone who starts a drug should have a timeline of when you're going to stop it and how you're going to stop it. And it should be reviewed regularly. So this is trying to push back against this set and forget this sort of open ended, lifelong prescriptions that were never intended. I sort of say it's a bit analogous to a car. You sell cars with brakes. The idea that we're giving out medications that aren't easy to stop and that don't have plans to stop, to me is fairly unethical. I think that that should be a core part of deciding to start a medication. Also involves when are you going to stop it? With antibiotics, it's built in seven days, still have a cough, give you five more days, otherwise we'll stop it, we'll go down to half the dose and then stop it. That should be the same for mental health medication

Dr. Stephanie (69:02)

how much does the profession of psychiatry hate you? And I say that tongue in cheek, almost joking, but I can only imagine the amount of professional blowback that you may have endured from coming out and talking about what in some cases is the professional lifeline and lifeblood of psychiatry. I mean, you've mentioned before you go into a psychiatrist, there's no brain scans, there's no blood work. They kind of base something off of a checklist. A lot of the women I work with aren't tired because they're lazy or they're unmotivated. They're tired because their brains are overloaded. They're juggling work and family and health and hormones and constant decision making. And somewhere along the way, mental clarity just starts slipping. Focus gets harder, brain fog creeps in, sleep feels lighter and even caffeine stops helping. Or in some cases it makes it even worse. That's why I want to share something that I have been personally using and loving. It's called kinetic. And kinetic isn't just an energy drink. It's brain fuel. It's designed to support calm clarity, mental performance and focus without caffeine jitters and without caffeine crashes. And what I love is that it works with your biology and not against it. So instead of forcing stimulation, Kinetics provides your brain with a clean fuel source it already knows how to use, which is why the energy feels so steady, focused and calm without disrupting sleep later on that night. And yes, it's powered by ketones, but you don't need to follow a keto diet or change how you eat at all. This is just about supporting brain energy, especially during midlife when that glucose based energy can become much less efficient to the perimenopausal and menopausal brain. If you're doing all the right things but your mind still feels fried, this may be the missing piece for you. You can learn more about kinetic and try it out for yourself by going to drinkkinetic.com better better and use code better for 15 off of your purchase. That's drink kinetic K E N e t I k.com better and use code better for 15 off at checkout. But what kind of feedback have you received from colleagues and professional associations as a result of your stance and and practice this.

Dr. Mark Horowitz (71:28)

Sure. So you're not far off. I've been taken off a lot of dinner party lists in the last few years. There's a subset of psychiatrists that strongly agree with me. I don't know what percentage they are. 5, 10% who are much more Humanistically inclined think about people in the context of their lives who have been skeptical for years about medication, have seen what I'm talking about, and I get very, very nice emails from them. But you're right, from most psychiatrists and professional organizations, they are built around prescribing medications. That's how they differentiate themselves from psychologists, from therapists. They are medication prescribers. And that is all built on the idea of these things being diseases that doctors can treat. And so, yes, there's been great defensiveness to the work that. I mean, it's not just me, there's many other people doing similar work talking about the negative effects of drugs, the withdrawal effects, dependency. Yes, there's been a lot of. I sort of compare it a little bit to the response of fossil fuel companies to climate change. First of all, there was denial. This is not happening. Ignore these hippies talking about this nonsense. When there was too much information to ignore it, they minimized it. Yes, it's happening. It's not a big deal. Then there was delay tactics. We're not quite sure. Let's not jump the gun, let's not destroy our economies to deal with this. And the same sorts of things have happened with psychiatrists, with drug companies and this issue. They've ignored it for years. They've said withdrawal effects are in people's heads. It's actually relapse. You know, can you really trust mental health patients? They're all a bit crazy anyway. You know, what do they know about what they're talking about? That's, that's still happening, I think, very much in America still. Then there's been enough papers now, enough news articles. The New York Times, the BBC, npr, Canadian newspapers, Australian newspapers. It's harder to deny. So there's a lot of minimization. It's rare. It only happens to a very small number of people. These drugs are so useful. You know, you've got to crack a few eggs to make a delicious antidepressant omelet. Don't worry about it. That's kind of where the debate is in different countries. And some countries are a bit ahead, like the uk, where they're starting to arrange health services around this. We need to have services to help people stop their drugs. We need to have more warnings for doctors. We need to have more education. All of that is happening slowly in the uk where the National Health Service is starting to put out guidance. In Canada, there's a few green shoots, different organizations putting out guidance. But yes, I think the average psychiatrist doesn't want to Hear this. Because of course, it has implications for their work, you know, for, you know, for how they. How they pay their mortgages. And I think it's also, I've got to say, I think it a bit hurts their self image. And I understand that, you know, doctors, obviously, psychiatrists, get out of bed in the morning wanting to help people, you know, as I. As I do.

Dr. Stephanie (74:32)

Fundamentally. Yes. Yes.

Dr. Mark Horowitz (74:34)

Yeah. I mean, fundamentally, some people think. I think all psychiatrists are on the take from drug companies and laughing into their Ferraris. That's not the case. Half of my friends are psychiatrists. They're nice people. They want to do a good trade, they want to pay their mortgage. They want to do good things for their patients. They don't want to hear that they're causing their patients negative experiences. So there's a lot of cognitive dissonance. It's easier to shoot the messenger than to face up to the issues brought about by all of these things. And I gotta say, I totally understand their resistance because I would have been the same way if I hadn't gone through the process of antidepressant withdrawal. So if I hadn't had firsthand experience of going through this, I would have found it hard to believe as well. I would have been very resistant to hearing about it because I was taught in my training these drugs are about as safe as paracetamol, Tylenol. You know, if you have trouble coming off, you must need the drug, you know, and I would have accepted that on the. You know, I'm used to listening to professors, like all doctors are. I would have accepted that, too. And so, you know, a lot of. That's the other thing I get. I get a lot of emails from psychiatrists saying I've been through the same thing or my wife has or my child has. You know, I've gotten some pretty interesting emails in my time. I've got from the senior management in major drug companies saying, my daughter can't get off these drugs. Can you help me? You know, I've got it from the editors of major medical journals. I've got it from politicians, children. So, you know, this is a very widespread issue. And you're right, there's a lot of resistance to hearing it, and it's definitely affected my social life.

Dr. Stephanie (76:11)

So if a woman who is listening, maybe she's been on antidepressants, maybe she's part of the legacy prescription. You know, she had a tough time, or she went to her doctor, she had, she. She received a prescription for these drugs, she's been on them for several years. And maybe she's, you know, after thinking about it, hearing about this idea that long term use causes increased stroke and fractures and osteoporosis and cataracts and early death and that they were never, these drugs were never really intended for long term use. And she says, okay, I want to have a conversation with my doctor about it. Like, I don't know if I'm, I just want to talk to my prescriber. What are some questions that she can bring to her GP psychiatrist, whoever to open up the conversation. And you mentioned something really interesting before, which was the doctors are waiting for the patients to start the conversation. The patients are waiting for the job and then we're just sort of sitting in the waiting room waiting for someone to start the convo. So if she is going to be the advocate for her health, she's going to go in and she's going to be the courageous one and start the convo. What should she be saying?

Dr. Mark Horowitz (77:14)

I mean, look, to some degree, I think, you know, you should just tell the doctor what you want to do. To some degree. But, but I, because I, I mean, it depends on the doctor. You know, some doctors have this knee jerk reaction, no, don't do that. You know, don't come off your drugs. Often. We've interviewed some of these doctors often because they've had bad experiences of people coming off their drugs, probably withdrawal, and it's made them gun shy. And so some doctors have a default kind of response, no, don't do that. Others are more open minded and some are quite supportive. So it sort of, of depends probably on who you're speaking to. I think all the things that we've said today, you know, worth raising if you're going to have the discussion collaboratively with your doctor. You know, My mother died 10 years ago. I don't think it's an issue in my life anymore. I'm feeling okay. You know, I have these side effects, I have sexual side effects. I have emotional numbing, I have weight gain. I understand this could be due to the drug. I'd like to come off, I'd like to do it carefully. I don't want to get into trouble. I know if you come off too quickly, you can get withdrawal. You know, I'd like you to support me. You know, that's, I think most gps I hope would say that sounds pretty reasonable. Been on it for 10 years, you know, you're functioning pretty well. I would hope that most would support the person. What comes next, I think is more important how they then recommend coming off the drug. And I think 95% of doctors will say, halve your dose for two weeks, halve it again for two weeks, then stop it. And that's going to be problematic for most people. Some people can do that. We think there's about 6 or 7% of people that can do that, maybe a bit more. But for most long term users, that's going to be extremely troublesome. And so then it's about finding somebody that understands what a gradual, ideally hyperbolic taper looks like. And there are more and more people around who have listened to my work or other people's work and follow that. So, you know, I would be asking, I'd be interviewing your doctor and say, do you know what a gradual taper looks like? Do you know what a hypolic taper looks like? Are you prepared to give me a liquid version of the drug? That would be, you know, if I was interviewing my doctor to know, can this guy do it safely? That's what I'd be asking. You know, there are a few places now that are a bit more specialized. I've been involved in a series of clinics in America called altrohealth. That is a telehealth clinic. It operates In I think 13 or 14 states in America, New York, California, a number of other big ones where I've helped to train with other psychiatrists that are knowledgeable about this topic, nurse practitioners that oversee gradual hypolic tapers in just the way that I've described. That's a good option because, you know, those people know what they're doing. But now there's more and more individual practitioners that have taken this up, you know, themselves. But I'd be asking, I would definitely want, I would want to know that the person in front of me is going to be in charge of medications affecting my body, knows some of the concepts I've talked about today, about what gradual means, why low doses matter and why tablets and capsules from the pharmacy is probably not the best approach.

Dr. Stephanie (80:06)

Yeah. And the difference between a relapse and withdrawal.

Dr. Mark Horowitz (80:10)

Absolutely. Exactly.

Dr. Stephanie (80:11)

Of course. Is there any other avenues that can help? So beyond the taper can, you know, helping these patients get off medication successfully? Do we want to think about diet, exercise? Is there anything else that you typically. Is there other things that come into the mix here or is a primary, the primary stone that needs to be put in place is a proper hyperbolic taper and then maybe with that we integrate strength training or anything else?

Dr. Mark Horowitz (80:40)

I think the answer is both. I would Say this. I think anything that makes somebody more stable, less stressed, happier is useful in coming off the drugs. So everything you've mentioned, whatever works for the person, if that's exercise, if it's strength training, if it's improving their diet, if it's mindfulness, if it's therapy, I say yes to all of the above. That can't be bad for you. All that stuff makes it easier to come off because you're a more stable, centered person. Having said that, coming back to my analogy of altitude sickness, even if you're an Olympian, Olympian fit, and you rush up a mountain, you'll still get altitude sickness. So you still have to be careful about going up too quickly. So I would say primarily coming off slowly, especially at the end, is the main thing. But everything else around that can be helpful to buffer things. I've seen some people get into the kind of mindset where they say, well, I'm very good at mindfulness now, so I'll just stop my drugs. And I'm very pro mindfulness. Nothing against that, but it's not enough to, you know, that doesn't change all the receptors in your body, so you can just stop it now. So I think if I had to put numbers on it, I think it's 90% a careful taper, but yes, 10%. You can help yourself with all these other things. And why not? I sometimes think the things that people do to manage withdrawal equip them so much better than for the rest of their lives to manage any mental health issues. I've had people say to me, if I had done the things that helped me get through withdrawal when I had my original problem, I would never have needed to use medication in the first place. And so I think if there's a silver lining to this process, that might be one of one of them.

Dr. Stephanie (82:19)

Fantastic. Well, this has been so incredibly helpful. I know that this is, like I said it before, this is going to change the perspective of so many women who are listening and potentially all the people that they know around them that could be potentially affected. So tell us where we can find more about your work. You mentioned Outro Health. I wrote down 13 states. We'll make sure that there's a link there in the show notes for people to take a look at that. But where can people find more about you and your work?

Dr. Mark Horowitz (82:45)

So I've got a dinky little website@markhorowitz.org I'm on Twitter Arkhorrow and altrohealth.com is the website for the clinic. If you're in the uk we run a deprescribing clinic in the National Health Service that you can look up. It's called the NELFT Deprescribing Clinic. Just for people in the UK though.

Dr. Stephanie (83:09)

Okay, wonderful. We'll make sure that all that information is available to our audience. Thank you, Doc. This has been absolutely fantastic.

Dr. Mark Horowitz (83:15)

Thanks for having me on. Thanks. Thanks, Stephanie, for focusing on this, on this issue.

Dr. Stephanie (83:21)

All right. All right. Welcome to the after party where I talk to you candidly and truthfully about what I thought of this episode and some, some closing thoughts. I do first want to say that I fully understand that this conversation can be incredibly activating and triggering for some people. And the intention of this episode is not to shame. It is not to cast moral judgment on anybody who is on an antidepressant. Everybody, including myself, will have incredibly difficult moments that can last weeks, months, years in our lives. And these medications can certainly help as a crux to help you get through really difficult times. So I want to make that very clear. What my intention is with this episode is for you, if you are somebody who is on an antidepressant or if you know and love somebody who's been on antidepressants, long term, is to think about what the long term effects of being on this or any drug truthfully. But we'll just keep it to the class of antidepressant medications. What this is doing to your brain, what this is doing to your physiology, and is it time for you to think about tapering off? And if it is time, what are some of the things that you need to be doing so that it doesn't feel like you're dying? Because I have seen, I mentioned it briefly in my conversation with Dr. Horowitz that I've had patients that I've, I've supported alongside tapers and they literally felt some. I'm thinking of two patients in particular that I assisted over many years, just felt like they were dying, like it was the hardest thing that they had ever gone through. And now reflecting back on that, the taper was probably too aggressive for them. So I really liked how he was able to, to distinguish between what a, when you are addicted versus physical dependency, and then further taking that to say, okay, what is the difference between withdrawal symptoms from the drug? Because now my physiology and my neurochemistry is fundamentally different versus a relapse of original symptoms. And how can we not mess those up? Because if, if it, if 70 to 90% of the symptoms are withdrawal symptoms, it means that you're getting off the drug too quickly. So how can we do this in an intelligent and gentle way that honors the body and you're not trying to force the body into doing anything? And in many ways, it's very much parallel to what I talk about with weight loss. Right. I am not a fan of an eight week boot camp. It is going to be painfully hard. And the likelihood of you maintaining that over time is highly unlikely. Versus if you say, I'm going to give myself three years to lose this weight, that feels a lot easier, it feels less abrasive and it's less of an affront to your physiology. And I think that that is really the through line of what mark and I, Dr. Horowitz and I were talking about today. It's like, what are the symptoms of antidepressants or the class of medications of antidepressants? Because they're so vast, it's hard to pinpoint chronologically if this is like the weight gain. You know, I highlighted that in our conversation. 30% of people will become overweight, 30% will become obese. That is, that is not nothing. You know what I'm saying? Like, that is a significant number of people. And if you've been on an antidepressant for five years, two years, 10 years, whatever it is, and you're suddenly noticing now that you're in perimenopause and menopause that you are obese, it's not the obesity gene, Oprah. It might be that this is actually one of the contributing factors to obesity. Of course, obesity is multifactorial, but when you take away agency of the individual, you take away their ability to actually direct their own lives. So that is really the crux of the conversation. It's like, use the drugs when you need them. Give, let the drugs be the opportunity, like open a window of opportunity for you. But then in that it's like, let them open a door, but now you get to walk through the door. Okay, so I do think that there is a, there's an important moment in the conversation where I asked him, like, do you, is it fair to say that your opinion is everybody should get off these drugs? And he not only said yes, but he said this is actually the direction of medical societies now. At least, at least in the U.K. i mean, we, this is, I know that most of the, most of my Betty's are in the United States and Canada. We have a handful of, of in Australia and hello Bhutan. We know that you love, you know, we're always number one in Bhutan, which is the only country in the world, by the way, that has a happiness index. So, so I know that in the States and in Canada and in the, you know, North America, let's say that these practices are not. Or that these, these policies are not commonplace yet. But that's why you listen to the show, right? Is to get conversations from world leaders. And I hope that, that you take some of these questions to heart, like, how do you know? Do you think you might be ready? Is this worth a conversation with your GP or whoever's managing your prescription? And then can you find someone who knows how to intelligently taper so you're not forcing your body into some of these withdrawal symptoms? So that's what I want, what I wanted to say. I really loved this conversation. I have to say this was. He's so, I mean, he's so well spoken, so well researched. But I really loved this conversation because it's, it aligns very closely with my philosophy for most things in life, which is use what. Like, if you need an. If you are acutely stressed, if you are some, if there's something, there's, you know, chaos or something is happening acutely, like, use whatever tools are available to you, but just do it. Understanding the side effects, you know, like the whole premise of the show is informed consent. Like, that's the secret message. It's like you can get into the drugs, do the drug, know what you're getting into, understand the side benefit, the side effects, the benefits and the side effects. And if you make a call yourself, because you are more than, you are more than capable of making that call yourself, if you are okay with those side effects for now, because you just need something to help you get you through, then by all means, girl, like, do it. You know what I'm saying? There's no judgment. It's like we all have been there. We've all, like, there were times when I was like, you know what? It would be easier if I wasn't here. You know, like, there's. Everybody's had that thought at some point and, you know, getting the help that you need, social support, cognitive behavioral therapy, medications in, in, in, in whatever case, use all the tools available to you and also have a plan to get off of them. I am interested in how you received this message, how you received this conversation. So leave us comments on Spotify, on Apple. I'd love to see it. It we check all around the world so you don't have to just be in the States and Canada for us to see them. We see them from Britain, we see them from. We see them from down under, we see them from everywhere. And we use Google Translate when it's in a different language, so we also know what you're saying. So please leave us a review if you feel like this podcast is giving you value in any way, feel free to give us a five star rating on itunes. It helps more people. The algorithm just serves it up to more people as suggestions. And thank you. Thank you for your time, thank you for your interest, thank you for your open heart and mind because I know sometimes conversations like this can be difficult to hear. So until next time, I bid you adieu and we'll see you then. All right, all right. I hope you enjoyed today's episode and I must give you the obligatory legal and medical disclaimer here. This podcast, Better with Dr. Stephanie, is for Generation General information only and the advice recommendations we discuss do not replace medicine, chiropractic or any other primary healthcare provider's advice, treatment or care in the consumption of this podcast. There is no doctor patient relationship that has been formed and the use and implementation of the information discussed are at the sole discretion of the listener. The information and opinions shared on this podcast are not intended to be a substitute for primary care diagnosis or treatment. In other words, guys, be smart about this. Take it with a grain of salt. Take this information to your primary healthcare provider and have a discussion with him or her to make the best choice. That is for you. Remember, I am a doctor, but I am not your doctor and these conversations stations are meant for educational purposes only.