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- [00:04]
Dr. Kelly Casperson
Welcome to youo Are Not Broken, the podcast that challenges everything we've been taught about midlife hormones and sexuality. I'm Dr. Kelly Casperson, board certified urologist, author and a leading voice in women's sexual and hormone health. Enjoy the show.
- [00:17]
Podcast Host
Hey everybody. Welcome back to the you're Not Broken podcast. Today it's going to be a fascinating conversation with Dr. Mark Horowitz, who wrote, literally wrote the book deprescribing guidelines. Antidepressants, benzodiazepines, gabapentinoids, and Z drugs. Look at this textbook. I wrote two, like layperson books. How did you do this?
- [00:35]
Dr. Mark Horowitz
Sorry, it ruined my life for a few years. That's how I did it. So I'm glad that someone other than my mother has bought it. So it's nice to see it in your hands.
- [00:43]
Podcast Host
It's a very big deal because I think it's a conversation that I think is just starting. And SSRIs and antidepressants and the drugs before them have been around for decades. And I think I've been saying this for a couple of years on the podcast of you can't put 25% of American women on a drug and not have a reckoning coming. There was just an article in the Wall Street Journal about this. I think the reckoning, if that's the right word or not, is coming of like, how did we get 1 in 4American women on these medications? Is that the right thing to do? And can we get them off? So thank you so much for coming onto the podcast today.
- [01:23]
Dr. Mark Horowitz
My pleasure. And it's how do we get people off a drug that doesn't have an inbuilt off ramp that doesn't. I sort of say it's a bit like putting cars on the road without brakes because there really wasn't given thought after years on the drugs. How can you stop these drugs after a few weeks? It's very easy. That's not a big deal. But now we have not just one in four women in America on these drugs, but a lot of them are on it for years or decades. So there are 25 million people in America who are on the drugs for years. Now.
- [01:56]
Podcast Host
How did you get into this topic?
- [01:59]
Dr. Mark Horowitz
I'd like to say it's because I'm very intellectual and academic.
- [02:01]
Podcast Host
Innately curious.
- [02:02]
Dr. Mark Horowitz
Yeah, I am. But no, unfortunately it's because I sort of fell down a manhole in the street. You know, the SSRI manhole, I guess, briefly. You know, I took antidepressants for many years, like one in six Adults in the Western world, America, Europe, Australia. I did a PhD. You know, I trained as a doctor. I trained as I started my training as a psychiatrist. I moved to London to do a PhD in how antidepressants work, the biology of depression. I thought I could stare down a microscope and work out what is going wrong in my mind and the mind of my family. You know, I'll fix my life with microscopes. The delusion of the young nerdy man. At the end of my PhD, I read an academic article that talked about withdrawal effects from antidepressants. And I found that very startling because I hadn't come across that in my medical training, in my psychiatry training. And my first thought was basically, drugs that cause withdrawal are not very good for you. Benzodiazepines, opioids, everyone will know. OxyContin in America, or street drugs, recreational drugs cause withdrawal effects. It means two things to me. One, withdrawal effects means the drug wears off, because tolerance and withdrawal are two sides of the same coin. And the drugs that cause withdrawal generally aren't very good for you. So I thought at that point, I've now been on this drug for more than 10 years. Is it still doing anything because of tolerance effects and is it good for me? And I had a few health issues that I had had since I'd been on antidepressants and they were being tired all the time. It had profoundly affected my life, issues with concentration and memory. And once my memory had been brilliant and it was sort of going down the drain over the time that I was on these drugs, which was my 20s, so not normally when your memory goes down the drain. And I'd always had in back of my mind, is it the drugs? When I read that article about withdrawal effects, that was the trick of me to try to come off the drugs. And I again, in nerdy fashion, I went and read every article that had been written about how to come off these drugs. And some of them were written by my professors because I was then doing my PhD at King's College in London that passed Harvard as the most cited research institute for psychiatry in the world. So I was working with all the top people and they all said, coming off with antidepressants is very easy. Few weeks, halve the dose, halve it again, stop it. You might get some mild discontinuation symptoms, this kind of industry euphemism. I thought, all right, that sounds pretty good. And then because I'm a millennial, albeit a pretty geriatric millennial, I went and checked Google and It gave me a very different story from people. They said coming off antidepressants was one of the hardest things they'd ever done. It took them years. They were forced to be sort of Walter White, like characters from Breaking Bad in their kitchen, kind of grinding down
- [05:09]
Podcast Host
tablets, like really having to microdose. Teeny, teeny, teeny decreases in these drugs. Otherwise you get big withdrawal symptoms.
- [05:17]
Dr. Mark Horowitz
Exactly. Thousands of a milligram, kitchen chemistry, all of this stuff. And I thought, I sort of didn't know who to trust. I'm a kind of fairly institutionalized person with six academic degrees, used to listening to professors. These were sort of unknown people on the Internet. So I sort of split the difference. And I came off my antebesant in a few months. Not the years these people talked about, not the kind of weeks that the presses talked about. I used equipment from my molecular biology lab. I used pipettes. I was Walter White, not as much fun, didn't make as much money. And I thought I was being very careful. I was going a lot slower than the guidelines said. And as I got to the end of my taper coming off these drugs, my life exploded. I had trouble sleeping. I would wake up in the mornings in full blown panic, terror, like I was being chased by a wild animal. You know, sweaty palms, heart pacing, racing. And I would be in that state for 8, 9, 10 hours of the day. Panic I'd never experienced before. It was excruciating. I felt dizzy, things around me appeared unreal. I had never had anything like this before. When I went on the drugs, I was a miserable young man. Didn't like my course, didn't know who I was. Standard existential things. In my 20s when I came off the drugs, it was a different level of intensity. I'd give it three out of 10. When I was 21, when I went on the drugs, when I came off in my 30s, it was 10 out of 10. And week after week of those symptoms went on. And I tried to white knuckle through. I took up, ran 10km a day. I ran into my feet bled. I listened to hundreds of body scan meditations from Jon Kabat Zinn, which I now know off by heart. He's got a very soothing voice. And after a few weeks that I thought, I cannot continue like this. It was just the most terrifying experience every morning to wake up to that.
- [07:14]
Podcast Host
And you went into this very intentional knowing you might have side effects, knowing it might be uncomfortable, but you had no idea.
- [07:22]
Dr. Mark Horowitz
That's right. I mean, I thought I could do this For a couple of days, you know, I could barely. But after six weeks or eight weeks, I thought, you know, I'm exhausted, I'm terrified. You know, I was sort of like shaking like a leaf. I come across people as I was coming off who had had exactly the same health effects as me. Lots of tiredness, lots of concentration problems, lots of memory problems, which it turns out has been shown in studies. We can come back to that. So I sort of thought being on this drug has caused me serious health problems. Coming off it has almost killed me. What the hell do I do? And in the end, I sort of had no choice. I went back on the drugs. Things did settle down for me, which actually is quite lucky. Some people, when they go back on, they can't quite put the toothpaste back in the tube. But it did for me. And I realized now I'm on these drugs not because they're helpful, but because I'm trapped on them. I can't get off them because the withdrawal is too severe. Basically, I went back to my training. I forgot about this for a couple of years because it was so frightening. And when I came to come off my drugs again a few years ago, I understood who the experts were. Now, they weren't my professors. There were people on these online forums who had been forced to become experts, you know, retired engineers, homemakers, truck drivers. And I followed their guidance. I thought, this is kind of absurd. I've got six degrees in medicine, science, psychiatry, but I'm following guidelines from an online social media group. And I did come off my drugs with their advice. It took me years, not weeks. And I had to go down to very small doses like you mentioned. And a lot of those health problems that I had on the drugs did clear up. Fatigue, memory, concentration. I went back to working full time. I had been impaired when I was on the drugs. I sort of thought, this is kind of ridiculous. And I wrote an article about the things that I'd learned from coming off the drugs from these groups, combined with some neuroimaging from research that I'd been aware of during my PhD. And that article on how to come off antidepressants was published in the Lance of Psychiatry, a very good journal in Europe, and it has triggered changes in the guidelines in England over the last few years. They now more and more say what I say in that paper, and they give advice to doctors, and we're sort of working on ways of educating doctors. It's been very. It's like turning around a supertanker because they've been sort of taught these drugs are very easy to stop. And there's been some progress around a clinic now publicly funded in the nhs, the Public Health Service. But around the world there's been very little attention, especially in America. In America, it's been very much a kind of hand over eyes, fingers and ears. These drugs are still fine, minimising, denying people don't have trouble coming off. It's in their heads, they must be very ill, they must need the drugs.
- [10:07]
Podcast Host
Oh, like withdrawal symptoms are a sign that you actually need the drug.
- [10:11]
Dr. Mark Horowitz
Exactly. So if you feel bad when you come off your antidepressant, the most common response of a doctor is if you feel bad and you're off your drug, well, you must need to be on your drug. That's the sort of knee jerk that sounds ridiculous when you think about cigarettes. But with antidepressants, because they've kind of been famous products, their doctors give them with white coats. It's all been kind of sanitized and so withdrawal has been pushed under the rug. And they use euphemisms. They don't even talk about withdrawal in America. They talk about discontinuation symptoms, which sounds very soft, very benign. My joke is it's like describing a car crash as a discontinuation event involving a wall. It sort of sounds a little bit softer than what's really happening because I absolutely hit the wall when I came off my drugs.
- [10:57]
Podcast Host
I have to think the amount of emails that you get from people, I mean, just the sheer number of people who are on these medications, and then for them to find that there's actually a person who's trying in a systematic way to help and not dismiss. Dismissal's huge in healthcare anyways, but this is a huge dismissal area. Like your emails have to be every single day. People emailing you.
- [11:20]
Dr. Mark Horowitz
Yeah. I've had, I think last count, 15,000 emails from patients around the world since I've started working in this area. I get several every day, mostly saying, my doctors told me I must need the drug. But I said to them, I went on the drug. When my wife died 10 years ago, I was, you know, low in mood, definitely, but now I'm having panic attacks, I can't sleep, I'm having brain zaps as it'll zaps in my head.
- [11:46]
Dr. Kelly Casperson
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- [12:38]
Dr. Mark Horowitz
telling me this is just a form of anxiety. You know, he sounds quite mad to me. He won't help me come off the drug. He says that I need it and if I stop it, it's against medical advice. So I've sort of been thrown out of my doctor's office.
- [12:50]
Podcast Host
They feel very trapped.
- [12:51]
Dr. Mark Horowitz
Well, yeah. So what do I do now exactly? You know, where do I go? And that's why they end up on social media sites where people are much more sensible. Sort of ironic. A bit of an inversion of the usual order of things.
- [13:02]
Podcast Host
Right. Well, that's. I mean, that's menopause and hormones too, just to tie it in of like. Like you found, like the real story is in the people trying to figure out how to come off of this because the medical system never planned for this long term. I think in America it's also complicated because we're one of the two countries in the world that can advertise pharmaceuticals directly to people. And these ads make it look as if all your cares are gone.
- [13:26]
Dr. Mark Horowitz
Right, Right. Yes. Happy people running in the sunshine with
- [13:29]
Podcast Host
making dinner for people and having great relationships. And there is kind of this sheen on top of these medications that you too can have no worries. So if you've been on it for a while and it's really hard to come off, why stay on them? And I think what you were alluding to is because these medications in and of themselves have side effects. Because you're taking them, they have side effects. Can you go in? Because I think a lot of people don't know that of like, why not just stay on them for life?
- [14:01]
Dr. Mark Horowitz
Sure, it's a great question. I mean, so one, the drugs have lots of side effects and, you know, why is that not central in people's minds? I think there's a couple of reasons. One, there's a kind of reassuring line given by Doctors, which is these side effects will go away, you know, just there for a few weeks. That's not accurate. In long term studies of people on antidepressants, most have side effects and many people have multiple side effects. I think one of the reasons people don't put it together with the drug is they're insidious. It takes time to build up. So for example, if you take an antibiotic and you vomit your guts out the next day, it's obvious it's the antibiotic. No one is confused about that. But if you take an antidepressant for 10 years and every year it makes you 5% foggier, tireder, your concentration off, you don't notice that if you're in your 60s or 70s, people will say to you, well, you're getting older. It must be that if you put on weight, they'll say you're getting older. If your sex drive goes away, they'll say you're getting older. So all of these things are a little bit harder to pull out than vomiting from an antibiotic. But studies show the following antidepressants cause significant weight gain. In the short term studies, it didn't show that over six weeks wasn't enough time. But over years of use, 30% of people will go from being normal weight to being overweight or going from overweight to being obese. So it's a significant compared it against people that are not on antidepressants, that are age matched and matched for other characteristics. Because there aren't long term randomized, placebo controlled studies. And that's part of why there's a lack of clarity about this. Because the companies haven't looked at, at long term effects.
- [15:42]
Podcast Host
Why would they want to? That's expensive. And 25% of Americans are already on it. I don't know if it's higher. Is it higher in any other country?
- [15:49]
Dr. Mark Horowitz
A lot of things. This is where America is number one. You know, you guys are behind in a few things, but in this you're number one. Definitely.
- [15:55]
Podcast Host
We're 4% of the world's population and we take something like 70% of the pharmaceuticals, 70 or 80% of the pharmaceuticals, like 90% of the opioids. Like we are winning in a very losing sort of way.
- [16:08]
Dr. Mark Horowitz
Definitely. Definitely. Yes. First and coming last.
- [16:10]
Podcast Host
One of the things that I was discovering, and I was discovering this because I was getting into hormones and menopause and, you know, the risks of hormones, et cetera. And I start, I got down the rabbit hole of SSRIs and the risk of independent risk of bone fracture with SSRIs, to the point that there's multiple meta analyses on this. Like, it's actually well studied, well published. Then I talked to an orthopedic surgeon friend and I said, do you know this association? And he's like, nope. I talked to a primary care friend and I said, do you know this association between SSRIs and bone fracture? No. They think it has to do with the serotonin effect because bones have serotonin receptors in them. But I'm like, you're putting these on people who are older, getting frail, gaining weight. These are high risk fall people. And they have. They're taking a medication that they don't know is independently associated with bone fracture.
- [17:02]
Dr. Mark Horowitz
I'll go to that point now. I mean, so serotonin and other chemicals that these antidepressants affect, people think that they're just in the brain, they're just to do with anxiety. But of course, they're pleiotropic hormones. That means they have multiple different roles in different parts of the body. They affect the way that smooth muscle works in the bladder. They affect the way that platelets aggregate to form clots. They affect the autonomic nervous system. So they affect blood pressure and dizziness. So in older people, yes, osteoporosis is increased with use of antidepressants. So your bones are thinner. You're also more likely to have a fall. People think because you're dizzy, you've got postural hypotension, and that is probably what contributes to the overall effect of having more fractures. You're also more likely to have various different cardiovascular events, like stroke and like myocardial infarction. And people think, maybe that's to do with the platelets. But because platelets are not clotting as well as usual, because you've got serotonin playing a role now you've got too much of it. It's inhibiting platelets, so you're more prone to bleeding risks. There's also signals that there's an increased risk of dementia with certain antidepressants, particularly cholinergic ones like Paxil or Paroxetine. All of these things are associations because there aren't randomized controlled trials of placebo versus antidepressants. So what these studies involve is they compare people are on antidepressants and not on them, and they try to control for them. So you can't make a perfect causative argument. But the other argument is that people that are depressed have this happen more often. But it doesn't make any sense. Why would a depressed person have more osteoporosis? These people, they're not so depressed, they're lying in bed for 20 years. So there's not a plausible explanation.
- [18:43]
Podcast Host
Yeah, I mean, I've seen like, well, you know, depression is an independent risk factor for dementia. But if you're on the SSRI or antidepressant, the theory should be you're not depressed, so maybe you should have lower risk of dementia.
- [18:54]
Dr. Mark Horowitz
Exactly. And that's not what it shows. Exactly. So the studies don't show that. So, you know, depression may not be good for you. I'm not arguing that it's good for you, but these studies are showing that antidepressants themselves are associated with all these negative outcomes. Those are kind of the long term health things I should add to it. The other thing they find in these studies is that you die earlier. So that people on antidepressants have greater mortality than people that are not on antidepressants. And it's quite significant for some antidepressants. So the average.
- [19:22]
Podcast Host
Are we talking years?
- [19:24]
Dr. Mark Horowitz
We're talking about percentage dying per year. And so it does turn out to be years. So for example, someone who's not on antidepressants over the age of 65, their chance of dying per year is 7% every year. And on certain antidepressants their risk goes up to 11%. So there's a 4% increased risk of dying. So over a number of years that does add up. So the answer is yes, it does seem to be associated with an earlier mortality by several years, whether it's causative or not. It's a question mark, but it doesn't look very encouraging. And some of these things have dose response relationships. The more, the higher the dose you're on, the greater the risk of these outcomes. That's the sort of long term health consequences. The other side of things I've talked about weight gain. There's also sexual problems. So we know that the rate of treatment emergent sexual problems, this means before treatment, no problems, after treatment problems is between 50 and 80% for different antidepressants. That means reduced desire, reduced ability to be aroused, to sustain an erection as a man or to have an orgasm as both sexes. So it's the majority of people. And we also know that for some people, when they stop antidepressants, these issues persevere. And they call this post SSRI Sexual Dysfunction pssd, another acronym. And there's a debate about how common it is. And there's a study that suggests it may be as common as one in seven people on antidepressants, which is really terrifying because most people have been told, okay, you might have sexual problems on the drugs, but if you stop them, they'll go away. And some of these studies are showing that's not the case. And there are some very unhappy people, young people and older people who are off antidepressants and still have these persistent issues after being on them.
- [21:08]
Podcast Host
And I bet they get dismissed like nobody's business because doctors aren't good at talking about sexual health anyways. And the kind of the stigma of the protection of SSRIs culturally in medicine where I see this in America, and I don't know if this is the same where you are but people, when people even bring up the idea of is an antidepressant the right thing to do, are there options besides antidepressants? Always marked with but for people who really need it, you need to keep taking it. Like there's always this like statement after it, which we don't say with high blood pressure, Medica or any other medications, there's like this protection of these medications. Do you see that?
- [21:49]
Dr. Kelly Casperson
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- [23:01]
Dr. Mark Horowitz
Yes, that is, I think that's just to do with four decades of relentless marketing. It's sort of. If you think back to Opioids, Antidepressants are not as dangerous as opioids because opioids make you stop breathing. So they've got clearly a very much high mortality. But there's something similar in the structure of marketing. When we talk about opioids, doctors, you should look for pain. It's the fifth vital sign. You must treat it. It's very unethical not to treat it. These drugs are not addictive. They're very helpful. All those things are basically not true. They're not very effective in the long term. Chronic pain, lots of pain, goes away by itself. They were addictive, et cetera, et cetera. And I think with antidepressants there's been the same kind of bombardment of propaganda. The antidepressants are very effective. Studies show it's very difficult to distinguish placebo from antidepressants. The effectiveness is very minor. Antidepressants are life saving. It's another line that's not borne out in research papers. If you look at randomized controlled trials in young people, there's a clear effect that antidepressants make people more suicidal than placebo does, which is why there's a black box warning from the FDA on antidepressant packets in adults. The debate is, is there no effect of antidepressants or do they also slightly increase the risk of suicidality? So there's no studies that show that antidepressants reduce the suicide rate, but they've been talked about as life savings as part of a marketing push. And that's where all this, you must use them because otherwise you're not doing right by your patients and you must own your drugs. I think that's been kind of talking points that have been pushed out over years and become almost self perpetuating.
- [24:37]
Podcast Host
I see the other thing in America because we have the fear of litigation. And you're much more likely to get sued for not prescribing the antidepressant. And then something bad happens to that person. Then I prescribed an antidepressant. Something bad happened to that person. Least you tried. It's that like first do no harm, which gets very mixed up in the try not to get sued, which is very real in America. It's very real. People stop being doctors over this.
- [25:05]
Dr. Mark Horowitz
Yeah. So I mean, you're right. It's, you know, they say the sins of omission are punished more than sins of commission. Where you do something, it does come. There's a few kind of famous lawsuits where people have been sued, where people have sued for not being prescribed Antidepressants, but the opposite hasn't happened. I think you're right. I think legal risk is a very essential part of doctors thinking they want to get home, pay their mortgages, they don't lose their jobs. It's unfortunate because antidepressants do not reduce the suicide rate. They probably contribute to it in many ways. Lots of people recover naturally without medications. There are lots of effective treatments that don't involve medication for depression. But no one's ever sued, as you say, for prescribing one. Whereas I think they should be. Because some people get trapped on them, people get really unwell coming off them. They're disabled. But you're right, the kind of legal pressure is in one direction to prescribe. And so doctors feel much more comfortable prescribing than not prescribing. You know, that kind of distorts medicine because this is sort of this a fear based on litigation, not on the best practice for patients.
- [26:09]
Podcast Host
Absolutely. I see a lot of people come in to my clinic, usually for hormone issues and sexual health issues, and they're on an ssri. And I say, why are you on this? And they don't know why they've been on it. Like they can't tell me why I'm on this and they can't tell me how long they've been on it. For decades. At this point, it's just kind of like part of what we're working kind of against it. But to tell somebody this thing you've been taking for two decades might be contributing to your anorgasmia, your low desire, your inability to lose weight, your X, Y and Z. It's not crossing their mind. Cause they. It's just so normalized.
- [26:50]
Dr. Mark Horowitz
Yes. And I can't. And there's the other thing. With a long term drug, you almost can't remember how you were before you were on it. If you started at 20 and now you're 40 and you're having worse sex life, you can't quite be sure. That's a very classic situation. This is the most common story. Someone has something go wrong in their lives. They get divorced, they lose their job, they fail an exam, their mother dies, they're miserable. They get put on a drug and no one reviews it. Now take a step back. We are medicalizing lots of normal misery. Everybody's mother dies, everyone will lose a job. All relationships have problems. The natural history of these conditions, anxiety and depression, is very good, Even very severe depression. 85% of cases resolve without treatment within a year. By three months, about half of people feel better if you do nothing. So we are. Medicine has really pushed forward. This is an illness, we need to treat it. So there's already a lot of medicalizing. Even if you accept that most guidelines in America say for an episode of depression or anxiety should be on an antidepressant for six to 12 months, most people don't get their drugs stopped because doctors have priorities elsewhere. They don't know how to do it. They've had bad experiences. They back away from it. And so this is how a single event in someone's lives in their 20s or 30s or 40s can lead to decades of treatment, because doctors are much better at starting these drugs than they are at stopping the drugs. And that's how this sort of, you know, a bad episode in someone's life can lead to lifelong treatment with these drugs that can have quietly toxic effects on sexuality, weight, concentration, memory, sleep.
- [28:27]
Podcast Host
I didn't know. I didn't know stroke risk went up. That's new to me.
- [28:31]
Dr. Mark Horowitz
Yeah, it fits with the bleeding. It fits with all the issues with clotting, probably, that you've now got issues with bleeding risk. What are the things that to do with bleeding are cerebrovascular issues.
- [28:43]
Podcast Host
That's super interesting. Where do you see? You had talked earlier about, like, well, let's talk about how these things work. The serotonin hypothesis is kind of what came out with the advent of SSRIs to say, hey, these are gonna help serotonin be around in your brain more. And serotonin is the happy molecule. And that's how these antidepressants work. That's been proven. It's called into question. Yeah, I feel like a urologist trying to understand this. Of like, I have no skin in the game. And I'm fascinated. But, like, my neurobiology might be blunted, but what it seems to do is it seems to blunt the high highs and the low lows of emotional response.
- [29:20]
Dr. Mark Horowitz
The story kind of goes, in the 60s, there was a hypothesis that depression is caused by low serotonin or norepinephrine. And six decades of research has been dedicated to that topic. And basically, it's found nothing. We did a review a few years ago. We looked at healthy volunteers versus depressed people, and there was no difference in serotonin in any way. You measured it. And now most academic institutions say that this was a hypothesis that didn't pan out. But it's gone wild in the public because drug companies jumped on it. They made ads in America showing little unhappy blobs with low serotonin in their brains. You give them Zoloft and suddenly they're playing team sports and having great lives. And so it's been stuck into GPS brains and the public's brains. We know 90% of the public believes this. And so it really is a marketing line. Of course, we cannot boil down a complex state like depression to a single chemical. You know, it sounds incredibly appealing, but it's not as simple as diabetes.
- [30:16]
Podcast Host
It was very sexy.
- [30:17]
Dr. Mark Horowitz
Very. Exactly. Very appealing. And you can just fix it by adding in drugs. So what do the drugs do if they're not fixing a chemical imbalance like low serotonin? What are they doing? And you said it exactly in surveys. Three quarters of people on antidepressants say they feel emotionally numbed. That means their experience of very positive and very negative emotions has been squished into the middle. And if you're very panicked, depressed or anxious, having the volume turned from a 10 to a 3 can be a great relief. But we can't target anxious and negative thoughts. We. We do the whole thing. We're blunting all emotions, including enthusiasm, love interest. And so one of the main reasons people come to me to come off their drugs is they say, I used to enjoy music, sport. Now I feel meh. I don't know what I think about my partner. I don't know if I. One of the saddest things I've heard from a mother is I don't know whether I bonded with my children properly. Cause I was numbed their entire childhood. And you can see. I think it's very misleading when you say to somebody, this drug will fix an underlying chemical imbalance. It's very compelling. It sounds very safe as well. Someone said to me, I've got low thyroid hormone. Do you want to take thyroid hormones? I'd say, yes, that sounds sensible. And it's the same kind of story. But if you're actually giving them a drug that numbs their emotions and that numbing is connected to the numbing sexually, those are correlated in studies. In fact, if you chew up antidepressants and swish them around your mouth, it will numb your mouth a bit. So there's definitely a kind of mild anesthetic property of the whole thing. And so now you sort of misled somebody into believing they're taking a drug that's as healthy for them as insulin for diabetes. But actually what it's doing is it's kind of creating a chemical imbalance because you have a normal serotonin now, you have it very high and this affects your hematological system, your sexual system, your brain. It has all sorts of consequences. So I think people are not being given, they're not giving informed consent to take these drugs because they're given this kind of just so story that misleadingly makes the drugs appear safer and more targeted than they really are. And so I think it's not just, you know, a whoopsie, but it's really, really a, you know, a real deficit of information for people.
- [32:28]
Podcast Host
I say that over and over again. I think we have a failure of informed consent when we prescribe these medications. And you know, I think one argument is, can you truly give an informed consent if you're coming in so sad, so depressed? Like, if the doctors are trying to get you out of an acute emotional
- [32:43]
Dr. Mark Horowitz
event, that's not who is turning up. I'll just say just to jump that, there's 56 million people on these drugs. Most of them are not coming in acutely suicidal. We know that most people prescribed antidepressants have mild to moderate symptoms. They're people coming in in everyday circumstances after heartbreak, grief, breakups, demoralization. So, you know, there's a little bit of a kind of the advertising, desperate people on the edge. You know, most of the time it's just general unhappiness, you know, not, not, not pleasant. Not pleasant. And you can give informed consent in that situation.
- [33:16]
Dr. Kelly Casperson
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- [34:23]
Podcast Host
So to me I'm like an informed consent is we don't know how these things work. They tend to help short term by blunting negative emotions. After a certain amount of time, what do you know, six months, a year, it actually becomes difficult to get off these things. Do you think there's a window we can tell people where, like watch it if you want to take this longer than X because that's when it gets tricky.
- [34:43]
Dr. Mark Horowitz
There's no line in the sand. It'll happen slowly. We know that it's easier in the first six months. It becomes much harder after a couple of years. It's already significant between six months and two years. I think the first thing is to follow guidelines. Get people off within six to 12 months. That's a lot better than keeping them on for years. And I'll just say on one point you made, you said these drugs work for a bit in the short term. It's very hard to show that in studies after studies, the difference between an antidepressant and placebo is 2 points on a 52 point depression scale. And most doctors say need to see a seven point difference from mild improvement in someone's mood. So these drugs are statistically significantly better than placebo. That's true. But in terms of clinical importance, imagine a weight loss drug that's better than water, but it only makes you lose one ounce of weight. It's not clinically important. So people argue the drugs are statistically significantly better than placebo but the degree is so small as to not matter. So there's a huge debate. Are antidepressants effective? I think people say that they feel better probably because of that numbing. Then there's tolerance effects in the long term so they wear off. There's all these side effects that I've mentioned some of and that is very hard to come off in the long term. So I think that is closer to informed consent than what most people are receiving at the moment.
- [36:00]
Podcast Host
Absolutely. What resources do you have for people who their doctors don't know how to get them off? They're curious about it, they're afraid of the withdrawal side effects. What resources are established now to help people with protocols? Support groups?
- [36:15]
Dr. Mark Horowitz
Yes, there's a few things. So one I wrote sort of now the textbook in the field about how to come off the drugs held it up. The morsely deprescribing guidelines. Sometimes doctors, sometimes patients buy that book for their doctors, which I find is a bit tragic. It should be the other way around. You know, doctors should be buying textbooks. It's because Doctors have sort of been taught for so many years these drugs are very easy to come off and patients plead with them. Please go a bit slower. I think doctors are a bit intimidated by this thick book, but you can sort of open it up and it goes to Zoloft and goes to Effexor in a couple of pages. You know, I have helped to set up a clinic in America called Outro Health because I got so many emails from Americans where I've helped to train nurse practitioners who help people to come off in this kind of slow, gradual way that I describe in the book at a rate people can tolerate, that gives you wraparound care. There's also free resources, actually. Outro Health has a good library that's free for people to read about. The Royal College of Psychiatrists in the UK has a free guide about how to come off antidepressants that I help to put together that's free for people to read. There are lots of social media sites now, Facebook groups. If you type in the name of your drug and coming off it, you'll probably find a couple of different sites with thousands of people on them. So there are increasing numbers of resources. One place you can't look is in the American Psychiatric association guides for depression, where it just says, come off in a few weeks and you'll have no troubles. So you do have to go outside a little bit established institutions at the moment. Maybe that'll change over time from where
- [37:50]
Podcast Host
you started on this journey. Where do you see this going right now? Do you see this reckoning happening? Do you see this becoming more mainstream? What are you seeing with your finger on the pulse of this?
- [38:04]
Dr. Mark Horowitz
I guess my answer to that is I'm in the uk, which I feel is five years in front of America on this topic. And what's happened the last five years is there's been a thousand newspaper articles about this topic. There's been a BBC documentary, a bit like a major channel in America. There's been a government inquiry into the issue. There's been changes to guidelines, there's been directives put out to doctors. Please reduce inappropriate prescribing of antidepressants. There's been opinion articles, there's politicians involved. Has it changed culture in a big way? No, but it's on the edge of that. There's people, interested, decision makers, and America is five years behind that. There are you mentioned a couple of newspaper articles. The Wall Street Journal, npr, even the New York Times have talked about these issues in the last couple of months in big psychiatric magazines. They've had kind of argument, counter argument articles. People say this is a problem, but we don't think it is a problem. The fact that they've got to even argue against it in a public forum means it's becoming more prominent. And I think the real kind of pusher is there is now hundreds of thousands of people on Twitter, Reddit, Facebook, complaining about this issue. Just regular patients. And at some point when there's millions of people talking about this issue, it's very hard to ignore. So I think this is a sort of slow tipping point of greater institutional recognition, greater awareness by the public, media awareness about it, and that that will slowly come to be more mainstream. There's a little bit of a complication in America that RFK Jr. Has talked a lot about this topic. Now, as it happens, I don't agree with RFK Jr about a lot, but I do agree with him on this topic. He's talked about these drugs can be very hard to stop. We haven't looked at long term effects in children. We should look at it. I agree completely. But because he's sort of seen as a bit of a poison chalice, the mainstream media thinks that everything he says must be wrong because he's with Trump. It does a bit. It's an unfortunate messenger. So that's a complication in the kind of culture wars in America.
- [40:16]
Podcast Host
I think the change, I mean, to me, I've been paying attention to this topic for a couple of years. I've had this podcast for seven years and I'd say even two to three years ago I was like, I can't talk about this yet on the podcast. People aren't ready. They're too protective of this class of medications. They're too protective of first do no harm with people. And now that I saw your book come out and I'm like, great. I actually have an expert now and I'm comfortable bringing this on the podcast. I just feel like the time is more right now. There's a big reckoning and I think the power of social media for people's experiences to be heard makes it more real. But I have to think, like I'm so incredibly passionate about this topic. Like, it's absolutely insane that these drugs do harm and how they're kind of marketed as they only help. Like there's so many Hot topic issues about this that are just so infuriating to me. But if I became the person who like kind of became obsessed with this and talked about it, I know I would be dismissed. People would be like, yeah, but she doesn't like it. Like there's still like a big dismissal for the people who are speaking out against the status quo on this.
- [41:24]
Dr. Mark Horowitz
Yes. So that's true. And of course I've been sort of attacked. They try to shoot the messenger. It reminds me a lot of the response to climate change. First of all, people, fossil fuel companies said, tobacco companies and smoking, they said, there's a crank saying that smoking causes cancer or that CO2 causes climate change dismissal. Then there was minimization.
- [41:48]
Dr. Kelly Casperson
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Podcast Host
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Dr. Kelly Casperson
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- [43:08]
Dr. Mark Horowitz
There are other things that cause cancer. It's asbestos, it's stress.
- [43:12]
Podcast Host
Let's distract you. Let's give you a different topic to think about.
- [43:14]
Dr. Mark Horowitz
Let's not get it tested. One thing, and they put out all these articles, asbestos, stress, blah, blah, blah, or climate change. Yes, it's happening, but you know, let's not destroy the entire economy for it. And sort of, as there's more and more evidence, they had to concede more and more. I mean, in America, they haven't conceded very much these days. In the rest of the functioning world, they have conceded more about climate change. And I see the same sort of thing happening. Denial, minimization, arguing. They're sort of getting to that stage in America where they've gone from denial to minimization and now to sort of this argument. And in the uk, they've gone to, I guess, constructive action. How can we solve this problem? They've kind of accepted it. And so, yes, there are people in the UK who say, maybe I'm a Scientologist, I'm an anti psychiatrist. I'm a pretty weird anti psychiatrist. I've taken the drugs, studied for years, done my degrees, prescribed to patients, got a PhD.
- [44:10]
Podcast Host
If not you, who is my thought of? You are the perfect person.
- [44:15]
Dr. Mark Horowitz
Look, there's more and more people around. It's not just me. There's lots of researchers, doctors, patient advocates, politicians, because one in six people are on these drugs. Everybody knows someone that's had trouble. So every time a journalist contacts me or a politician, I know that they've got a sister or a brother or a wife with the troubles. I'll give you some salacious stories. I've had senior management from large drug companies contact me to help me get their daughter off Zoloft. I've had psychiatrists come to me and say, I can't come off my own antidepressant politicians, journal editors, you name it. Because everyone is on these drugs. And I think that makes it inevitable that this will come out more and more.
- [45:03]
Podcast Host
Oh, fascinating work. It's groundbreaking work. I think it's very validating for people to hear this. I had a patient stop her SSRI pretty quickly, cut it in half, and she was like, all my menopause symptoms are back. It was like hot flashes, not sleeping, moodiness, blah, blah. And I'm like, you just cut your SSRI in half overnight. Get back on that. Those symptoms, you know, we got to do this. You got to do this differently if you're going to do it.
- [45:27]
Dr. Mark Horowitz
So maybe I'll just jump on that. That's a big issue. People stop their drugs, they feel terrible, and they think that must mean they need the drugs. It's like the alcohol or smoking example, but there's a word called rebound, which I think can be a bit helpful in this case, which is things that you do have, but withdrawal makes it much worse. So, you know, you do have hot flashes because you're going through menopause, but coming off the drug upsets your system so much, it's fivefold worse. And it's not because you're off the drug, it's because you've come off too quickly. And the trick is go back on, you come off more slowly. Your system is not so upset by the process. You don't get that surge in symptoms. And so that's kind of if I had to summarize all my work about coming off the drugs. If you do it slowly down to these very low doses, it can be so gradual and gentle. It doesn't upset your system. You know, I give an analogy like going up a mountain. If you do it very quickly you get altitude sickness, but if you do it slowly, you don't get altitude sickness. It's the same. You go on the same heights, but it's how you do it. And the same with coming off these drugs.
- [46:28]
Podcast Host
I love it. Thank you so much for spending time with us and educating us. I know you gave a lot of people a lot of things to think about. And at the end of the day, I'm a physician. I think doctors want to do best by their patients. They want to do right. I think they were given a tool and they weren't told about the long term issues with the tool. And I think you're part of righting that wrong. So thank you so much for being here.
- [46:52]
Dr. Mark Horowitz
Thanks for paying attention to this issue. I really appreciate it.
- [46:55]
Dr. Kelly Casperson
If you found this episode funny, helpful, insightful, please take a moment to follow, rate and share the youe Are Not Broken podcast with someone who might need this conversation too. That support is how this information reaches more people. And thank you. For courses, books and my monthly membership and the Caspersen clinic information, visit KellyCaspersonMD.com this podcast and all content from Dr. Kelly Casperson is intended for educational and informational purposes only, and this is not a substitute for individual medical coaching or psychological advice, diagnosis or treatment. Always seek the guidance of your qualified healthcare professional with any questions you may have regarding your health. Never disregard or delay medical advice because of something you've heard on this or other podcasts. Thanks for being here. And remember, you are not broken.