Top Psychiatrist: Are Antidepressants Making Depression Harder to Escape? | Dr Mark Horowitz

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31:53Individual experiences may vary. It's not intended to diagnose, treat, cure, or prevent any disease. So if it sounds interesting, give it a go and let me know what you think. The studies go for eight weeks. Drugs wear off over time. You know, things like opioids and alcohol can be quite effective eight weeks, but they wear off over time. And so the same is probably true for antidepressants. So these small changes in short-term studies probably are exaggerated and probably wear off over time. So the effect of antidepressants is minimal. The other thing people say is, well, it's more important for severe depression.

32:29But studies don't show that. there's a three-point improvement for severe depression and a one point for minor depression it's still a very small effect they try to work out because i'm talking to you about points on a scale what does it mean they try to get doctors to try to make sense of what do those points mean and they've done a study where they've asked doctors here are all these different patients you see them once you see them again when they're they've been given medication who do you think is better so trying to turn these points into what are real doctors think about this and when they see a seven-point improvement, they think people are minimally better.

33:01It takes about a 15-point improvement for doctors to think that patients are moderately better. And so these two - and three-point differences, doctors don't notice it at all. They see this as they clinically know significant improvement. So these drugs have shown statistically significant improvement over placebo, but not to a clinically significant effect. I'll give you an analogy. It's like a diet pill that was better than placebo, but it only made you lose 100 grams of weight or two ounces of weight. In other words, it's very small, the differences. It's very minimal in its effect. So why do some people who are on antidepressants say, you know, it really did help me and it really did change my life?

33:42Because there will be people listening to this, I guess, and writing in the comments. I mean, I'd actually love people to write in the comments whether they've been on the drug, what their outcome has been. And we're going to talk about the tapering effects because that's the big one we're going to get to later. because I think actually speaking about this more widely you can also hear other people's experiences and journeys but what about people that have said well antidepressants have saved my life what's happening with them so I think there's a few things going on so number one we kind of know that people are given placebo also say that because in these studies they have an eight point improvement and they say you know I'm a lot better this has really saved my life I feel much improved and they're improved because they've been given time eight weeks they've been given something that makes them feel like something's being done for them.

34:26So people in the placebo group say the same thing. So the first thing is there are placebo effects. The second thing you've mentioned is in lots of studies, people who asked, what do these drugs do? What do they actually do to you? What do you feel different? And they say, I feel this emotionally restrictive effect, emotionally constrictive, emotional numbing. And what they're saying is my range of emotions from very positive to very negative has been squeezed into the middle. I don't feel very high, I don't feel very low. And that can be a great relief to people. So if you're very anxious, you're very panicked, you're very depressed, to have something that turns the volume down from a 10 to a 3 can be a great relief.

35:03Yeah, I think it can be life-saving. Yeah, if people are in the middle of huge strife, it can make people feel calmer or less tormented by it. So I think when I see people who say that, they often will say, yes these were very helpful and I do feel a bit emotionally restricted and I think there's a difference between short-term effects and long-term effects so I think in the short term in the middle of a storm in one's life having that happen where it it numbs or it dulls your feelings can be a great relief but I hear the other side of things where it's people's biggest complaint they say I don't know what I think about my spouse my partner my children my parents I don't feel strong emotions for them.

35:45I've lost a feeling of intimacy and love. People on antipresents often say they can't cry. They don't feel a sense of sadness. It affects their enthusiasm for life. People say, I used to enjoy sport, music, arts, travel. I don't have that sense of that spark anymore. And that seems to correlate with sexual issues as well. Do you think people also feel that before they get on the drug? Because a lot of people might go on the drug because they just feel like a sense of complete loneliness and loss and they don't get the enjoyment from things anymore that's why they go on the drug sure it it um it's interesting people definitely report feeling um you know low in mood and some people can feel that sort of flatness so people say yes maybe these studies where people say that they're feeling flat is because of their underlying condition and not the drug but a group of researchers at Cambridge did a study where they gave antidepressants to healthy volunteers not depressed people they gave them blinded they gave them three weeks of Lexapro very common antidepressant in America and they showed the exact same effect.

36:44These people reported feeling emotionally blunted having a lack of emotional range so you know that sort of solves that argument is it the condition or is it the drug. It might be involved in the condition as well but the drug very clearly does that and lots of people also I've seen studies that say even in the midst of depression they can feel you know occasional joy they have some you know sense of up as well as down whereas people on medication that they call it the um the kind of antidepressant amotivational or apathy syndrome where people just feel a bit foggy a bit flat a bit a bit meh on the on the drugs i mean you're right there's a kind of confusion what's the drug what's the condition but but it's pretty clear evidence from lots of people that that it's that's the drug playing a role at least uh to a portion so who would you say would be right to explore this treatment with antidepressant or or am i and tell me if I'm wrong or am I interpreting that no one should be?

37:42I think people need to understand. So I think this is sort of about informed choice. I think there's sort of five things people need to understand about the drugs, how effective they are, what the side effects are, or adverse effects are called side effects, how the drugs work, how to come off them at the end, and alternatives and maybe what doing nothing looks like. So that's sort of my informed consent. I've talked about how effective the drugs are. I show people these graphs. There's small differences. They vary for some people. Some people have slightly large, some people have slightly shorter, smaller differences.

38:19But in general, for the average person, they're very small effects. The adverse effects we've talked about briefly, they include things like emotional numbing, weight gain in the long term, cognitive impairments. People have problems with memory and concentration on the drugs often, probably because they interrupt sleep a bit. They disrupt nighttime sleep architecture. They kind of suppress REM sleep. People often don't dream while taking antidepressants. They interrupt slow wave sleep, which is often restorative. Yeah, so people think sometimes people become a bit more emotionally labile on antidepressants, and maybe it's because they don't have this kind of emotional consolidation that goes on in REM sleep.

39:00People can become nauseous. People have lots of sexual problems. That's a big issue for people. Most people who are given an antidepressant will have treatment emergent sexual side effects, a lack of desire, lack of ability to sustain an erection, trouble having an orgasm in both sexes. And we know now for some people that won't go away when they stop the drugs. There's this condition called post-SSRI sexual dysfunction, PSSD, where there's different estimates, up to one in seven some studies suggest. People who stop antidepressants will not get back their sexual function. and so it becomes some people say it takes a few years to come back some people say it can be more permanent research kind of hasn't hasn't come back in yet but there are risks about long-term use and so there's a whole series of side effects and i should say you know some of those side effects what so-called side effects are more common than the you know the intended effects the antidepressant effects you know they say that say 10 percent of people will have an improved response over placebo whereas between 50 and 80 percent will have sexual problems so there's people have to sort of weigh that up.

40:01The third thing is, how do the drugs work? Sort of talked about that. You know, if you are told these drugs will correct a chemical imbalance, a line often, you know, told to people is, you know, if you had diabetes, you would take insulin, this is similar. And that's sort of playing with that chemical imbalance ideas will fix it. I think if people are told, look, the way the drugs are probably working is by dulling down your emotions. I think it's a very different way of explaining things. I think it's much more accurate. I think people will make, I think people if they took medications in that case would realize it's probably better to take it short term than take it long term the fourth thing is that's when they're more helpful then in the short term acute moments than the longer term effects I think I think that um I think it does make more sense to use them shorter term the longer term I think you know the sort of side effects can build up over time withdrawal effects which which we'll get to talk about get get more likely the longer you're on a drug so I think it makes much more sense to use these drugs for shorter periods of time um you know the other things to talk about so how the drugs work alternatives you know in england the nice guidelines the government guidelines say there's 18 different treatments for depression less severe and more severe that don't involve medications that are just as effective and cost effective you know and they include various forms of therapy and exercise and mindfulness and in fact diet is not in the guidelines because there isn't research but i'm sure that's that's just because that's my world that's just because i can say there is i'm sure there is because the nice guidelines have a very narrow yeah interpretation of what counts as studies and of course the people that do the studies that nice pays attention to are drug companies are very good at doing those studies so you'd love the smiles trial by felice jacker she did the first rc she's in australia she's an australian who looked at diet intervention with clinical depression and 33 % of people who had clinical depression overcame it following the smart diet which is a modified Mediterranean diet that was like the first of its kind to prove and there's been lots ever since okay you should you should write to the NICE guidelines because they don't I haven't seen that as part of the guidelines Felice Jacker should she's been on the show I will contact her but so there are lots of different you know options for treatment that don't involve medications that are just as effective you know and cost effective in fact the most cost-effective treatment for severe depression is problem-solving therapy what are your major problems what's the next step you're going to take to solve them if you have if you encounter obstacles come back and we'll talk about it which i think really brings it back to it's the problems in our lives that cause our mood and so addressing them directly you know is useful and even you know people like that list of nice options but zooming out you've got to really think about what's going on in someone's life so i you know i sort of think using the word like depression really boils down many different experiences into one word some people are unhappy because of their relationships some people aren't happy because of finances some people are unhappy because you know they're someone in their family just died so i think the idea there's a sort of one size fits all solution for all people with all different problems i think is a kind of that's where medicalization kind of you know it's very reductionist so i think it's really useful to think about you know people in their own lives just to finish up my long informed consent procedure um you know then what those are alternatives what does coming off look like coming off can be really hard the longer you use a drug you know it can take months or years you may need to use small doses we can talk about that more and the last thing is what about doing nothing people find that you know you know how can you must people are in trouble you must do something you know there's a great book written by a psychiatrist saying that the the guiding law in psychiatry should be don't just do something stand there you know and the reason why he's inverted the usual aphorism is because the natural history of depression is very good you know over time people recover from things so there are studies that find even for severe depression within 12 months 85 of people are better with no intervention you know that's just there are internal documents from the drug companies because they're they're initially their drugs were knocked back by the regulators in germany because they weren't effective and they were worried about the risks of suicidality that were being found in these studies and the internal documents of the companies said we are in trouble because the natural history of these conditions is so good there's no space for medication i think they were being very honest then because you know with lots you know as i said before when things go bad people find solutions they recover they find ways of changing their lives you know they forget about things and so the natural history you know what happens when you do nothing is very good for depression so this idea that we must get in and do something makes a lot of sense of broken bones and heart attacks but i think it's the wrong mindset when it comes to people's moods about their lives these are complex problems and to sort of try to use a simple chemical to knock out one neurotransmitter i think is you know very crude i think it's a very crude tool you know this sort of this potentially numbing effect when people have all sorts of complex life issues i can't get over 85 i have one small ask while you're watching this show if you're enjoying it please hit subscribe on whichever platform you're listening on this really really helps the show more than you can realize it helps people that have never listened to the show before come across it and see all the incredible episodes that we have with the amazing guests so if there's one small favor today if you're not already a subscriber please do subscribe that get better with depression after 12 months by doing nothing I mean I really don't want to um what's the word make people who are really struggling right now and feeling really alone i mean suicide is it's the biggest killer in men under 30 i can't remember what the statistic is but it's for young men yes it's massive um and i know that you know a lot of women can suffer with pmdd and it can be i've got a couple of friends that you know half of the month literally can't cope then you've got postnatal depression where women don't feel connected and there's so many different types where I've been exposed through friends family you know even when I've gone through bad breakups felt like it's just like clinically horrible like the anxiety around all of those things um it's so I don't want to kind of like take that away from people but what I'm hearing is kind of shocking me at the same time because I'm like does that mean that we just have to sit in the discomfort of the pain which is something that a therapist would actually say a lot like you've got to feel the pain you've got to go through the pain to get to the other side and that's where my brain now is kind of like having a bit of a tripping moment because I'm going are we just meant to sit there and feel this extreme pain because I guess what the antidepressants are offering right is this like door to not feeling that pain and saying no okay you don't have to live like this and have the antidepressant yeah i mean look i'm so you're sort of predicting a very masochistic message you gotta you gotta you know endure the pain look i guess i'm just trying to figure out i think there are lots of things you can do i mean i'm not i'm not saying do nothing i'm just i'm just i guess i'm 85 is is something i think nobody would because that in a weird way gives hope yeah that's right that's that's what i'm trying to do so i'm not saying you must do nothing, you just sit there and be miserable.

47:20What I'm trying to say is I'm trying to sort of level set, because people, there's a lot of, I think there's a lot of hyperbole about this. We must do something. People are suffering. We must, you know, people are, suicide is a risk. You know, the few things, antidepressants don't reduce suicide. You know, that's not what studies show. Studies show that they either have no effect or a slight increase in effect, because some people get very agitated. So, you know, people might describe for themselves as life-saving, I won't question that, but the randomised controlled data does not show that. You mentioned young men under the age of 30.

47:52Well, there's a black box warning on antidepressants that they increase the risk of suicidality and suicide attempts in people under the age of 25. So they're not the best thing to give to people that are suicidal because they can increase the risk of suicide. In adults, there's a debate in the literature, is there no effect or is there a slight increase like for young people that's probably because these drugs make some people agitated and that agitation can sometimes lead to suicidality so it's sort of even though it's repeated again and again it's not strictly evidence-based to say that antipresents are life-saving i guess what i'm talking about when i talk about the natural history is yeah not to say do nothing we should do everything we can to help people you know i'm not i'm not saying nothing we should support them they need therapy take up exercise they might change community gardening gardening exactly i'm not we should do everything we possibly can do what i'm saying is um not to be so hopeless because you know i think this is where doctors come in you know when someone has a heart attack you want to jump in you want to do something you want a really you know aggressive doctor who's going to do the right things and shock the thing i just think depression is a different sort of problem and this idea that you know we must jump in there and even if there are lots of side effects to these drugs that are changing our brain lots of different ways i mean And the other thing is if there's not a chemical imbalance in depression, but we're introducing chemicals that change the chemical balance, we are, to be glib about it, we are inducing a chemical imbalance.

49:16It has all sorts of consequences about memory, sleep, sexuality, cognition. So if these conditions are generally self-limiting, we can do other things that aren't so invasive and so disruptive to our neurochemistry. We should do that. you know so i guess i'm just trying to kind of give a bigger frame about what what the problem really is what's causing it so we can think more clearly about what makes sense i'm not saying people shouldn't use antidepressants but i think they should be aware of the limitations of them the harms you know other options and also sort of seeing the big picture that that medicalizing these issues that seeing them as illnesses may not be the most useful way to look at these problems Well, I think it's just so important because, you know, we spoke a little bit about before this, and I've had a lot of friends, I've even had a lot of friends that have later been diagnosed with autism that were actually misdiagnosed and put on antidepressants for a very long time.

50:12And it was just completely the wrong thing to do. And I even think that now people that have been diagnosed with ADHD or some type of neurodiversity are also prescribed antidepressants at the same time. And so there's this kind of real mixture of, well, this is the next stage of what you're going to have, as opposed to let's try all these other. I mean, you even listed 18, and even on the 18, it wasn't diet. Yeah, exactly. You know, there's a lot of other things that one can do as opposed to, but it is hard when you're told by, you know, and I have a lot of respect for GPs because they have such a finite amount of time.

50:52and you know they train for so long and they don't get as much training no training in nutrition and mental health is so limited so you know for them they only have a certain amount of resources but I think this is when podcasts like this become so helpful to people when they're really trying to make an informed decision because some of the stats you were telling me today are like really shocking because actually it might make people rethink maybe this isn't going to give me the result that I want and I say that because you've been through this yourself like before we get on to the tapering and the withdrawal and all of the things that I think is going to be actually life-changing for people to hear on this podcast.

51:29You know, you even have a deprescribing clinic. I'm dyslexic, so bear with me on that word. That's hard. But you are an associate professor of psychiatry. And I'm so aware that everyone who comes on here is an expert, outstanding in their field, making massive changes. But I'm also really interested in why that person's got into it. And I think to bring it back to the human level, you know, sometimes we can talk about stats and figures and graphs and put all these things up there. I will bring out graphs. Don't tempt me. I'll bring them out. We do have a TV being rolled out in the next part of this podcast.

52:03So do stay tuned to actually show the graphs. But I want to just be human here for a moment, Mark, because, you know, you've been through this as well. And I think this is the most important thing because people might be screaming at this podcast right now who maybe disagree. We welcome all opinions on this show. And I also feel like you probably have had a lot of hardship probably from the medical community at the same time, which we will probably talk about. But you've also, not just from an expert, you've been there. You've been in that dark state. So can you just talk to me a little bit about your own journey with antidepressants?

52:38And one, I want to know, do you regret going on them? Is that something that you maybe wish you hadn't done? Or do you actually have no regrets at all going on them and you do think that helped you. Like, talk to me a little bit about your story. Yeah. I guess the first thing to say is, you're right, I'm sure, you know, people respond critically to my work sometimes. You know, I want to say I'm not criticising people for taking antidepressants. You know, number one, I took them for 21 years, so I'm certainly not sitting in judgement of people. You know, I was in a desperate spot in my life and I made that choice and I get why other people would do it.

53:08You know, I'm trying to seek to bring some, you know, information for people to make more informed choices and I'm also not criticising GPs. You know, I've got friends that are GPs, They have very hard jobs. I don't know how they look after every organ in the body. You know, they stay on top of everything. You know, people say, well, I'm criticising them for not knowing how to deal with antidepressants. No. You know, I have huge respect for them. You know, you've got 12-minute appointments. You know, I think the system is slightly, you know, is not set up in the best way. It's the system. It's the system, exactly.

53:34It's all the system, and I think everyone agrees with that. Exactly. I think, you know, making GPs deal with all of the issues in our society with a prescription pad, you know, is putting GPs in a very tough position. So, you know, I have huge sympathy with them. So at 21, how did I come to this? Why am I appearing on podcasts talking about all these stats? As a 21-year-old, I was miserable. I was a miserable young man. I was in fourth-year medicine. I was overwhelmed by the work. I wasn't so interested in what I was studying. I'd had difficult experiences at school. I was miserable like so many people in America and the UK.

54:08And I went to a GP. And in a couple-minute appointment, I was given an antidepressant. um you know and i took that antidepressant for you know 15 years without even thinking about it i i thought like everyone else i thought you know there's something chemical here this is something useful um you know i had all sorts of side effects from it but i thought well that's the price of admission you know these things cause side effects if they're going to do anything you know i didn't really think about it um i had something in the back of my mind though while i was on these drugs i had a lot of trouble with being very tired during the day and having trouble with memory and concentration.

54:44And I had been kind of my US period. I had a very good memory. That's how I got through medical school. But as the years went on, my memory was getting worse and worse. I was tired during the day where I was sort of napping during the day. I was falling asleep. I saw doctors. I was given all sorts of diagnosis, chronic fatigue, narcolepsy. Different doctors had different diagnoses. People said, oh, it's age. You're not 21 anymore. I wasn't sure, but it affected my life in a big way. And part of me thought, could this be the antidepressants? I wasn't quite sure. It all came to a bit of a head. I moved from Australia to England to do a PhD in how antidepressants work.

55:21You know, like everyone around, I was researching, you know, my own problems, like whatever you specialize in your own defects. And so I went, I moved, you know, from Australia to the big smokes in London, and I went to King's College London to do a PhD there in what's the biology of depression and how do antidepressants work. And I spent huge numbers of my evenings and weekends over cells in a dish trying to understand what's happening in my brain and the brains of my friends and my family. Didn't get very far, I can talk about that more. But it was a paper I read at the end of my PhD that really changed the course of my life.

55:55And that paper talked about withdrawal effects from antidepressants. And I found that paper to be shocking because I'd never heard about withdrawal effects from antidepressants in medical school or in my psychiatry training. And a little sort of alarm bell went off in my head because you know drugs that cause withdrawal effects generally are not that good for you you know benzodiazepines not good to use long term opioids street drugs you know withdrawal effects are kind of and I was reading this list of effects sweating you know shaking headaches panic attacks and it sounds like coming off a street drug an opioid and I thought and at that point when I read that paper I'd been on an antidepressant Lexapro esotelopram a very common antidepressant for 13 years.

56:38The second thought I had was the flip side of withdrawal is tolerance. The more tolerant a custom you get to a drug, the more you get withdrawal from it. So if you're a heavy alcohol user or a caffeine user, you become very tolerant to its effects and therefore it's harder to stop. So I thought, if I've been on a drug that causes tolerance for 13 years, what is it doing after 13 years? And so I had these questions and that made me think maybe I should try to come off this drug. I also had these thoughts about, are these medical conditions I've got, is it related to the drug? And so I, being a sort of very diligent geek, I went and read all the different studies about how to come off the drugs.

57:17And some of them were written by professors that I was working with at my institution. Because, you know, while I was there, it passed Harvard as the most cited research institute for psychiatry in the world. So I was working with, you know, all the big names. And all of these papers said discontinuation effects from antidepressants. This is a kind of euphemism. Companies don't use the word withdrawal, they use discontinuation, which to me is kind of like describing a car crash as a discontinuation event involving a wall. It sort of sounds very benign. They say these were mild and brief, last a couple of weeks, no major problems.

57:53You can come off your antidepressants in three, four, six weeks. Sounded very reassuring. And then because I'm a millennial, albeit a geriatric millennial, I went and looked on Google to see what else what were people saying and they said something very different people said getting off antidepressants was the hardest thing I've ever done it took me years I lost my job in the middle of it because I was so sick coming off it it was much worse than the condition I went on the drug for I was in my kitchen grinding up tablets you know like Walter White from Breaking Bad I was you know I had to get syringes my doctors didn't know what was going on they said like there should be no problems coming off and I sort of thought I don't know quite who to trust you know I'm sort of a very institutionalized person I spent six I've got six degrees I'm used to listening to professors you know so I sort of thought I'll sort of split the difference I'll kind of I won't come off over years like these patients online I won't come off in four weeks like the professors are saying I'll come off in four months that sort of difference and I went to my laboratory actually that I was doing my PhD and I and I borrowed all this high tech equipment to make liquids use specific syringes I was you know I went went over the top you know it was a real experimentation it was it was a bit of self-experimentation and I came off what I thought was very slowly over four months much slower than guidelines than I was told exactly and when I came down to a very small dose of my Lexapro my life exploded I had trouble sleeping I would wake in the morning in full-blown terror you know like I was being chased by a wild animal or hanging on the edge of a cliff you know I would wake up heart pounding you know sweating in full-blown panic and that would last for eight eight nine ten hours of the day and at what point had you gone down to your dose what was the smallest part you were on I'd gone I've started on I think 10 milligrams a kind of standard dose the smallest dose is five and I'd gone down to one milligrams so much smaller than the smallest available tablet and I I mean I'd never experienced anything like that before in my life you know things appeared to me a bit sort of unreal they call it derealization I was a bit dizzy and and you know that was the most awful period of my life and I you know I after several weeks that I thought I cannot keep living like this and I thought it was the first time in my life I thought I don't think I can keep living um at that point i thought i've got to go back on the drug and so i slowly went back up over the next few weeks and that you know let that main thing settle down i think there's two things to say about that number one that was nothing exactly the the correct terminology is a physical dependence because i wasn't you know people don't crave antidepressants they don't inject it they don't you know steal to get more because it doesn't get you high the correct sort of scientific term is physical dependence which you know i'd say probably you and many of your listeners will have to caffeine you know you're not stealing it you're not injecting it but if you stop caffeine you'd get a headache and feel a bit crappy for a few days it's not a particularly severe withdrawal syndrome but it is physical dependence and the same is true for antidepressants you know what i had when i came off these drugs was nothing like what i got on the drugs from the first place at 21 i told you i was miserable didn't like my course i had self-esteem issues but i didn't have panic attacks I didn't have trouble sleeping I didn't have any of these symptoms so you know in retrospect what I had when I was 21 was you know a three out of ten or a four out of ten when I came off the drugs it was a ten out of ten it was the most you know terrifying experience of my life it's number one number two I was then back on the drug not because it was helpful but because I was trapped on it I couldn't you know I couldn't tolerate getting off it was too awful and I I actually basically moved back from London to my parents house in Sydney because I was so shattered by this experience it was really you know I can't explain to you how sort of awful it was A couple of years later, because I was really gun-shy after that, I decided to come off again.

1:01:51And this time I kind of understood, you know, the experts in the field were not the professors at my institute, not the people at Harvard, Oxford and Cambridge that I was working with, but the people online who had been through this and had worked out ways of coming off that were much more gradual. And what these people did online is reduced by small amounts, tiny little fractions of a dose every few days or weeks, and it would take them years to come off. and I can show you a graph in a bit why it makes sense to go down to very low doses but I basically copied them. I thought this is quite absurd.

1:02:25I have six degrees in medicine, science, psychiatry. I'm getting advice from homemakers and engineers and truck drivers online and the sort of punchline is I did come off my antidepressants. It took me years not weeks. Doing it in these small amounts made it a lot easier. It made my withdrawal effects much more tolerable. You know, at the end of that, in the middle of that, I sort of thought, and I should say, all those tiredness, concentration, memory problems largely went away as I came off the drugs. So all those issues that had plagued me for years, I realised were due to the drugs. I think that's a common theme, that most people don't recognise what the side effects of the drugs are because they're insidious.

1:03:08They take months or years to develop. So, you know, when you take an antibiotic and you vomit the next day, it's obvious it's the antibiotic. When you take an antidepressant that has, you know, solid emotional numbing, sexual issues, gut problems, gives a lot of people what looks like IBS, you don't put it together with the drug. And so I think that's very common when I see patients and I show them a list of the side effects of the drugs and they circle 10 of them, they haven't realized it could be the drug causing those issues. and I basically at that point thought you know this is kind of absurd why am I getting better advice on how to come off these drugs for online peer support forums than the sort of top people in the field and I wrote an article about coming off antidepressants things that I learned from this website bits of research that I'd encountered you know it was published in a good journal in the uk called the lads at psychiatry yeah um and you know that has led to guideline change in the uk um i would say it's not perfect but they now say much closer to the way that i came off my drugs my it's called hyperbolic tapering again i can show you i'm gonna get a graph a graph yeah i'm gonna don't worry it's getting back to science i'm gonna inflict i'm gonna inflict that on you and your listeners, I apologise.

1:04:21Oh, love it. Yeah. But I should say, you know, there's been improvements in the UK. I think there's still not enough funding, not enough availability for most patients, you know, to access this kind of help coming off, which is why I've set up a clinic in the NHS that helps people to come off these drugs at my NELF, one of the local trust. There has not been a lot of change in America so far or many other countries around the world, which is why I get a lot of people kind of asking me for help which is part of why I set up a clinic in America called Outro Health that helps people to come off these drugs safely and so I guess what this taught me so I should say you know first of all I thought maybe this is just me you know I've just been very unlucky but you know on the internet I found very quickly dozens of people with similar stories then hundreds and eventually tens of thousands of people saying the exact same thing I went on this drug because I had a miserable period in my life.

1:05:17I got divorced. I lost my job. All those things. I didn't like university. When I came off the drug, it caused such severe symptoms that were completely out of proportion to what I went on the drug for. And doctors told me this can't be happening. These drugs cause mild effects at most on stopping. And so now here I am on these forums to get support because my NHS doctor, my fancy psychiatrist from an Ivy League university doesn't recognise this as a problem. And so it leads to this huge stranding of patients, you know, hundreds of thousands at the moment, who are having severe problems coming off that can last for a long time.

1:05:56That's the other point here. People hear withdrawal effects. They kind of think of train spotting, a guy in a room vomiting for a few days, and then it's done. But from psychiatric drugs, the withdrawal effects can last for weeks, for months, and for years. You know, some people, they have their entire lives for years upturned. And we think that's because these drugs cause profound changes in the brain that can take months or years to reset. And that's why this symptoms can last so long. And so there's, to me, there's an epidemic of kind of withdrawal harms from these drugs that most doctors are unaware of.

1:06:33You know, and that's why I'm such a kind of overwhelmed person because I get thousands of emails a year. You see it all. And we're trying to set up clinics in England and America to try to deal with all these problems. Can I ask a very kind of, and I don't want it to sound as extreme, but from what I'm hearing, and if it can last, you know, years, I remember watching Dope Sick, which is about OxyContin, which is all about, you know, the opioid crisis in America. And if you look at, you know, San Francisco and you look at the fentanyl crisis and what's happening over there with the homeless and everything, We aren't so aware of just how extreme the dependence is, the physical dependence on these drugs.

1:07:15Would you put antidepressants in a similar league? So I'll say two things about that. I'll say three things about that. Number one, you know, opioids and antidepressants are very different drugs. You know, one of the things that confuses people is that opioids are addictive and antidepressants are not. So they therefore think antidepressants aren't a worry. but it's physical dependence that is a serious issue that just by using drugs, not by mis... Because people think, oh, it's people that misuse or abuse drugs, they get into problems. But it's just people taking the drugs as prescribed by their doctors.

1:07:47Your brain adapts to the drug in profound ways. That's because of homeostasis. When it's hot outside, we sweat. When it's cold outside, we shiver. If you take a drug that increases serotonin, your brain becomes less sensitive to serotonin over time. And when you stop it, you can get withdrawal effects that are so severe people die from withdrawal effects they can get this thing called akathisia this sort of agitation where they can't sit still they're pacing they become they have a sort of feeling of terror i had a mild taste of that it was really awful and i get you know email after email of people who whose family members have taken their lives in withdrawal from the drugs they were put on it for work stress for relationship problems all this kind of usual stuff but in coming off the drugs that had this profound upset to the nervous system people could get stuck on the drugs because they're so severe.

1:08:32So in other words, you don't need a drug to be addictive for it to be extremely hard to come off and to cause severe problems on stopping. So opioids are more dangerous than antidepressants because they can stop you breathing. That's why that's all over the American media because you can sort of see the bodies on the side of the road. The harms from antidepressants are a bit more subtle but can be quite profound. I should say there are studies that find that the withdrawal effects from antidepressants are similar to buprenorphine. Buprenorphine is an opioid. It's not as strong as heroin or OxyContin.

1:09:06But sometimes people say it's hyperbolic or exaggeration to say that antiviracinists are as hard to stop as opioids. But there is research that finds they're not that dissimilar. So I think they are different. I don't want to be a snapshot on social media saying they're the same drugs. But there are similar issues with physical dependence that can have profound effects on people's health and even be life-threatening. So in that sense, there are similarities. Wow. Okay. So before people would like completely lose hope and freak out, I don't want people to, if anyone's on antidepressants, I really don't want people to be spiraling.

1:09:42I'm very like, worry about people listening to this going, oh my gosh, I've been on antidepressants for 10 years and now I'm going to go through this. So I think this is a good time to set the TV up, to get out the graphs and to show people the right way, the least harmful way to start tapering and what that means. Sure. And they can like keep this for when they're ready to do it. Can we do it? Great plan. Let's get the graphs out. Let's get serious. Let's get the graphs out. When the going gets tough, the tough graphs get going. Okay. We have a graph. Sorry. I apologize. I apologize. I can't help myself.

1:10:23So I'm going to say if you're not watching on YouTube or Spotify, definitely go over there because you can get the video so let's talk about withdrawal and tapering so we left just a second ago with you had basically liquidized in your own lab your own way of coming off these drugs and now you're changing guidelines that people can actually understand how to do this firstly can people actually go and get this liquid formula that's just in my breath you know Great, good question. That's the key. If I had to sort of give one message to doctors and patients, I would say, use a liquid version of your drug and do it slowly.

1:11:01And in America and the UK, most antidepressants come as liquids. Amazing. So yes, you can. So you can actually, there's nothing worse than giving advice where you can actually access it. Exactly, exactly. No, you can. So that's an amazing advice. So if anyone is now stopping or wanting to stop or now being intrigued by listening to you, the first question they say to their GP or their psychiatrist is, I would like the liquid formula of this drug. Full marks, exactly. Thank you. If you remember nothing else from what I said, ask for a liquid of the drug. That's what we want. Okay, so what are the steps that people are maybe on?

1:11:31I'm thinking 50 milligrams is probably the average dose. Say 20 milligrams. That'll cue me up better. Okay, sorry. 20 milligrams. Okay, so someone's on 20 milligrams and they're, okay, I want to come off. What are the steps they take? How do they look at their dosaging? So let me just zoom out a bit before I inflict a graph on your poor listeners. I think they're going to love this. They can visually see it. Okay, so number one, what problem are we trying to solve? If you come off a drug too quickly, you get withdrawal. If you do it more slowly, it becomes easier. Let me give you an analogy. The analogy I like using is altitude sickness.

1:12:06If you go up a mountain too quickly, your body can't adapt to lower air pressure at higher bits of the mountain, and you get altitude sickness. You feel headache, dizziness, joint pain. It's not the height that gets you. It's the rate at which you go up. So for example, if you go from sea level to the top of Everest in two days, guaranteed you'll get terrible altitude sickness and it might even kill you. If you go from sea level to the top of Everest in two years, your body has lots of time to adapt, you're not going to get any altitude sickness. Same as coming off an antidepressant. While you've been on the drug, your body has adapted to the levels of chemicals that the drug produces.

1:12:44If you come off in four weeks, it's a very quick change in your body and your body goes into disarray and you get all the sort of symptoms that I mentioned. If you do it over months, maybe over more than a year, you give your body much more time to reset. So that's the first principle coming off. Doing it gradually is better than doing it quickly. Principle two is you've got to do it at a rate that you can tolerate. There's lots of risk factors. If you've been on it for long periods of time, it's worse. Certain drugs are worse. But basically, if you start to feel withdrawal effects, you should pause, go back up a step and then go down more slowly again like mountain climbing you start to get altitude sickness what do you do you should pause where you are to adapt to the new level of air pressure or go back down the mountain and they got more slowly so you got to adapt it to how you feel and the third principle is where i need a graph and this is why when you get down to lower doses you should do it more slowly so i'm going to show you this so this is a paper we published in the lats of psychiatry a few years ago, and I'm giving an example here of citalopram or Celexa.

1:13:47But this principle I'm about to show you applies to all antidepressants. Lexapro, Cymbalta, Effexor, any antidepressant you're on. In fact, sertraline, Zoloft, Prozac, fluoxetine, in fact, any psychiatric drug. And what I'm showing you here is on the x-axis is dose, and on the y-axis is effect on the brain. It happens to be something fancy about affecting serotonin transporters. We can think about it as effect on the brain. and the main point of this graph is it's not a straight line. So the most common doses of citalopram or Celexa are 20 milligrams and 40 milligrams and increasing from 20 to 40 doesn't increase the effect on the brain by that much.

1:14:26Oh, wow. It's only a small increase and the smallest tablet in lots of countries is either 20 milligrams or sometimes 10 milligrams but even a little tiny dose like 2 milligrams actually has about half the effect of 60 milligrams. Can I say one thing here? Go for it. I'm sorry. So I have something called Raynaud's disease, which is very severe circulation for anyone that doesn't know. I get like chill blades on my hands. And I, you know, I can't, basically I can't hold my ski poles when I want to ski. It's very, it's a very annoying condition. Terrible, terrible condition. And my toenails fall off.

1:15:02Right. So I've totally just lost anyone that would ever fancy me. Anyway, when I go and see my doctor for Raynaud's, the thing that they prescribe 80 % of patients is fluroxetine, which is an antidepressant. Right, right, right. Obviously, they told me that I should go on fluroxetine, and I went off and on. Sorry, this is not to be a personal story. This is just because of the dosaging. But they were like, look, it's the only treatment unless you go into hospital and have kind of an infusion for four days. And it is quite a debilitating thing to live with, especially in the winter if you live in the UK.

1:15:40They told me that going on 20 is such a low dose that it's never used for psychiatry and mental health purposes. And it would never change my brain. And I would be absolutely fine. And the reassurance around that was massive. And that I was in the very small percentage of people that aren't going on this. And I really need to rethink my decisions about going on this. and I mean I've been treated now for probably like 10 years and I never chose to go on it and there was a point where I nearly did because they kept saying to me it will physically not change your brain it will not have any frequency of effect that's totally false so that's why I'm looking at this so I'll just say I'll just say that so the same graph exists for phyloxetine I don't think I've actually got it here I normally have it I can show it to you in a second so that is commonly what doctors say they say you're on a very this is what they say not just to you for your, I'm sorry, I made fun of your disfiguring disease.

1:16:33No, we can't. It's fine. You've got to laugh about it. But it's what they say to lots of patients. You're on a very small dose. You can just stop it. And what they're saying is you're on the smallest available tablet or capsule, but your brain doesn't care what you're putting in your mouth. It cares about the effect on target receptors. So the smallest tablet for Celexa, 20 milligrams, for Prozac, 20 milligrams, for Zoloft, 50 milligrams, is a small tablet, but a very big effect. So it's always falls and people get as i'll show you in the next slide people get pushed off what they call a small dose but actually they're being pushed out of the eighth floor of a building and that's why they're end up in trouble that's the that's the key issue because like i was never being treated for something that was depression it's like and it's an off so if you doesn't know off labeling is basically when you can use a drug for multiple things for instance viagra is another one that they use for reynolds because it helps increase your blood it's your vascular system right so it helps the same reason it works on viagra bringing blood stimulation it works the same with your extremities but the amount of convincing that nothing was ever going to like affect me mentally but i was also just so terrified of taking it because i hadn't suffered with depression that you know and i was in that very rare case that wouldn't accept it yes well it's again the other thing they said is false is you won't you won't have any effects from it even these doses have profound effects it has profound effects on the brain and so even small doses so people exact doctors will say you're not on a high dose you'll have no problem that's not true high doses don't have much more of an effect than very low doses and so the point is that even very tiny doses like two milligrams still have large effects and that makes doctors sometimes chuckle because they say it's a homeopathic dose two milligrams but according to this graph and lots of other research it's not a small dose so let me show you what happens when people come off the drugs.

1:18:16So you walk into a doctor and you say I'm on 20 milligrams of Celexa, how should I stop it? And the doctor says look let's break it into small steps. We'll go down 15, 10, 5, 0. They might split the tablets, give it to you every second day and it sounds intuitively right, 20, 15, it sounds like it's evenly spread. But in terms of effect on the brain it's not evenly spread. So the first reduction from 20 to 15 causes a small change in effect on the brain. Some people find that okay, Some people already find that quite difficult. The next reduction from 15 to 10 causes twice as big a change on the brain.

1:18:4810 to 5, twice as big again. And going down from 5 to 0 is like jumping off a cliff. I mean, it is literally jumping off a cliff. If anyone, this is like the changes in the brain on this axis. On the y-axis, exactly. On the axis is the dose. That's like, I mean, three squares versus one square. Exactly. So going from 5 to 0 is about 20 times the effect. So it's a 58 % change compared to the 3 % change going from 20 to 15. So yes, if you can't see this graph, it's basically the side of an archway on the left-hand side. It goes up extremely steeply and then it flattens out. And people have kind of pushed off this because the doctor says to them, you're on now half of the smallest dose.

1:19:28This can't be causing you half of the smallest tablet. This can't cause you any trouble. And what people say is the first few reductives were fairly easy. and the last few reductions were hell. And the doctor looks at them and says, this can't be the drug, it must be you. You've either had a relapse of your depression or anxiety. It's unintentional gaslighting. Medical gaslighting. The doctors are not meaning. They don't know. They're ignorant. Yeah, of course. They don't know this relationship. But it is. But people are told this is in your head, it's your condition, it must be something else, it can't be the drugs.

1:19:59Because look at the textbook, the drugs only cause mild withdrawal effects for two or three weeks. And you're coming in after three months with severe panic attacks, can't sleep, it can't be the drug, you must have developed a new panic disorder. So then you put you back on more. Put you back on the drug, maybe sometimes more of the drug, and you're told you've got a severe lifelong condition that needs the drug. And this becomes this revolving door. So let me... Sorry, I said a lot of bleak things potentially on this. Let me say something a bit hopeful here. Understanding this can make you understand how to come off these drugs more safely.

1:20:32So what I've done with this graph is, rather than drawing horizontal lines along the x-axis i've drawn lines along the y-axis so what makes sense is to come off the drug in such a way that reduces the effect on the brain by even amounts and not dose by even amounts so i've drawn four horizontal lines equally spread apart and that means you've got to go down by smaller and smaller amounts down to very small final doses as if you're imagine if you're walking down this curve it starts off as an easy country walk you can run along it as it gets steeper and steeper and turns into a cliff you've got to go down this is with crampons you know inch by inch yeah and because this shape is called a hyperbola if anyone remembers their high school mathematics this is called hyperbolic tapering because it fits along this curve and it goes down to extremely small doses before stopping so the smallest tablet was 10 milligrams these are you know microscopic doses that you need to go to so you're not making a big jump at the end so for anyone who doesn't know the smallest tablet that you can get is 10 milligrams.

1:21:33What the graph is actually showing is that it goes down to 5.4 milligrams, which is, I guess, half of... About half, yeah. Then it's 2.3 milligrams, and then it's 0.8, which is why that must be physically impossible in a tablet formula. And we were saying just a minute ago, you have to do it in a liquid. And so this is also just a very kind of simplified version. People often need intermediate steps. They might need to do, say, 10 % of their most recent dose every month. That's why it can take people months or even years to come off. and exactly to make these smaller doses using a liquid. There are other tricks people can use.

1:22:06Compounding pharmacies can make up tablets and capsules, all sorts of tricks. There are off-label things you can do at home. You can crush up tablets and so forth. But the point is, so to summarise the whole thing, come off slowly at a rate you can tolerate and go much slower at the end. And a good rule of thumb to summarise all of that is most long-term users can come off at about 5 % to 10 % of their most recent dose every month. So if you're on 20 milligrams, go down to 18. If you're at 18, go down by 1.8 milligrams and so on. A bit of variation, something can go a bit quicker, a bit slower, and that's the way to kind of get off these drugs safely.

1:22:42How long is this? Because when we were speaking earlier, you know, I guess in the UK they're saying... Sorry, I just want to show you fluoxetine. Is that like a year or is that...? It's a bit of a how long is a piece of string. It depends on how the person responds. so it's very hard to guess just by looking at somebody there are certain risk factors certain drugs take longer to get off effects or cymbalta paxil pristique if you've been on the drug for 10 years it often takes you longer than if you've been on the drug for six months so what we do in my clinic in outro and in my nhs clinic is you make a test reduction see how people respond if going from 20 to 18 is fine you might go a bit quicker you're going from 20 to 18 is horrible, you might go slower.

1:23:29And so what you're doing is you're adjusting it to the person as they go down, like climbing a mountain. If you start to get altitude sickness, slow down. And when you feel better, go up more slowly. And so you're adjusting things. You're sort of estimating at the beginning what this person should do, adjusting it, and people take, in my clinic, long-term users. I don't see people who've been on the drugs for six weeks. That doesn't make sense. Most people have been on the drugs for more than five years, and on average it takes people about 18 months to come off. So between 12 months and three years is what I would see as broadly the kind of range.

1:24:04People aren't told that when they're going on these drugs. Exactly, that's the other thing that you need to be told. When you put on these drugs, people need to be told you may not be able to come off the drugs. Coming off the drugs too quickly may cause life-threatening issues and if you want to come off it safely, it might take months or years. You may have to pay for specialised liquids. You may not be able to find a doctor that can do this. You know, a lot of doctors will say, unfortunately, we don't prescribe liquids because that's expensive for the NHS. So I think people need to be told that it's much easier to start these drugs than it is to stop these drugs.

1:24:35It takes a second to put it in your mouth, but it can take months or years to come off safely and it can cause all sorts of issues. So I think that's an important part of informed consent or informed choice. 100%. I think if people can understand, I mean, we were speaking about this earlier, you know, when you look at cigarette packets and now they're like labelled with black lungs and you can get lung cancer and all of these things. We know so much about the damages and the effects of smoking that it's now that individual's choice that they are so aware of the disadvantages that come to having a cigarette that that's their informed choice.

1:25:09There is no like, this is fine, because actually when my grandmother was going through a very bad separation, she was told by her GP before to start smoking because it would calm her down. so she went with extreme anxiety and the doctor said well to help calm your nervous system down you should start smoking this is before the extreme understanding of like how detrimental it was and then she's hooked for life and she had emphysema and so you know she had to live on on oxygen that was because in a bad but uninformed understanding of what smoking did i'm just picturing in my head the kind of rise in uptake of these antidepressants and if people are going on them but not realizing the risks now if people are giving boxes of these antidepressants with warning signs on increases suicidal ideation you know increases xxx is that then going to make that person think yeah a little bit more yeah i don't try not to be extremist here but i guess smoking is the only way i can kind of like understand it a bit more i mean you know i think the thing to say is you know the drugs do come with those warnings you know if you are in america it has a boxed warning that says will increase the risk of suicidality in young people under the age of 25.

1:26:22If you open up the drug leaflet inside antidepressants in any country, it'll list all the common, uncommon and rare side effects and it mentions a lot of the ones I've talked about. Weight gain and sexual issues and so forth. It even mentions that you might experience permanent or long-lasting sexual problems even after stopping the drugs. All the things that I've mentioned are to some degree in the leaflets not in great detail often not strong enough but they're there but no one reads those things and doctors you know in 12 minute appointments don't go through those things and there's also a bit of a paternalism i think in doctors where they think this drug is good for somebody i don't want to scare them off the drug by telling them all the negative things i'll try to sort of sell it so i i was kind of taught that in medical school i was kind of told um don't show people this leaflet because it'll scare them off you know it's written by the lawyers don't worry about it i now say to people this is a leaflet was written by the lawyers you should worry about it they wouldn't put it in if there wasn't evidence that this is what occurs and so i think people are not when you ask people were you told about side effects we talk about withdrawal effects often less than 10 percent of people were given informed consent informed choice and so i think i think the benefits of these drugs are exaggerated because of drug company kind of talking points evidence studies that influences guidelines influences education hurried doctors give very superficial informed consent.

1:27:46They say this will help you. They might say this is like insulin for diabetes. And they often say any side effects will be temporary and go away. And that's not true. Some side effects do go away. And by the way, that's because of tolerance to the drug. If your side effects go away at the beginning, it's because your body's becoming accustomed to the drug. It's going to set you up for withdrawal. And the other line that is important is, for example, the suicidality issue, which would be a real big warning for people, the drug companies have found ways around it and they have a line where they say, the reason why young people become suicidal on our drugs is because it gives them energy before it solves their depression, so they have more energy to act on their suicidal impulses.

1:28:27But that's false. There is no evidence showing that they have more energy or that there's delayed effects. What the studies show is that more people, young people that are given antidepressants than placebo in the studies, will try to kill themselves or have suicidal thoughts. So the marketing team has spun it, and I was taught to say that in my training, that when you give it to a young person, you're basically saying, yes, it says on the packet it'll make you more suicidal, but it's actually a good thing, because actually it's giving you energy. That's a good thing. So they've kind of found a way to spin it to make it sound good.

1:28:58And so I think in all sorts of ways, doctors and patients have an exaggerated sense of how good the drugs are, have minimised the negatives of the drug, the harms. and so I would say that nobody in the UK or America has ever really made an informed choice about these drugs because they haven't been given the right information. So what are the questions that you think an individual should be asking? I mean looking at that graph and seeing just how... I don't want to say the word catastrophic because I really don't want to scare people but I think just how hard it is and the physical dependence that can come with these drugs and actually potentially feeling worse afterwards.

1:29:39And also this is a lot to also do every day, the tapering of the drug assist. It's a lot of energy when you're also not feeling great. We kind of forgot about that part. What are the three things that one person should probably ask themselves before making this decision of going on them? Look, I think it's all those things that I talked about. I think people should ask their doctors and do some reading themselves and go through those points that I asked, that I mentioned. How effective are the drugs? Maybe before that, why are they so unhappy? You know, I mean, it's very hard for people in the middle of things, but, you know, what is going on?

1:30:16What else can they try, you know, before they try medications? You know, you've talked about diet, exercise, therapy, changing your life. You know, there's a whole lot of things. None of them are easy. You know, I think that's the key thing, to change your diet, to exercise, to do therapy. None of that is a magic bullet. You know, antipersons look like a magic bullet because you see ads, you hear people. I guess what I'm trying to say is if you think about them more deeply, they're not quite as magical as they sound. So I think what else can they do? How effective are the drugs? Look carefully into the harm so that you're not surprised by them.

1:30:48What are the alternatives? How do the drugs work? Ask the doctor, how long will I be on this drug for? When are we planning to stop it? Because when you start on antibiotics, they say we'll do seven days. If there's no response, we'll do 14 days. There's a plan to stop when you start. I think that should be true for antidepressants and all the guidelines say that. Guidelines in America say you should be on antidepressants for six to nine months for an episode of depression. There's issues with that but it's a good starting point. It's not an indefinite prescription although for a lot of people it ends up being that.

1:31:18When are we going to stop it? How are we going to stop it? What's the plan? That's sort of a sensible thing to ask and also maybe what would happen if I did nothing? So I think you ought to have the answer to all of those things. I'll add one more thing which is the power of wait and see. So there's a study that was done in secondary mental health, so psychiatry clinics, where people who had depression, if you're going to see a psychiatrist with depression, it's severe. This is not just for GPs. And they gave everybody some explanation of what depression is. It's not a chemical imbalance. It's something about your life.

1:31:51Often things can help it go away. They basically tried a policy of wait and see. In three months, two-thirds of people were better, didn't need any more treatment. They didn't give therapy. They didn't give medication. so I often say to people say this to friends of mine if you get a prescription for an antidepressant put it under your pillow for six weeks if you still want to take it then and studies show that lots of people won't take it so I'm not saying you know if you're very desperate you want to try something I'm just saying put put a pause on things there's a policy they're trying to bring in the NHS that helps doctors to not prescribe on the first occasion but only on the second occasion so you can't so there's a bit of a barrier a bit of time to thinking about things you know to consider to reflect on all the implications of taking these medications.

1:32:33What about children and teenagers because you were 21 when you went on it I'm thinking about a subs group of people now that are you know teenagers maybe between 12 and 18 or 12 and 16 you know where I think there's a rise in neurodivergence of understanding that people might be anxious more isolated and maybe they're being put on antidepressants what's your like view on that because obviously the brain is so malleable at that age sure so there's a few things to say about that number one so yes that's a very that's a sort of rising group of people one in ten teenagers are on antidepressants in the uk and the us and it's rising every year the evidence for antidepressants in that age group is much worse than it is in adults so i've talked there's a two-point difference in adults for all antidepressants except for one there's general agreement there's no effect in in young people solof sertraline venlafaxine effects or the evidence shows there's no difference between placebo and antidepressant the only drug that's in guidelines is fluoxetine or prozac which has a small difference we've done some work recently and so have other people that show the difference has got smaller and smaller over time people like how can a drug change over time it's because the early studies were done by the manufacturer of Prozac and they've got incentives to make it look better.

1:33:53As time goes on that drug is used by other drug companies as a comparison and they do fairer studies because they're not so interested in it. If you put together the studies the drug becomes less and less effective over time until in 2023 from memory it became ineffective. In other words put together all the studies in a meta-analysis fluoxetine like other antidepressants is not effective in depression. So that's number one there's no evidence for effectiveness of these drugs they're still widely used because doctors kind of want to do something they need something when they've got distressed children your question you know your your dilemma is what is it doing to the developing brain and the answer is we don't know except there are some very worrying signals so the sexual problems that I've talked about being permanent sometimes happens a lot to young people now animal studies are not always direct correlates to human studies but animals that are adolescent before they go through puberty that are given antidepressants don't develop sexually normally they have abnormalities to their hormonal systems they have physical abnormalities to their genitals some of similar things are seen in humans given these drugs we don't know what happens to the brains because there haven't been long-term studies as you said the studies go for eight weeks sometimes they do safety studies for 40 weeks but there's no studies that go for long longer periods i know people that were started on the drugs when they were young they can't get off because the withdrawal effects are so severe.

1:35:15They have sexual problems. Some of them have never had sex before they start the drugs. They don't even know what a normal sex life is to compare things to. So I think there's a professor of psychiatry in America who says, we are running the largest open-air experiment that we've ever run, giving people antidepressants for long periods of time when the studies go for eight weeks. I think that's even more of a dilemma when it comes to young people. So I don't know what the drugs are doing in the long term to people. There is not great evidence of efficacy. there's some worrying signals about harm so i think it's a very big area of concern so i want you to finish this sentence for me then you're not broken your brain is dot dot dot right so it's a great there's actually a colleague of mine in australia who set up something called the not broken brain project not broken project not broken brain project and he's trying to inform the public that when you feel distressed lost demoralized it's not because your brain is broken it's because you're overwhelmed by life things have gone wrong so i would say you know it's it's the problems are in your life you know it's not that your brain is broken it's that you have you know overwhelming problems in your life that you need help with so i i um so i think the idea of a broken brain you know is about you know chemicals or some sort of abnormality you need a doctor to fix i would say that is a very um unconvincing i think unhelpful framing of things and I'll put one more study there they just say where they randomized people with depression to one of two explanations they told them one of them you've got a biochemical problem in your brain causing your depression and the other group they said you've got a series of problems in your life you're you're you're in a rough spot causing a depression the group that was told that they had a chemical problem were more pessimistic about recovery they've now been told that a major organ has a problem they wanted medications more because how can they fix the chemicals in their brain they need a chemical doctor to help them they were less likely to do things for themselves again how can they fix you know they can't change the chemicals of their liver they need a specialist and in the end they were more depressed the group that were told it was a rough spot felt more empowered to something themselves were less likely to want medications were more optimistic about recovery and did better in the end so what we this story we're telling people has a big effect on what how they think of themselves and affects you know their self-image Are you a broken person, maybe lifelong with a genetic condition, which is not very well supported by research?

1:37:42Or are you a regular person, 70 % of us, who's going through a tough time and need some kind of change or some kind of help? And so I think we've got to be very careful about the story we're telling the public about their emotions. I honestly think the way that we describe our health in literature to patient, doctor to patient, and the internal language is so profound. I mean I touched upon it in the book with food just about like how you talk to yourself actually changes the way you Hormonally respond, right, you know how your digestion responds how your hormones responds how your hunger hormones react But it's so important like our limiting beliefs, you know understanding that there's hope Understanding that you have self autonomy like these things I think that especially with depression can just feel like that like ripped away from you and actually feeling that you can have some type of authority over that is it's just I guess really empowering absolutely so many people yeah so I guess it's profoundly disempowering story to be told you have an illness it's in your brain you know you need medical treatments I think that's it's not I think it's accurate I think it's helpful and it's very you know it's a very demoralizing story to hear so you know some people are out there saying I was told by my doctor I've got a chemical imbalance that's why i took the drug you know that wasn't true so i was i was given a drug under false pretenses i feel like i've been you know i've been misled and i think there's a good you know if someone told me i've got a a chemical imbalance in my heart i need a drug i'm going to be pretty quick to get that drug if it turns out that that wasn't a chemical imbalance or electrical electrical imbalance in my heart i'm going to feel like i was given a drug you know under false pretenses so i think you know people have a right to know what the evidence shows to make an informed choice as i said again and again people can choose to use antidepressants i'm not trying to take that away from people and i know people have found it helpful i just think they should know the overall story i suspect a lot of people will choose to use the medications for shorter periods of time rather than open-ended you know if if it's an emotional band-aid that causes numbing in the short term there may be a role for that but to use it lifelong for years i think is a very different prospect that people should be more um you know apprehensive about yeah well I would say if you feel that you want to know the next step to maybe things you can do Dr Lisa Feldman Barrett speaks about this really amazingly with her body budget theory she's a neuroscientist at Harvard and she actually talks about her own daughter's depression in the episode and how about she believes the body is in depletion and actually you've got to like work with the body with food and exercise and all those things to help it kind of rebalance the brain Dr Felice Jaka that was an amazing episode all about nutrition and how that can support depression near Earl he talked about his limiting beliefs and how that can change your mood and your mind so we've got we'll link them all in the show notes but there's lots of different ones that if this feels really relatable to you that there is actually other ways that you can also support your brain without just solely medication and I also make the point in the book that even if you are on medication I have a very short part within this book that I talk about food and the mental health but actually even if you are on the drug of an antidepressant doing all these other things is also really important we shouldn't just solely be relying on the medication we should also making sure that we are doing the social subscribing the nature the community the support all of those things to give you that individual the best kind of outcome possible so mark i mean i know that you are totally overwhelmed um and you have one clinic but if people you know have been really touched by this episode what's the next steps for them really like how can they maybe come and see you or if their wait list is too long because it's nhs like what do you say is the next best thing so i'll tell you a few things one i wrote i wrote a textbook called the mawesley deprescribing guidelines which explains this sort of technique it's aimed at clinicians i know that a lot of patients have bought it to inform themselves or given it to their doctors i think it's a somewhat sad christmas or easter gift to give to your doctor but people have done that um because they've tried to come off their drugs before, they've had trouble, they want to try it in an easier way.

1:41:49If you're in America, Outro Health has a website. We're opening now 14-plus states. Sorry, I'll do that.

1:42:01Outro Health, which is open in 14 or more states in America where I've trained clinicians on how to come off drugs in a safer way and you can get personalised support there. If you're in England, we have a national deprescribing clinic, which you can get referred to by any GP in England, which is in north-east London. We've got a website you can find online. I've got a dinky website that has more academic articles and blogs about how to come off the drugs. Those are the places to start looking. The Royal College of Psychiatrists, I work with them to write some guidelines on this, so there's a few more authoritative pieces of advice around.

1:42:39Amazing. Well, Mark, thank you just for going against the grain. um using your personal experience to help other people it's very admirable that you've actually kind of really put your neck on the line i know you get a lot of flack um and so thank you for sharing and this is going to be so helpful i honestly think if you know any everyone will know somebody that is affected by depression in their life whether it's themselves or someone that they love dearly so i really really really encourage people to share this episode um with as many people as possible to get this out there i leave with one final question mark which i ask to everyone and I ask this because I love how individual everybody's answer is and that's what I believe health is very individual so Mark what does live well be well mean to you gosh I should have been given notice I was going to give it a tough answer everyone says that but it should come from the heart

1:43:35I can't say pass on this live well be well you know means

1:43:42I think you know feeling having a balanced life having things where you don't feel overwhelmed and it's about finding I think you know everyone needs to find their niche in life where things work and I think that's you know it's very hard for young people who are sort of thrown into circumstances that I control and as you get older you choose and what you eat how you exercise who spend time with what job you do I think that's a big challenge for young people is to try to find what niche fits them I think it's a very big part of mental health yeah yeah well that is literally understanding yourself I guess yeah it comes exactly self knowledge yeah it's not really we don't come with operating manuals you know like a team exactly make life a lot easier so you've got to work it out yourself yeah this podcast thank you so much Thanks, thanks for having me on.

1:44:40Appreciate it.