SSRI addiction and withdrawal

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thelastpsych

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So, I know there is a consensus among psychiatrists that antidepressants, and especially SSRIs are not addictive, contrary to - say - benzodiazepinic drugs or psychostimulants.

The thing is, I've seen some studies that DO mention that most patients being tapered off antidepressants have withdrawal symptoms (commonly named 'discontinuation symptoms' - I even heard that it was a term coined by the pharmaceutical industry to disassociate it with withdrawal, since it implies a dependency), and in my practice I've seen a lot of patients with severe discontinuation symptoms, and some of these patients maintain these for quite some time, with a few studies relating that patients stay with sexual dysfunction or emotional blunting even YEARS after discontinuation.

One systematic review mentions: "Clinicians need to add SSRI to the list of drugs potentially inducing withdrawal symptoms upon discontinuation, together with benzodiazepines, barbiturates, and other psychotropic drugs. The term 'discontinuation syndrome' that is currently used minimizes the potential vulnerabilities induced by SSRI and should be replaced by 'withdrawal syndrome'" ¹

Some studies, even go as far as saying that benzos are safer for anxiety disorders and much less dependency-prone in these conditions than once thought, and most patients will not require larger doses of, say, alprazolam or clonazepam for their panic disorder. Here is a direct quote from one meta-analysis:² "According to the systematic review, no consistent evidence emerged supporting the advantage of using TCA over BDZ in treating generalized anxiety disorder (GAD), complex phobias and mixed anxiety-depressive disorders. Indeed, BDZ showed fewer treatment withdrawals and adverse events than AD."

There are even some claims about tolerance in the oppositional model, and patients requiring higher doses as time goes on, something I've seen in some patients in my practice.³

Now, I know these studies are quite controversial, and I'll put the citations in the end here, but I was wondering from other practitioners what have you observed in terms of SSRI safety, withdrawal, and 'addictive' potential, as well as it's BDZ counterpart on anxiety disorders.

¹ Fava GA, Gatti A, Belaise C, Guidi J, Offidani E. Withdrawal Symptoms after Selective Serotonin Reuptake Inhibitor Discontinuation: A Systematic Review. Psychother Psychosom. 2015;84(2):72-81. doi: 10.1159/000370338. Epub 2015 Feb 21. PMID: 25721705.
² Offidani E, Guidi J, Tomba E, Fava GA. Efficacy and tolerability of benzodiazepines versus antidepressants in anxiety disorders: a systematic review and meta-analysis. Psychother Psychosom. 2013;82(6):355-62. doi: 10.1159/000353198. Epub 2013 Sep 20. PMID: 24061211.
³ Fava GA, Cosci F. Understanding and Managing Withdrawal Syndromes After Discontinuation of Antidepressant Drugs. J Clin Psychiatry. 2019 Nov 26;80(6):19com12794. doi: 10.4088/JCP.19com12794. PMID: 31774947.

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Addiction is a behavioral syndrome that includes compulsive drug seeking, escalating use in the face of negative consequences, and an inability to control or regulate use even when aware of those negative consequences. This behavior pattern is not a thing I have ever seen or heard of with SSRIs.

Physical discontinuation symptoms by themselves are not synonymous with addiction.

You can use the term 'withdrawal symptoms ' if you prefer it but personally I find this causes a lot of confusion since people tend to associate the term 'withdrawal' with addiction.
 
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If the rat won't push the lever for it to be injected, it's not addictive. There's also rebound hypertension with clonidine, but that doesn't make it addictive.
 
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I’m not sure I understand the debate here. Propranolol, synthroid, and prednisone cause more significant concerns than SSRI’s when discontinued abruptly. They have more withdrawal symptoms, and thus theoretically more “addiction potential” through the OP’s definition. Would you associate those non-psychotropics as addictive? If not, you understand that withdrawal symptoms do not equal addiction.

Having worked in addiction treatment centers for awhile, I can tell you that 0 patients have showed up reporting addiction related issues to SSRI’s. Alprazolam admissions are a weekly occurrence.
 
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Patients don't turn tricks on the street corner for their Zoloft fix when you cut them off.
 
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Yeah, I also dont think there is any significant evidence to call SSRIs addictive, but they have some side effects that are not discussed commonly (severe withdrawal, tolerance, lasting discontinuation symptoms).
 
If OP worded this as SSRI "dependence" and not "addiction," I think it would make more sense. Though it's going to be tough to argue on a psychiatry forum that SSRI use leads to "SSRI dependence," even if it's technically true in a lot of cases.
 
SSRIs definitely cause withdrawal symptoms, and "discontinuation symptoms" is definitely drug company double speak. You can become dependent on SSRIs, though I've seen or heard of anyone becoming addicted to SSRIs.

Benzo withdrawal is usually much worse than SSRI withdrawal. And of course it can be fatal. No ever died from SSRI withdrawal to my knowledge.
While benzos are certainly addictive, benzo dependence is much more common than benzo addiction.
 
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Wouldn’t say SSRIs are addictive, but withdrawal symptoms can certainly be a potential issue. We know that medications with a shorter half-life eg. paroxetine can have much more severe effects when stopping than say fluoxetine, necessitating a slow taper and/or additional support with short term benzodiazepine use. From what I have seen, withdrawal symptoms appears to be relatively short lived – usually a few weeks, up to a few months at most.

Recently this topic has blown up on my social media feeds, and I think I can link it back to this article in the Guardian by Carmine Pariante which referenced a study in the Lancet on antidepressant discontinuation syndrome.

This analysis, which I took no part in, looks at 79 previous studies, encompassing more than 16,000 people stopping antidepressants, and compares them with more than 4,000 people ceasing to take a placebo. Pharmaceutical companies were not involved in this new analysis, although some of the data analysed was from trials funded by industry.

The most important finding is that the proportion of people who stop antidepressants and experience severe discontinuation symptoms (which would probably necessitate restarting the antidepressant) is 1 in 30 to 35 patients: much, much smaller than the previous headline figure of about 1 in 4 patients.

This conclusion seems to have attracted a lot of ire online from the Critical Psychiatrists, a niche UK group who have links to the antipsychiatry movement. The 1 in 4 figure has been championed by a number of their members, including founder Joanna Moncrieff who frequently criticises psychotropic medications (mainly strawman attacks on chemical imbalance theory), although her most recent effort to take down antipsychotics fell flat. RADAR Trial: A Reality Check for Critics of Antipsychotics

Moncrieff’s protégé Mark Horowitz has also been very vocal about it. Mark authored the Maudsley Deprescribing Guidelines and seems to think he has invented antidepressant tapering. Interestingly it appears that Horowitz is not a psychiatrist – he started psychiatry training in Australia, but never completed it before moving to the UK. My first reaction is that he is unlikely to have much practical experience in prescribing antidepressants and it appears that some on the /Psychiatry subReddit have come to a similar conclusion. It also appears he has financial interests in Outro, a US based deprescribing clinic that is charging patients $295 a month and advertises that psychiatrists and PCPs don’t know what they’re doing as noted by Australian psychiatrist Sanil Rege on Twitter
 
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Addiction is a behavioral syndrome that includes compulsive drug seeking, escalating use in the face of negative consequences, and an inability to control or regulate use even when aware of those negative consequences. This behavior pattern is not a thing I have ever seen or heard of with SSRIs.

Physical discontinuation symptoms by themselves are not synonymous with addiction.

You can use the term 'withdrawal symptoms ' if you prefer it but personally I find this causes a lot of confusion since people tend to associate the term 'withdrawal' with addiction.
Agree 100%. I've seen this addicted to SSRI because it causes withdrawal approach taken by the antipsychiatry crowd.
 
So, I know there is a consensus among psychiatrists that antidepressants, and especially SSRIs are not addictive, contrary to - say - benzodiazepinic drugs or psychostimulants.

The thing is, I've seen some studies that DO mention that most patients being tapered off antidepressants have withdrawal symptoms (commonly named 'discontinuation symptoms' - I even heard that it was a term coined by the pharmaceutical industry to disassociate it with withdrawal, since it implies a dependency), and in my practice I've seen a lot of patients with severe discontinuation symptoms, and some of these patients maintain these for quite some time, with a few studies relating that patients stay with sexual dysfunction or emotional blunting even YEARS after discontinuation.

One systematic review mentions: "Clinicians need to add SSRI to the list of drugs potentially inducing withdrawal symptoms upon discontinuation, together with benzodiazepines, barbiturates, and other psychotropic drugs. The term 'discontinuation syndrome' that is currently used minimizes the potential vulnerabilities induced by SSRI and should be replaced by 'withdrawal syndrome'" ¹

Some studies, even go as far as saying that benzos are safer for anxiety disorders and much less dependency-prone in these conditions than once thought, and most patients will not require larger doses of, say, alprazolam or clonazepam for their panic disorder. Here is a direct quote from one meta-analysis:² "According to the systematic review, no consistent evidence emerged supporting the advantage of using TCA over BDZ in treating generalized anxiety disorder (GAD), complex phobias and mixed anxiety-depressive disorders. Indeed, BDZ showed fewer treatment withdrawals and adverse events than AD."

There are even some claims about tolerance in the oppositional model, and patients requiring higher doses as time goes on, something I've seen in some patients in my practice.³

Now, I know these studies are quite controversial, and I'll put the citations in the end here, but I was wondering from other practitioners what have you observed in terms of SSRI safety, withdrawal, and 'addictive' potential, as well as it's BDZ counterpart on anxiety disorders.

¹ Fava GA, Gatti A, Belaise C, Guidi J, Offidani E. Withdrawal Symptoms after Selective Serotonin Reuptake Inhibitor Discontinuation: A Systematic Review. Psychother Psychosom. 2015;84(2):72-81. doi: 10.1159/000370338. Epub 2015 Feb 21. PMID: 25721705.
² Offidani E, Guidi J, Tomba E, Fava GA. Efficacy and tolerability of benzodiazepines versus antidepressants in anxiety disorders: a systematic review and meta-analysis. Psychother Psychosom. 2013;82(6):355-62. doi: 10.1159/000353198. Epub 2013 Sep 20. PMID: 24061211.
³ Fava GA, Cosci F. Understanding and Managing Withdrawal Syndromes After Discontinuation of Antidepressant Drugs. J Clin Psychiatry. 2019 Nov 26;80(6):19com12794. doi: 10.4088/JCP.19com12794. PMID: 31774947.
All of your sources (and most of the research) for this are coming out of one university in Italy (U of Bologna). When all the data against something which has been well-known for decades is coming from one place I would question the motives behind that data, especially when there is a single author driving all of those papers...
 
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necessitating a slow taper and/or additional support with short term benzodiazepine use.
Do you not first try augmenting with a longer-acting SRI or are you saying you try benzos after that? TBH this is the first I've heard of specifically using benzos for SRI discontinuation symptoms. Have you found them effective for the head shocks and disequilibrium and what-not?
 
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All of your sources (and most of the research) for this are coming out of one university in Italy (U of Bologna). When all the data against something which has been well-known for decades is coming from one place I would question the motives behind that data, especially when there is a single author driving all of those papers...

Implying that Giovanni Fava is some kind of wild-eyed anti-psychiatry activist is pretty silly. Reasonable to argue about whether "withdrawal symptoms" is the ideal language to discuss this but I don't think that the idea that some people have really unpleasant experiences stopping SSRIs is up for debate.
 
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Implying that Giovanni Fava is some kind of wild-eyed anti-psychiatry activist is pretty silly. Reasonable to argue about whether "withdrawal symptoms" is the ideal language to discuss this but I don't think that the idea that some people have really unpleasant experiences stopping SSRIs is up for debate.
I didn't say the bolded, but the fact that all of OP's arguments are stemming from one person should raise questions to anyone engaging in basic critical thinking. I don't personally know Fava, but I do know his focus is on med side effects and somatization disorders. Not hard to put 2 and 2 together that the papers cited might have some bias driving them.
 
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I didn't say the bolded, but the fact that all of OP's arguments are stemming from one person should raise questions to anyone engaging in basic critical thinking. I don't personally know Fava, but I do know his focus is on med side effects and somatization disorders. Not hard to put 2 and 2 together that the papers cited might have some bias driving them.

He has like 500 published papers. He's certainly published a fair amount on this but saying this is his chief focus is glossing over a heck of a lot. Argument by vague innuendo about bias is not very good argumentation.
 
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I didn't say the bolded, but the fact that all of OP's arguments are stemming from one person should raise questions to anyone engaging in basic critical thinking. I don't personally know Fava, but I do know his focus is on med side effects and somatization disorders. Not hard to put 2 and 2 together that the papers cited might have some bias driving them.
Thats the strangest thing about this thread: I never even said SSRIs are addictive, I think people simply read the first 2 words from the title, and simply assumed that was my argument.

I observed that some patients have strong and sometimes lasting side effects from these drugs, and some of the literature points in that direction. Fava is a respected researcher, but I can cite american authors as well. I was merely trying to start a conversation about side effect profile from these drugs, wich seems to be downplayed by the pharmaceutical industry.
 
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Do you not first try augmenting with a longer-acting SRI or are you saying you try benzos after that? TBH this is the first I've heard of specifically using benzos for SRI discontinuation symptoms. Have you found them effective for the head shocks and disequilibrium and what-not?

It depends. Would consider a number of options - usually a gradual taper is sufficient for most, but if not tolerated I agree with a swap to SSRI with a long half-life like fluoxetine as this often works. For SNRIs adding mirtazapine is usually effective to mitigate withdrawal effects in the tapering process. I would typically only suggest benzodiazepines for short term use if a patient can’t use the above options or if they have had some pretty bad withdrawal issues in the past. I have found of my patients prefer to try without, and if they do it tends to be only for the first few days which tend to be the worst.
 
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Thats the strangest thing about this thread: I never even said SSRIs are addictive, I think people simply read the first 2 words from the title, and simply assumed that was my argument.

I observed that some patients have strong and sometimes lasting side effects from these drugs, and some of the literature points in that direction. Fava is a respected researcher, but I can cite american authors as well. I was merely trying to start a conversation about side effect profile from these drugs, wich seems to be downplayed by the pharmaceutical industry.

When you start with - There is a consensus that antidepressants aren’t addictive…..The thing is …. You are implying an argument is to be had.
 
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He has like 500 published papers. He's certainly published a fair amount on this but saying this is his chief focus is glossing over a heck of a lot. Argument by vague innuendo about bias is not very good argumentation.
He's an expert on affective disorders in general but more specifically on wholistic aspects of psychiatry with depression (ie, looking at psychosocial stressors, good interviewing, including therapies with med management, etc). I'm pretty familiar with his publications as some of research crosses over significantly with the research my colleague/partner focuses on that we have given presentations on. However, he does have a bias against SS/NRIs and has multiple papers advocating for long-term benzodiazepine use over SSRIs. He's been on committees which have gone so far as to say the dangers of benzos are largely just propaganda (ITF on Benzos). Again, not saying it's his chief focus but the bias is there, or at least appears to be from the papers of his I've seen.

Thats the strangest thing about this thread: I never even said SSRIs are addictive, I think people simply read the first 2 words from the title, and simply assumed that was my argument.

I observed that some patients have strong and sometimes lasting side effects from these drugs, and some of the literature points in that direction. Fava is a respected researcher, but I can cite american authors as well. I was merely trying to start a conversation about side effect profile from these drugs, wich seems to be downplayed by the pharmaceutical industry.
See above. I'm sure there are, but I'm guessing they're likely people who work with Fava like Dr. Balon. Again, not saying we should disregard their statements or research, but being aware of bias isn't a bad thing.

The problem with this thread is that the language being used and definitions aren't being seen consistently in some ways. "Withdrawal" is probably going to hold a specific definition to most which requires addiction or at least dependence on a substance. We don't say that someone who is hungover is going through withdrawal. Below is one of my favorite images when teaching about addiction and dependence, specifically the lower right graphic for dependence with the shift in homeostatic point for mood. I do not see patients start SSRIs, develop tolerance requiring higher doses, and then have a shift in their homeostatic point without SSRIs. I do see this with chronic benzo users. The first two steps I have seen at times with SSRIs, and I have seen MDEs precipitated by suddenly (or gradually) stopping SSRIs. So short term changes immediately after discontinuation? Sure. Chronic or permanent changes lowering their baseline mood below what it was prior to us of SSRIs? No. If anyone has evidence of this I would love to see it.

I have never seen a patient legitimately have permanent sexual side effects from SRIs, it's always turned out they either had issues beforehand or there was another issue. I have seen a patient develop a permanent tic disorder from SSRIs, so I'm sure it's possible for permanent changes to occur, but this is not something I encounter frequently enough to even think about it unlike several other med classes we use, including benzos. Also, we talk about side effects of our meds so much more than pretty much every other field in medicine. Could this be a big pharma plot to make them more marketable? Sure, I guess. If patients take their meds appropriately this shouldn't be an issue at all though.

1718045864786.png
 
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ive never had a single person call my office and angrily demanding i prescribe them prozac. In fact, I think id currently welcome that change. Do people go to the ER drug seeking for zoloft? That might be a first.
 
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He's an expert on affective disorders in general but more specifically on wholistic aspects of psychiatry with depression (ie, looking at psychosocial stressors, good interviewing, including therapies with med management, etc). I'm pretty familiar with his publications as some of research crosses over significantly with the research my colleague/partner focuses on that we have given presentations on. However, he does have a bias against SS/NRIs and has multiple papers advocating for long-term benzodiazepine use over SSRIs. He's been on committees which have gone so far as to say the dangers of benzos are largely just propaganda (ITF on Benzos). Again, not saying it's his chief focus but the bias is there, or at least appears to be from the papers of his I've seen.


See above. I'm sure there are, but I'm guessing they're likely people who work with Fava like Dr. Balon. Again, not saying we should disregard their statements or research, but being aware of bias isn't a bad thing.

The problem with this thread is that the language being used and definitions aren't being seen consistently in some ways. "Withdrawal" is probably going to hold a specific definition to most which requires addiction or at least dependence on a substance. We don't say that someone who is hungover is going through withdrawal. Below is one of my favorite images when teaching about addiction and dependence, specifically the lower right graphic for dependence with the shift in homeostatic point for mood. I do not see patients start SSRIs, develop tolerance requiring higher doses, and then have a shift in their homeostatic point without SSRIs. I do see this with chronic benzo users. The first two steps I have seen at times with SSRIs, and I have seen MDEs precipitated by suddenly (or gradually) stopping SSRIs. So short term changes immediately after discontinuation? Sure. Chronic or permanent changes lowering their baseline mood below what it was prior to us of SSRIs? No. If anyone has evidence of this I would love to see it.

I have never seen a patient legitimately have permanent sexual side effects from SRIs, it's always turned out they either had issues beforehand or there was another issue. I have seen a patient develop a permanent tic disorder from SSRIs, so I'm sure it's possible for permanent changes to occur, but this is not something I encounter frequently enough to even think about it unlike several other med classes we use, including benzos. Also, we talk about side effects of our meds so much more than pretty much every other field in medicine. Could this be a big pharma plot to make them more marketable? Sure, I guess. If patients take their meds appropriately this shouldn't be an issue at all though.

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Interesting. Why is it that I see so many people trying to change SSRI's or always going up? Its rare that it worked, and this dose is too high and I would like to go down. Or I feel I made it through that depressive episode and want to stop? Are people just looking for answers in medication, or does something happen to receptors where there can be a lower baseline and feel they need something to maintain normal mood prior to the medication?
 
Interesting. Why is it that I see so many people trying to change SSRI's or always going up? Its rare that it worked, and this dose is too high and I would like to go down. Or I feel I made it through that depressive episode and want to stop? Are people just looking for answers in medication, or does something happen to receptors where there can be a lower baseline and feel they need something to maintain normal mood prior to the medication?
I'm not sure I follow. Is this what they're saying or what you're asking? People are always looking for answers in medication. Honestly, it's part of why I hate outpatient as a lot of people just want pills to "feel better" instead of actually getting better and it can be hard to differentiate who is who until you've been seeing them for a while.
 
Interesting. Why is it that I see so many people trying to change SSRI's or always going up?

Because I am guessing most of your outpatient experience is in resident clinics.

Its rare that it worked, and this dose is too high and I would like to go down. Or I feel I made it through that depressive episode and want to stop?


This actually happens all. the. time. in general outpatient land. I have way more conversations about why maybe waiting more than a month after feeling better before stopping an anti-depressant is a good idea than the inverse.

Are people just looking for answers in medication,

Some of the time. It turns out not to always be the people you'd expect who actually have fairly transformative change from these things, but then I work with a lot of OCD which is notorious for having a pitiful placebo response.
 
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Implying that Giovanni Fava is some kind of wild-eyed anti-psychiatry activist is pretty silly. Reasonable to argue about whether "withdrawal symptoms" is the ideal language to discuss this but I don't think that the idea that some people have really unpleasant experiences stopping SSRIs is up for debate.
Fava has a lot of bias against SSRIs and argues an oppositional model of tolerance where if you use SSRIs, it can make the depression worse if you are on it for a while. He's saying that continued drug treatment may recruit processes that oppose the initial acute effect of a drug. When drug treatment ends, these processes may operate unopposed, at least for some time and increase vulnerability to relapse.

The issue here is that it's a hypothesis and not very well supported by the data, especially when you consider all the covariates that go into risk of depressive relapse. He uses it as an explanation implying that it's better than all of the alternative explanations, which I don't buy.

He also makes a false equivalency between antidepressants and actually addictive drugs, saying that this is a psychotropic drug issue all together. He says that antidepressants are just as likely to cause withdrawal as benzodiazepines and just as dangerous, but that's a load of B.S.
 
Fava has a lot of bias against SSRIs and argues an oppositional model of tolerance where if you use SSRIs, it can make the depression worse if you are on it for a while. He's saying that continued drug treatment may recruit processes that oppose the initial acute effect of a drug. When drug treatment ends, these processes may operate unopposed, at least for some time and increase vulnerability to relapse.

The issue here is that it's a hypothesis and not very well supported by the data, especially when you consider all the covariates that go into risk of depressive relapse. He uses it as an explanation implying that it's better than all of the alternative explanations, which I don't buy.

He also makes a false equivalency between antidepressants and actually addictive drugs, saying that this is a psychotropic drug issue all together. He says that antidepressants are just as likely to cause withdrawal as benzodiazepines and just as dangerous, but that's a load of B.S.

Sure, he obviously has his viewpoints that I mostly don't agree with.

A very recent meta-analysis on this issue that has nothing to do with Fava:

 
Sure, he obviously has his viewpoints that I mostly don't agree with.

A very recent meta-analysis on this issue that has nothing to do with Fava:

Those don't seem all that related. I have yet to meet a single psychiatrist who doesn't discuss discontinuation effects of venlafaxine, it's not remotely controversial. That has nothing to do with SS/SNRIs being addictive or adding veracity to an "opposition model". It certainly doesn't support that pumping in a dramatic increase in BZDs into the population is safer than SS/SNRIs.

I have a patient struggling with BZD use disorder presently and she remarked how frustrated her parents were at how easily she doctor shopped extra pills. I live in a state with controlled substance monitoring and a relatively lower propensity to prescribe BZDs. I just can't even imagine what would happen if any real percentage of people on SS/SNRIs DCed them and started chronic daily BZDs.
 
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Those don't seem all that related. I have yet to meet a single psychiatrist who doesn't discuss discontinuation effects of venlafaxine, it's not remotely controversial. That has nothing to do with SS/SNRIs being addictive or adding veracity to an "opposition model". It certainly doesn't support that pumping in a dramatic increase in BZDs into the population is safer than SS/SNRIs.



Sure, he obviously has his viewpoints that I mostly don't agree with.


Not sure how much clearer I can be.

Someone cited the fact that all the OP's sources were related to one author in a post suggesting that this meant that the whole concern about prolonged discontinuation/withdrawal from SSRIs/SNRIs is overblown or just someone's bias showing. I responded to say I did not think that was a fair conclusion. Then I linked to a recent metanalysis of antidepressant withdrawal symptoms unrelated to the author in question to demonstrate it might not be total nonsense.

At no point did I suggest that we should be prescribing more BZDs, since I think that would be a terrible idea.
 
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