Talking to patients about access to medication given current events

[lockian]

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With the recent political climate, I've had several patients express concern and anxiety to me about access to their medication, from bans on manufacturing and prescription given RFK's views, to tariffs leading to shortages. I am not sure what to tell them, except general advice about doing what you can to prepare but being mindful to not let anxiety get the best of you until we actually see how things play out.

But in terms of being prepared, *are* there concrete steps that can be taken? I've heard of doctors prescribing higher doses than the patient actually takes to address cost issues but that's always felt uncomfortable to me on account of, you know, it not being the truth.

 

[comp1]

Do you mean in terms of talk therapy to reduce patient anxiety long term? I guess I would process why, with all the million things that could or even more likely will go wrong, this is where their mind goes. What do the medications do for them, what would it actually mean for them to not have access, how would they cope, etc. Some sort of mental exposure therapy? I mean it would of course depend on the patient and what it actually would mean to go off their medications. Most people on SSRIs could reasonably cope, for example, if possibly at a lower level of functioning. If you meant some concrete way of "prepping," no. I mean we've been dealing with stimulant shortages for years now and people make it work.

 

[Sushirolls]

Alcohol UD med shortages, too.

 

[lockian]

Do you mean in terms of talk therapy to reduce patient anxiety long term? I guess I would process why, with all the million things that could or even more likely will go wrong, this is where their mind goes. What do the medications do for them, what would it actually mean for them to not have access, how would they cope, etc. Some sort of mental exposure therapy? I mean it would of course depend on the patient and what it actually would mean to go off their medications. Most people on SSRIs could reasonably cope, for example, if possibly at a lower level of functioning. If you meant some concrete way of "prepping," no. I mean we've been dealing with stimulant shortages for years now and people make it work.

These do tend to be people for whom the consequences of going off medication would be profound, from severe withdrawal history to profound decompensation leading to hospitalization. It’s not just people whose anxiety is making them worry excessively about this specific issue, I promise.

With stimulants shortages people just call pharmacy after pharmacy until then find one with a supply, but I agree it’s nothing catastrophic. Those for whom the medication is important enough put in the legwork. Those for whom it is more optional don’t and simply wait. Perhaps that could be used as an example of what the future might hold in giving anticipatory guidance?

 

[TexasPhysician]

There is no factual evidence that psych meds will be banned or experience shortage compared to other meds.

If tariffs are 30% on Prozac, they may go from $4/month to $5.50/month. Branded med coupons are unlikely to change much but may add a few more dollars. This could affect some people as every dollar counts. That said, the tariffs just disappeared today while negotiations continue.

In other words, I see 0 reason to be concerned.

 

[clozareal]

I let them know that the RFK commission is to set up a committee to look at these medications and that they aren't being taken away. Being worried that they would be is jumping to conclusions and I will often help them with this cognitive distortion. I'm also concerned about the side effects of these medications and the lack of studies we have on some of them, especially in children.

Whether I trust them to study it without tremendous bias or for them to come up with a reasonable conclusion in 100 days when it's just not possible to do a study in that period is a different question.

I wouldn't say that there is 0 reason to be concerned, but to be overly concerned I think is not healthy.

 

[Crayola227]

With the recent political climate, I've had several patients express concern and anxiety to me about access to their medication, from bans on manufacturing and prescription given RFK's views, to tariffs leading to shortages. I am not sure what to tell them, except general advice about doing what you can to prepare but being mindful to not let anxiety get the best of you until we actually see how things play out.

But in terms of being prepared, *are* there concrete steps that can be taken? I've heard of doctors prescribing higher doses than the patient actually takes to address cost issues but that's always felt uncomfortable to me on account of, you know, it not being the truth.

Some medications where it would not be inappropriate for the patient to take a bit more or less on their own PRN, I think you can easily justify just writing for the higher amount. If you don't have that wiggle room it's less defensible.

 

[Stagg737]

With the recent political climate, I've had several patients express concern and anxiety to me about access to their medication, from bans on manufacturing and prescription given RFK's views, to tariffs leading to shortages. I am not sure what to tell them, except general advice about doing what you can to prepare but being mindful to not let anxiety get the best of you until we actually see how things play out.

At this point the fear of SSRIs being banned (or really and non-controlled substance) still seems like histrionics. RFK can "study" whatever he wants, but with how much power big pharma and their lobby has in DC I have exactly zero concerns that about any meds being banned. I'd be far more concerned about what scientology has done and continues to do to Mecta and Somatics and the possibility of losing ECT as a therapy in the US.

The concern about tariffs affecting what medications we have and/or the cost is more valid. Fortunately, many of our more commonly used meds (most SSRIs, benzos, anti-epileptics, and stimulants) are produced by companies with factories in the US (J&J, Pfizer, Eli Lily, etc) so likely won't see much change there. I think the actual question is will American companies be able to keep up with demand or are we going to see more shortages in other meds like we're currently seeing with IM/IV Ativan?

But in terms of being prepared, *are* there concrete steps that can be taken? I've heard of doctors prescribing higher doses than the patient actually takes to address cost issues but that's always felt uncomfortable to me on account of, you know, it not being the truth.

Of course there are, unless you're prescribing a very narrow range of meds most of us already deal with this regularly. It's the same concept as when insurance denies coverage of a med or a med is just too expensive, you look for alternative medication options or tapering if appropriate (which we should be doing anyway). I deal with this regularly when patients switch insurance and their new company has different formulary coverage. Yes, this sucks to deal with, but it is not really a new problem at all. It's the same old issue wrapped up in different packaging with a bow of anxiety d/t the political ties.

 

[Crayola227]

Do you mean in terms of talk therapy to reduce patient anxiety long term? I guess I would process why, with all the million things that could or even more likely will go wrong, this is where their mind goes. What do the medications do for them, what would it actually mean for them to not have access, how would they cope, etc. Some sort of mental exposure therapy? I mean it would of course depend on the patient and what it actually would mean to go off their medications. Most people on SSRIs could reasonably cope, for example, if possibly at a lower level of functioning. If you meant some concrete way of "prepping," no. I mean we've been dealing with stimulant shortages for years now and people make it work.

This is probably a lot scarier for your folks with BPAD or any of them with psychotic symptoms or conditions with potential psychotic symptoms. With everything going on, what could be scarier than the notion of losing touch with reality? Nothing is probably much more directly dangerous for them personally or their loved ones.

Some of those people on SSRIs or other depression medications would be at risk for suicide!!

I'm not really understanding your reaction to these fears honestly.*

 

[Crayola227]

*I don't mean debating the likelihood of politics actually threatening supply, but more, patients concerned about this. Not sure why we would assume it's NBD because these people can figure out a way to just truck along with talk therapy with minimal impact. I think it's fine to suggest as much to patients it applies to.

 

[comp1]

So my reaction or really more lack thereof to the OP comes from a couple of places. The effect of SSRIs on suicidal ideation is mixed and actual suicide attempts almost unknown. They (in a grossly generalized perspective) appear to increase risk with younger patients very slightly, have a neutral effect on average adults and there might be slight protective effects in elderly, but the key to all of it is slight in any direction. They are helpful medications that definitely can improve people's lives, but suicide is probably not what I'd jump to in arguing for them. My personal psychotic patients don't want to take medications at all and if they could understand, would be very, very happy if courts no longer were able to order them to do so. They have absolutely no insight into any possible benefit and honestly, the benefit often is more for society in keeping them out of jail or from harassing other people in most of their cases. Even when they have been on the medications for a long period, it is due to some sort of chronic external pressure and almost never anything resembling an internal desire. In terms of the patients I see who are most fixated on their medications, they generally are the people who have not shown much of an effect from any medication (rarely functional in any domain) and who would benefit most from a taper of at least one, often many of their medications. Now I know I have a select patient population. I can conceptualize an outpatient with clearcut bipolar 1 who is very stable, holding down a family and a job, on an atypical or lithium and then expresses anxiety about destabilization off medications. I get that people interepisode with bipolar disorder can have a lot of insight. It's why it responds so well to medication unlike a lot of other disorders. That's just nothing resembling my patient population.

 

[calvnandhobbs68]

Something like over 10% of the entire US adult population is on an antidepressant of some sort, I don't think they're cutting them off anytime soon.

I generally tell my patients that number and say I'm not too worried about it but I also can't predict the future.

 

[lockian]

So my reaction or really more lack thereof to the OP comes from a couple of places. The effect of SSRIs on suicidal ideation is mixed and actual suicide attempts almost unknown. They (in a grossly generalized perspective) appear to increase risk with younger patients very slightly, have a neutral effect on average adults and there might be slight protective effects in elderly, but the key to all of it is slight in any direction. They are helpful medications that definitely can improve people's lives, but suicide is probably not what I'd jump to in arguing for them. My personal psychotic patients don't want to take medications at all and if they could understand, would be very, very happy if courts no longer were able to order them to do so. They have absolutely no insight into any possible benefit and honestly, the benefit often is more for society in keeping them out of jail or from harassing other people in most of their cases. Even when they have been on the medications for a long period, it is due to some sort of chronic external pressure and almost never anything resembling an internal desire. In terms of the patients I see who are most fixated on their medications, they generally are the people who have not shown much of an effect from any medication (rarely functional in any domain) and who would benefit most from a taper of at least one, often many of their medications. Now I know I have a select patient population. I can conceptualize an outpatient with clearcut bipolar 1 who is very stable, holding down a family and a job, on an atypical or lithium and then expresses anxiety about destabilization off medications. I get that people interepisode with bipolar disorder can have a lot of insight. It's why it responds so well to medication unlike a lot of other disorders. That's just nothing resembling my patient population.

I have to admit my population and perspective is different. I've posted my story before; I'll post it again.

A few years back when I started practice I encountered a number of long term stable patients in my outpatient cohort, and got interested in deprescribing in cases of depression (particularly single episode) and uncomplicated anxiety. I've learned a lot about it since then, since unfortunately, it was not an issue well covered in my training. It remains a special interest of mine within psychiatry. I even get people referred to me for this now, so to some extent attempts at deprescribing may be overrepresented in my practice.

Let me tell you, deprescribing a lot more difficult and scary than it seems. First, on a semi related note, in my relatively short 5 years of independent practice, I've already seen people get *medically* hospitalized for going off "mere" SSRIs against medical advice, or for reasons beyond their control. Vomiting to the point of dehydration, crippling akathisia while not on any meds, insomnia that nothing could touch except reinstatement of the original drug even if it wasn't even *for* insomnia... This stuff is not so rare, if I've already seen it multiple times.

I've also overseen motivated people with good coping mechanisms and years of therapy under their belt try to wean off over many months. A very typical story is we go from, say, lexapro 10 to 5 to 2.5 over several months or even a year or more, and then the "party" starts, where intolerable withdrawal side effects get in the way of the lives of otherwise functional people - not decompensation, but actual withdrawal which is a distinct syndrome that the FINISH mnemonic doesn't even begin to describe, but can at times be mistaken for decompensation. What's even more "fun" is withdrawal symptoms can occur with a weeks to months delay after going off the medication completely.

What I now tell people who start struggling with a taper is we can, if available, use a liquid formulation or a compounding pharmacy or a DIY method such as counting beads or weighing pills to get off more slowly toward the end. The 10 percent guideline for reducing benzos is actually quite handy, but the available products make it difficult from a practical standpoint. I also tell them that yes, withdrawal likely will happen at a certain point and they need to cope through it because it will pass... eventually. The whole 6-8 weeks thing is a lie, by the way. That's just the acute phase, and the whole process is nonlinear, with symptoms at times coming and going and mutating over time.

Guess how many people actually decide to do any of the above, even when I'm willing and eager to help them? Hardly anybody.

Though who knows, maybe given current fears of losing access to meds, people might get more motivated even if it's an inconvenience on a number of levels.

 

[lockian]

But, withdrawal aside, interesting and complex as it is, I do have concerns about bipolar people and psychotic people losing access to their meds, and so do they. Far from all psychotic people lack insight. I've had patients with psychotic disorders tell me that antipsychotics saved their lives. Having worked with some people who've had schizophrenia for decades (again, a stable outpatient cohort will have some of these), I am aware that insight can grow.

 

[annoyedpsychiatrist]

Banning psychiatric medications would be the worst political move ever made. The adminstration has a lot of dumb people, including RFK. I tell my patients the future always holds the potential for oblivion, and has for the past 100 years, and we cant change of any of these events. We have had crazy people in positions of power for a while, now theyre just more vocal about it. The world always survives and people find a way to survive. if you do not trust in the future, then trust in yourself, in that you will find a way to adapt.

Speech is a little different if they have a psychotic disorder, but i dunno how the hell they would even fathom taking away antipsychotics. That would be mass chaos, even worse than SSRis. Can you imagine a country full of schizophrenic/bipolar 1 patients not on medications?

 

[TexasPhysician]

But, withdrawal aside, interesting and complex as it is, I do have concerns about bipolar people and psychotic people losing access to their meds

Why? The various politicians (I don’t want to make this political) said they want to evaluate certain classes of meds “in children and adolescents”. This research is an active area of study already. Metabolic risks are real. Everything they have claimed is within what the medical community is already doing.

They didn’t say they are banning meds. They didn’t say they will evaluate meds in adults. I’d argue that inappropriate prescribing by certain classes of clinicians is a problem, and restricting this to better trained clinicians could be a net positive. That is me jumping to a conclusion like the general public. I still think that is highly unlikely as a minimal adjustment for public benefit.

The likely result is absolutely nothing changes. Last time I researched plans and promises of politicians, they had a 50% success rate of plans becoming “partially true”. That isn’t even “completing the promise”. The promise was to “evaluate” classes of meds. The research was already in place. To reach the political promise being true, they need to fully read the studies already being done. History says they have a 50% chance of skimming the studies once published which would be partially true of “evaluating” classes of meds. It would be an easy promise to keep, but I won’t hold my breath.

If we jumped to conclusions in another area of life: This is similar to me being dysfunctionally worried that next Thursday I’ll die in a car accident due to rain when the forecast says there is a 50% chance of rain on a random day next week.

Politicians can’t decide on the day to initiate tariffs, what amount, if it will actually happen, and how much it will impact the world economy. I’m not sure they care about psych meds at the moment, and if they did, the likely result is nothing changes.

 

[clausewitz2]

Banning psychiatric medications would be the worst political move ever made. The adminstration has a lot of dumb people, including RFK. I tell my patients the future always holds the potential for oblivion, and has for the past 100 years, and we cant change of any of these events. We have had crazy people in positions of power for a while, now theyre just more vocal about it. The world always survives and people find a way to survive. if you do not trust in the future, then trust in yourself, in that you will find a way to adapt.

Speech is a little different if they have a psychotic disorder, but i dunno how the hell they would even fathom taking away antipsychotics. That would be mass chaos, even worse than SSRis. Can you imagine a country full of schizophrenic/bipolar 1 patients not on medications?

Yes, it's called literally any country in the world prior to 1951

 

[birchswing]

It seems like it's more likely existing drugs are grandfathered in, but approvals might be more difficult.

Novavax, a vaccine for Covid that has low reactogenicity and confers better cross-variant immunity and longer efficacy than its competitors, just had its BLA punted on by the FDA. RFK was asked about the deferral, and he said "It is a single antigen vaccine. And, for respiratory illnesses, the single antigen vaccines have never worked." Source: Key takeaways from RFK Jr.'s interview on measles vaccine, food dyes, weight loss drugs and more

This is despite the fact that Novavax tested a bivalent vaccine and found it had worse protection than one producing immunity to a single antigen. And this is a non-mRNA vaccine, which should appeal to people skeptical of mRNA vaccines.

And it's also despite the fact that RFK recently conceded that measles vaccination is the best way to prevent measles. I guess he could claim that the MMR vaccine is not single-antigen, but it was available as a single-antigen shot I believe for a couple of decades prior to the MMR shot.

Anyhow, Novavax continues to be available under its EUA, as are the mRNA vaccines that do have BLA but also produce immunity to a single antigen, which is apparently supposed be a non-starter.

That's why I surmise the MO will be to deny approvals rather than pull existing pharmaceuticals. There was no reason to deny the Novavax BLA except for some form of neuroses combined with unwarranted confidence.

The FDA also canceled the meeting that was to select flu strains to target for fall.

So I think change is in the pipeline but it's about ending the pipeline, so to speak.

I'm usually fairly non-reactive and equanimous, but it's difficult to watch a former heroin addict be so wrong and haughty at the same time in a way that limits people's choices because it mirrors family dynamics I've experienced.

If society let you try heroin and didn't imprison you (as is afforded any Kennedy for any crime), let someone else try a vaccine. These people who get religion and then want to police everyone else—and not even beneficially—have a special breed of ego.

 

[Stagg737]

I have to admit my population and perspective is different. I've posted my story before; I'll post it again.

A few years back when I started practice I encountered a number of long term stable patients in my outpatient cohort, and got interested in deprescribing in cases of depression (particularly single episode) and uncomplicated anxiety. I've learned a lot about it since then, since unfortunately, it was not an issue well covered in my training. It remains a special interest of mine within psychiatry. I even get people referred to me for this now, so to some extent attempts at deprescribing may be overrepresented in my practice.

Let me tell you, deprescribing a lot more difficult and scary than it seems. First, on a semi related note, in my relatively short 5 years of independent practice, I've already seen people get *medically* hospitalized for going off "mere" SSRIs against medical advice, or for reasons beyond their control. Vomiting to the point of dehydration, crippling akathisia while not on any meds, insomnia that nothing could touch except reinstatement of the original drug even if it wasn't even *for* insomnia... This stuff is not so rare, if I've already seen it multiple times.

I've also overseen motivated people with good coping mechanisms and years of therapy under their belt try to wean off over many months. A very typical story is we go from, say, lexapro 10 to 5 to 2.5 over several months or even a year or more, and then the "party" starts, where intolerable withdrawal side effects get in the way of the lives of otherwise functional people - not decompensation, but actual withdrawal which is a distinct syndrome that the FINISH mnemonic doesn't even begin to describe, but can at times be mistaken for decompensation. What's even more "fun" is withdrawal symptoms can occur with a weeks to months delay after going off the medication completely.

What I now tell people who start struggling with a taper is we can, if available, use a liquid formulation or a compounding pharmacy or a DIY method such as counting beads or weighing pills to get off more slowly toward the end. The 10 percent guideline for reducing benzos is actually quite handy, but the available products make it difficult from a practical standpoint. I also tell them that yes, withdrawal likely will happen at a certain point and they need to cope through it because it will pass... eventually. The whole 6-8 weeks thing is a lie, by the way. That's just the acute phase, and the whole process is nonlinear, with symptoms at times coming and going and mutating over time.

Guess how many people actually decide to do any of the above, even when I'm willing and eager to help them? Hardly anybody.

Though who knows, maybe given current fears of losing access to meds, people might get more motivated even if it's an inconvenience on a number of levels.

Not gonna lie, I do a LOT of deprescribing both outpatient and on our consult service where meds have to be stopped for various medical reasons. Unless someone is going cold turkey on high doses what you're describing is exceptionally rare and almost always has some other confounding variable involved as well (suddenly stopped or started an illicit substance/THC/alcohol, withdrawal from a concurrent med like an opiate or benzo, medical illness/infection, significant personality/somatic tendencies, etc). Can withdrawal/discontinuation syndromes be bad? Sure. Is it common or as severe for 95% of people as what you're suggesting? Absolutely not.

Also, if you have data for the bolded I'd love to see it. I've never seen actual data for a delayed SSRI withdrawal and it seems like more of a scare tactic I've heard from people with a political agenda like RFK or anti-med fear-mongerers like Horowitz or Moncrieff.

 

[Stagg737]

*I don't mean debating the likelihood of politics actually threatening supply, but more, patients concerned about this. Not sure why we would assume it's NBD because these people can figure out a way to just truck along with talk therapy with minimal impact. I think it's fine to suggest as much to patients it applies to.

Because antidepressants don't actually "fix" the risks of suicide. Yes they modify one risk factor (depression) but that is only a part of suicide risk and frankly most patients that are at moderate or higher risk for suicide are going to have several or many other factors, some which are likely severe, contributing to or driving those thoughts. Remember, antidepressants other than lithium don't actually decrease SI and on our consult service there are a host of other issues that take priority over starting or adjusting an SSRI for our patients at higher risk.

 

[lockian]

Not gonna lie, I do a LOT of deprescribing both outpatient and on our consult service where meds have to be stopped for various medical reasons. Unless someone is going cold turkey on high doses what you're describing is exceptionally rare and almost always has some other confounding variable involved as well (suddenly stopped or started an illicit substance/THC/alcohol, withdrawal from a concurrent med like an opiate or benzo, medical illness/infection, significant personality/somatic tendencies, etc). Can withdrawal/discontinuation syndromes be bad? Sure. Is it common or as severe for 95% of people as what you're suggesting? Absolutely not.

Also, if you have data for the bolded I'd love to see it. I've never seen actual data for a delayed SSRI withdrawal and it seems like more of a scare tactic I've heard from people with a political agenda like RFK or anti-med fear-mongerers like Horowitz or Moncrieff.

No studies that I’ve seen of delayed withdrawal, which was why I was surprised. Maybe I should write a case report.

I don’t know if withdrawal, including severe withdrawal, is that rare.

I’ve seen studies placing incidence at anywhere from 30-90%, with 50% of those experiencing withdrawal or more rating symptoms as severe, including needing to take time off work. There is also evidence of symptoms lasting a year or more. A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based? - PubMed; https://www.drugsandalcohol.ie/29794/7/APPG-PDD-Survey-of-antidepressant-withdrawal-experiences.pdf

Also, in my deprescribing experience, I was fully expecting withdrawal from CT d/c from high doses, that’s logical, but what I actually see is motivated, stable, psychologically minded people do fine until they get to the last little bit, and then they start to struggle. Regarding the somatization angle, not impossible, but withdrawal is something I’ve seen people get even if they’ve never been informed about the possibility (this usually occurs when I inherit a patient and my predecessor told them to decrease a dose or stop a medication and didn’t due to dilengence to mention the potential consequences). While presentation can vary widely, there are characteristic patterns that happen across very disparate patients. It is a clinical syndrome.

To some extent you see what you ask about. Once I started asking people about withdrawal, I started seeing it a lot more. People may not realize what they’re experiencing is withdrawal, so they may not talk to psychiatry about it, but rather to other specialties first. They might end up in the ER and nothing is found. They may assume they’re relapsing, but if you ask in more detail, you realize their presentation looks different from prior ones and the only major change is a medication dose change.

I don’t wish to scaremonger, but I do think discussion of withdrawal needs to be part of the risk and benefit discussions we have with patients. Even let's say that studies overestimate incidence of withdrawal and particularly severe withdrawal via flaws in methodology. Other severe side effects are talked about even if they’re rare, so this should be as well.

To be clear, I don't think this is THE worst thing that can happen with loss of access to medications, just an underappreciated one.

And no, this is not a reason not to use medications. Has anyone ever not used benzos because they can cause seizures if stopped abruptly? Of course not.

 

[clausewitz2]

No studies that I’ve seen of delayed withdrawal, which was why I was surprised. Maybe I should write a case report.

I don’t know if withdrawal, including severe withdrawal, is that rare.

I’ve seen studies placing incidence at anywhere from 30-90%, with 50% of those experiencing withdrawal or more rating symptoms as severe, including needing to take time off work. There is also evidence of symptoms lasting a year or more. A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based? - PubMed; https://www.drugsandalcohol.ie/29794/7/APPG-PDD-Survey-of-antidepressant-withdrawal-experiences.pdf

Also, in my deprescribing experience, I was fully expecting withdrawal from CT d/c from high doses, that’s logical, but what I actually see is motivated, stable, psychologically minded people do fine until they get to the last little bit, and then they start to struggle.

The receptor occupancy curve is hyperbolic, this is a well-known phenomenon that has a clear biological basis.

 

[lockian]

The receptor occupancy curve is hyperbolic, this is a well-known phenomenon that has a clear biological basis.

I know. I just brought it up because Stagg said that they tend to see severe withdrawal with abrupt d/c from high doses, and my point was that it's not exclusive to that because of the hyperbolic phenomenon.

 

[Stagg737]

I know. I just brought it up because Stagg said that they tend to see severe withdrawal with abrupt d/c from high doses, and my point was that it's not exclusive to that because of the hyperbolic phenomenon.

I'll address the longer post later, but I have never seen true "severe withdrawal" from suddenly stopping 5mg of Lexapro or 50mg of Zoloft. Mild withdrawal and discomfort? Yes. Severe/life altering symptoms that weren't accountable by something else? No.

Reason I say this is the few times I encountered this we restarted the SSRI/SNRI and the patient was still having said horrible "withdrawal" symptoms. If it's truly withdrawal, replacing the substance in question should improve those symptoms, otherwise it's not a true withdrawal and something else is going on. I say this as someone who actively looks for this as a daily part of my job where primary team physicians don't always appreciate the effects of abrupt medication changes.

 

[lockian]

I'll address the longer post later, but I have never seen true "severe withdrawal" from suddenly stopping 5mg of Lexapro or 50mg of Zoloft. Mild withdrawal and discomfort? Yes. Severe/life altering symptoms that weren't accountable by something else? No.

Reason I say this is the few times I encountered this we restarted the SSRI/SNRI and the patient was still having said horrible "withdrawal" symptoms. If it's truly withdrawal, replacing the substance in question should improve those symptoms, otherwise it's not a true withdrawal and something else is going on. I say this as someone who actively looks for this as a daily part of my job where primary team physicians don't always appreciate the effects of abrupt medication changes.

Interestingly, I've also seen the following. Patient goes off medication for several weeks, develops what may be withdrawal symptoms, then when the medication is resumed they get side effects they've never had before (i.e. unprecedented overactivation), and are generally much more sensitive to that agent in particular. I wonder if you've ever seen anything like that, and what your thoughts might be on such a phenomenon.

I wonder if, withdrawal being as complex as it is, attempts at reinstatement of medication can also vary in their success, or how long they even take to have the hoped for effect.

Also, as far as "something else going on," I do also make a point of thoroughly searching out medical contributors, physic issues, stressors when suspected withdrawal comes up. I consult other specialties. More often than not, I don't find anything, and neither does anyone else. Does that mean everyone having some elaborate form of somatization or conversion disorder? AFAIK, somatization can only be truly diagnosed if biological causes are ruled out, but are we perhaps too quick to rule out withdrawal as a biological cause?

 

[Crayola227]

But, withdrawal aside, interesting and complex as it is, I do have concerns about bipolar people and psychotic people losing access to their meds, and so do they. Far from all psychotic people lack insight. I've had patients with psychotic disorders tell me that antipsychotics saved their lives. Having worked with some people who've had schizophrenia for decades (again, a stable outpatient cohort will have some of these), I am aware that insight can grow.

Yes, and people may suggest hey NBD, in an example where if they can't get say, aripiprazole, they can get still get olanzipine on the market. But they gain 40 pounds, that's a huge health risk and one that may not be easily turned back. Not to mention other SE like QTc, etc.

Forgive me for my statement earlier about suicide, but you still have enormous possibility for all kinds of harms. I don't think I ever truly understood the stakes of the impact on loved ones of untreated mental illness until I became the parent of a young child. Not so much their suffering in the moment but the potential long term impact. The difference between getting out of bed or not, to me, has much bigger implications now than just the individual suffering adult and their adult loved ones.

Is the theory that some forms of untreated mental illness can get worse and harder to treat with time and lack of control, still hanging around? Has it been debunked? Still an open question? More evidence in favor?

Also, I imagine that while many patients may lack insight and DGAF about their meds or condition, which imho would still be tragic if not given meds and left to the streets or what have you, I imagine they still have loved ones who are with it and would be greatly concerned or affected.

Effects on children or other vulnerable folks would only be compounded by cuts to social safety net programs and benefits such as head start, substance abuse programs, on and on.

Not all the ways patients lives are affected without meds going to be very easy to reverse even if meds are started again. Relationships and careers lost. Children harmed. Additional conditions acquired as a result of lack of treatment or treatment options.

We can argue none of this is going to come to pass, but the notion if it did, NBD is just, no. The concerns themselves in absence of considering likelihood are valid. So I agree with others to encourage people not to be too alarmed at this juncture for reasons others suggested. I guess I would make it clear that I understood their concerns and validate the concerns themselves. The only thing more concerning than RFK's "medical opinions" would be feeling like your psychiatrist didn't take your fears seriously.

There are a number of ways to address these concerns and reassure the patient that we would do whatever we could. That there are non-pharmacological approaches and we might have to just focus harder on them (they should be in place regardless, still), coping methods, medication changes, all of which to their credit posters have mentioned. Just make sure they don't feel alone and that someone with some sense is in their corner.

Go to Mexico if possible?

Just trying to imagine a black market for antipsychotics. Seems more bizarre even than one for abortion agents. Weird times we live in.

 

[Crayola227]

Yes, it's called literally any country in the world prior to 1951

Tragic we want to return to a world where that is just as endemic as polio used to be. Dark ages.

 

[Crayola227]

It seems like it's more likely existing drugs are grandfathered in, but approvals might be more difficult.

Novavax, a vaccine for Covid that has low reactogenicity and confers better cross-variant immunity and longer efficacy than its competitors, just had its BLA punted on by the FDA. RFK was asked about the deferral, and he said "It is a single antigen vaccine. And, for respiratory illnesses, the single antigen vaccines have never worked." Source: Key takeaways from RFK Jr.'s interview on measles vaccine, food dyes, weight loss drugs and more

This is despite the fact that Novavax tested a bivalent vaccine and found it had worse protection than one producing immunity to a single antigen. And this is a non-mRNA vaccine, which should appeal to people skeptical of mRNA vaccines.

And it's also despite the fact that RFK recently conceded that measles vaccination is the best way to prevent measles. I guess he could claim that the MMR vaccine is not single-antigen, but it was available as a single-antigen shot I believe for a couple of decades prior to the MMR shot.

Anyhow, Novavax continues to be available under its EUA, as are the mRNA vaccines that do have BLA but also produce immunity to a single antigen, which is apparently supposed be a non-starter.

That's why I surmise the MO will be to deny approvals rather than pull existing pharmaceuticals. There was no reason to deny the Novavax BLA except for some form of neuroses combined with unwarranted confidence.

The FDA also canceled the meeting that was to select flu strains to target for fall.

So I think change is in the pipeline but it's about ending the pipeline, so to speak.

I'm usually fairly non-reactive and equanimous, but it's difficult to watch a former heroin addict be so wrong and haughty at the same time in a way that limits people's choices because it mirrors family dynamics I've experienced.

If society let you try heroin and didn't imprison you (as is afforded any Kennedy for any crime), let someone else try a vaccine. These people who get religion and then want to police everyone else—and not even beneficially—have a special breed of ego.

The issue isn't just yanking meds from the market, there are concerns for the global market and tariffs and war. So availability. I'm not versed in drug manufacturing and import, but there were real concerns about the newer weight loss drugs mostly made by the Dutch, if we invaded Greenland as an example.

 

[Crayola227]

If we jumped to conclusions in another area of life: This is similar to me being dysfunctionally worried that next Thursday I’ll die in a car accident due to rain when the forecast says there is a 50% chance of rain on a random day next week.

Some people fear people with proven malfeasance in positions of enormous power more than the weather.

 

[Crayola227]

Interestingly, I've also seen the following. Patient goes off medication for several weeks, develops what may be withdrawal symptoms, then when the medication is resumed they get side effects they've never had before (i.e. unprecedented overactivation), and are generally much more sensitive to that agent in particular. I wonder if you've ever seen anything like that, and what your thoughts might be on such a phenomenon.

I wonder if, withdrawal being as complex as it is, attempts at reinstatement of medication can also vary in their success, or how long they even take to have the hoped for effect.

Also, as far as "something else going on," I do also make a point of thoroughly searching out medical contributors, physic issues, stressors when suspected withdrawal comes up. I consult other specialties. More often than not, I don't find anything, and neither does anyone else. Does that mean everyone having some elaborate form of somatization or conversion disorder? AFAIK, somatization can only be truly diagnosed if biological causes are ruled out, but are we perhaps too quick to rule out withdrawal as a biological cause?

I don't understand the thinking here. If we know it can take 6-8 weeks for the full effect of some of these drugs, then if someone develops w/d symptoms it doesn't seem strange to me that improvement of some of those symptoms might also take a few weeks to settle down after restarting the med. Not to mention the time if you titrate back up to some dose to manage SE and the withdrawal symptoms. And how much are the withdrawal symptoms themselves compounded by to what degree the primary condition being treated is affected by dosing?

Make no mistake, patients can feel pretty jacked up going on, going up, going down, going off, going back on, going back up, for the order of weeks to months, between the blend of physical symptoms and MH symptoms. Yuck.

 

[lockian]

Go to Mexico if possible?

Maybe not Mexico, but I'm unironically looked up how to relocate and practice in Australia or New Zealand or the UK. Apparently you don't need to retake licensing exams.

I honestly think that we don't have enough information about what actually can happen when people d/c medications because those who do often get lost to follow up. And many people who are on medications and could perhaps stand to go off don't do so, whether because of their own personal fears, or providers being reluctant to deprescribe. After all, it takes effort and there are risks. It's much easier to just keep clicking refill, particularly if it's not a controlled substance.

To my point about severe withdrawal, even if it's rare, it's valid and real to the patient who has had it before. Just like recurrence of mania is valid

I don't understand the thinking here. If we know it can take 6-8 weeks for the full effect of some of these drugs, then if someone develops w/d symptoms it doesn't seem strange to me that improvement of some of those symptoms might also take a few weeks to settle down after restarting the med. Not to mention the time if you titrate back up to some dose to manage SE and the withdrawal symptoms. And how much are the withdrawal symptoms themselves compounded by to what degree the primary condition being treated is affected by dosing?

Make no mistake, patients can feel pretty jacked up going on, going up, going down, going off, going back on, going back up, for the order of weeks to months, between the blend of physical symptoms and MH symptoms. Yuck.

I was just trying to counter Stagg's point about "if it's withdrawal then resuming the medication should help resolve it." I think you are exactly correct, it's not that simple. Resuming may not resolve withdrawal symptoms in a timely manner. Resuming can also, in my observation, give a person side effects they've never had before on even entry level doses, and that can look similar to or compound withdrawal.

One thing I do want to make clear is that withdrawal symptoms and side effects can be distinguished from primary symptoms with careful history taking. Oftentimes, patients have been living with primary conditions for many years. They know what to expect there, even at its worst. if the symptoms of concern have a new character, are unprecedented or ego dystonic, then a secondary cause, such as medications or substances or medical causes should be strongly considered.

 

[aim-agm]

I'll address the longer post later, but I have never seen true "severe withdrawal" from suddenly stopping 5mg of Lexapro or 50mg of Zoloft. Mild withdrawal and discomfort? Yes. Severe/life altering symptoms that weren't accountable by something else? No.

I had a patient, who had an OCD diathesis if looked closely but clearly did not have OCD, develop significantly problematic OCD symptoms when citalopram 5 mg was stopped that resolved when it was resumed. The development of those symptoms was somewhat delayed (weeks rather than days) but I don't recall offhand the exact timeframe. We were later able to titrate off the citalopram more slowly and the OCD symptoms did not recur.

 

[Merovinge]

Maybe not Mexico, but I'm unironically looked up how to relocate and practice in Australia or New Zealand or the UK. Apparently you don't need to retake licensing exams.

NZ pay (at least for locums) is abysmal for MDs, although it's a stunningly beautiful place and is in my top 5 of countries that I have visited. Australia is good pay but I think it takes some work to get licensed, unless you do some time in NZ first (they do have reciprocity with the UK for British docs). UK is also hogwash pay unless you can coble together a few jobs and jump through some hoops and the UK economy post brexit is not a horse I would want to be betting on.

I'd say Canada is the best bet with some provinces actively recruiting US docs, they have made it easier to practice there as a US MD over the years.

 

[TexasPhysician]

Some people fear people with proven malfeasance in positions of enormous power more than the weather.

Hopefully not. How many presidents have we had recently without some wrongdoings? Trump, Biden, Obama, Clinton, etc all have clear poor decisions, multiple with illegal activities and unethical behavior and clearly wrong decisions. We may as well all live in a constant state of panic?

Checks and balances exist. Presidents won’t be perfect. Trump has been here for 4 years before. We will persist.

 

[Crayola227]

Hopefully not. How many presidents have we had recently without some wrongdoings? Trump, Biden, Obama, Clinton, etc all have clear poor decisions, multiple with illegal activities and unethical behavior and clearly wrong decisions. We may as well all live in a constant state of panic?

Checks and balances exist. Presidents won’t be perfect. Trump has been here for 4 years before. We will persist.

Completely fair and rational. I think the admin is unique enough on its stance on mental health compared to previous, that I understand patients truly dependent on these meds for acceptable QOL are more alarmed than usual. And in light of what you're saying it's fair to liken that to feelings of concern about all the things that can threaten medication access like employment/health coverage, travel, transportation to the pharmacy, all the hiccups that can divorce people from their meds abruptly and addressing it quickly is challenging. But yes these are all things we can help patients adapt to.

 

[annoyedpsychiatrist]

Yes, it's called literally any country in the world prior to 1951

One major difference: the population of america has since doubled

 

[Stagg737]

Don't want to derail the thread too much, but said I'd respond more when I had time...

Interestingly, I've also seen the following. Patient goes off medication for several weeks, develops what may be withdrawal symptoms, then when the medication is resumed they get side effects they've never had before (i.e. unprecedented overactivation), and are generally much more sensitive to that agent in particular. I wonder if you've ever seen anything like that, and what your thoughts might be on such a phenomenon.

Only time I've seen something like this is in patients who had some other confounding medical issue or raging cluster B. Not saying it's not possible, but I haven't seen it and we regularly do the "million dollar work-ups".

I wonder if, withdrawal being as complex as it is, attempts at reinstatement of medication can also vary in their success, or how long they even take to have the hoped for effect.

I think this is where we may be missing each other. Withdrawal is a specific set of symptoms that can be expected with a discontinuation or rapid taper of a medication or substance. Typically, those symptoms are the opposite of what we'd expect from the effects of the substance (activated symptoms from GABAergic withdrawal, excessive parasympathetic symptoms from anticholinergic withdrawal, etc). Weird complex symptoms from stopping SSRIs are not "withdrawal". Yes, I'm sure it can and does happen and I have heard patients tell me this, but this isn't the same as what we're talking about when we talk about true withdrawal which improves or resolves when the removed agent is replaced. Our language has to have meaning otherwise it gets bast**dized through pop psychology BS and social media like terms such as "narcissist" or our "neuro-atypical"/ "neurospicy" diagnoses have.

Also, as far as "something else going on," I do also make a point of thoroughly searching out medical contributors, physic issues, stressors when suspected withdrawal comes up. I consult other specialties. More often than not, I don't find anything, and neither does anyone else. Does that mean everyone having some elaborate form of somatization or conversion disorder? AFAIK, somatization can only be truly diagnosed if biological causes are ruled out, but are we perhaps too quick to rule out withdrawal as a biological cause?

I don't think so in terms of true withdrawal, but I don't think you're wrong that plenty of patients get written off as everything "just being in their head" when there is probably a physiologic process contributing.

 

[Stagg737]

I don’t know if withdrawal, including severe withdrawal, is that rare.

I’ve seen studies placing incidence at anywhere from 30-90%, with 50% of those experiencing withdrawal or more rating symptoms as severe, including needing to take time off work. There is also evidence of symptoms lasting a year or more. A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based? - PubMed; https://www.drugsandalcohol.ie/29794/7/APPG-PDD-Survey-of-antidepressant-withdrawal-experiences.pdf

Couple of things with the first link. It's by James Davies who is very critical of psychiatric medications including SSRIs, not to the extent of Horowitz, but biased enough that I don't trust that data without taking a critical lens to it. If you look at the meta-analysis, only 14 studies out of over 300 were included for final analysis, and the 3 largest by far were online surveys. Not exactly the most reliable sources. It's also important to look at how they defined "withdrawal effects" and in several studies those effects included anxiety or depression. How do you differentiate that being withdrawal to return of symptoms? The studies didn't say...

Haven't read the second link, but may look at it later when I get the chance. I'm pretty critical of meta-analyses and how they incorporate individual studies to form data because we can get a lot of incorrect info when those analyses incorporate words or data from various studies when the individual studies may have very different contexts. It's one of my bigger critiques of EBM (generalizing data to justify practice on the individual).

To some extent you see what you ask about. Once I started asking people about withdrawal, I started seeing it a lot more. People may not realize what they’re experiencing is withdrawal, so they may not talk to psychiatry about it, but rather to other specialties first. They might end up in the ER and nothing is found. They may assume they’re relapsing, but if you ask in more detail, you realize their presentation looks different from prior ones and the only major change is a medication dose change.

If we're not asking about it when deprescribing then imo we're failing to meet standard of care. We also need to monitor our own confirmation bias though. It's something I have to regularly remind other teams about working on our consult service that just because they don't have an immediate answer to symptom X doesn't mean we knee-jerk to "must be a psych problem". Can't tell you how often we catch missed medical problems because of this where I'm at.

I don’t wish to scaremonger, but I do think discussion of withdrawal needs to be part of the risk and benefit discussions we have with patients. Even let's say that studies overestimate incidence of withdrawal and particularly severe withdrawal via flaws in methodology. Other severe side effects are talked about even if they’re rare, so this should be as well.

Agree.

 

[Stagg737]

Is the theory that some forms of untreated mental illness can get worse and harder to treat with time and lack of control, still hanging around? Has it been debunked? Still an open question? More evidence in favor?

The Kindling Effect is still around and data is still somewhat mixed for a lot of primary psychiatric disorders. That said, it's completely valid and has very strong evidence in some other areas like SUDs, vascular disease, and seizures disorders.

I had a patient, who had an OCD diathesis if looked closely but clearly did not have OCD, develop significantly problematic OCD symptoms when citalopram 5 mg was stopped that resolved when it was resumed. The development of those symptoms was somewhat delayed (weeks rather than days) but I don't recall offhand the exact timeframe. We were later able to titrate off the citalopram more slowly and the OCD symptoms did not recur.

That's weird. You should write that up.

 

[mistafab]

AFAIK, somatization can only be truly diagnosed if biological causes are ruled out, but are we perhaps too quick to rule out withdrawal as a biological cause?

No. Somatization can be diagnosed without ruling out biological causes. In fact, it is people with actual medical problems that have a higher, not lower, likelihood to somaticize.

Otherwise, to follow the course of this thread - I do think withdrawal is a complex topic that we look at too simplistically. The data is good though in supporting that MOST patients can discontinue an SRI cold turkey and experience no withdrawal effects (~80%). I think the population that does experience withdrawal effects we have a knowledge gap for. We have specific rates of symptoms we expect, but many cases of symptoms we don't expect. We also have lots of medication use in populations known to have higher rates of somatization. There is also cultural effects at play, and perhaps a culture-bound syndrome related to SRIs not present in other areas/cultures. Lots of interesting things to think about.

 

[Stagg737]

No. Somatization can be diagnosed without ruling out biological causes. In fact, it is people with actual medical problems that have a higher, not lower, likelihood to somaticize.

Otherwise, to follow the course of this thread - I do think withdrawal is a complex topic that we look at too simplistically. The data is good though in supporting that MOST patients can discontinue an SRI cold turkey and experience no withdrawal effects (~80%). I think the population that does experience withdrawal effects we have a knowledge gap for. We have specific rates of symptoms we expect, but many cases of symptoms we don't expect. We also have lots of medication use in populations known to have higher rates of somatization. There is also cultural effects at play, and perhaps a culture-bound syndrome related to SRIs not present in other areas/cultures. Lots of interesting things to think about.

So here's another question here since you mention SRI specifically. How do you know the withdrawal effects are from serotonin and not another molecule these medications affect? For example, I've had patients on our service experience "serotonin withdrawal" as is being described from going cold turkey off Paxil but then get better when we give then diphenhydramine. Seems like for those people it's more of a cholinergic rebound effect than SRI withdrawal even if Benadryl does have minimal SRI effects. So do we even call this withdrawal? Rebound? Syndrome? As problematic as the DSM is, the biggest point is to create a common language and definition for what we're seeing. So how do we define and differentiate these differences that should be easily documented by this point?

 

[mistafab]

So here's another question here since you mention SRI specifically. How do you know the withdrawal effects are from serotonin and not another molecule these medications affect? For example, I've had patients on our service experience "serotonin withdrawal" as is being described from going cold turkey off Paxil but then get better when we give then diphenhydramine. Seems like for those people it's more of a cholinergic rebound effect than SRI withdrawal even if Benadryl does have minimal SRI effects. So do we even call this withdrawal? Rebound? Syndrome? As problematic as the DSM is, the biggest point is to create a common language and definition for what we're seeing. So how do we define and differentiate these differences that should be easily documented by this point?

Great points.

I think the literature currently defines any symptom after cessation as "withdrawal" even if the mechanism is different. When I speak about "symptoms we don't expect" I am referring to withdrawal studies that typically utilize a standard set of symptoms per the checklist they decide to utilize. We have pretty fair data to say there are XYZ most common symptoms of withdrawal for drug X during XYZ period in SRIs, for example. There are many cases of people swearing up and down to prolonged (or permanent) SRI-related sexual dysfunction, for example, which as of current is not an "expected" effect from these medications after withdrawal. Also, most of the withdrawal research I have personally reviewed tends to define a 'window' of withdrawal.

 

[Stagg737]

Great points.

I think the literature currently defines any symptom after cessation as "withdrawal" even if the mechanism is different. When I speak about "symptoms we don't expect" I am referring to withdrawal studies that typically utilize a standard set of symptoms per the checklist they decide to utilize. We have pretty fair data to say there are XYZ most common symptoms of withdrawal for drug X during XYZ period in SRIs, for example. There are many cases of people swearing up and down to prolonged (or permanent) SRI-related sexual dysfunction, for example, which as of current is not an "expected" effect from these medications after withdrawal. Also, most of the withdrawal research I have personally reviewed tends to define a 'window' of withdrawal.

Sure, but again, why are we calling these effects withdrawal? In the addiction world (and really medicine in general), "withdrawal" symptoms from a given substance are typically well-documented and we know what symptoms to expect. So why are we calling these odd and possibly unrelated (at least from an understood physiological perspective) symptoms "withdrawal". We don't call TD symptoms which become prevalent when neuroleptics are tapered or discontinued withdrawal, so why do we do it here?

To be clear, I'm not saying we shouldn't warn patients about effects of our meds or true withdrawal as we understand it, but we already counsel patients on side effects more than pretty much any other field. Warning about strange, unexpected side effects or effects that don't have decent evidence that our meds are actually causing them is just overkill.

 

[mistafab]

Sure, but again, why are we calling these effects withdrawal? In the addiction world (and really medicine in general), "withdrawal" symptoms from a given substance are typically well-documented and we know what symptoms to expect. So why are we calling these odd and possibly unrelated (at least from an understood physiological perspective) symptoms "withdrawal". We don't call TD symptoms which become prevalent when neuroleptics are tapered or discontinued withdrawal, so why do we do it here?

To be clear, I'm not saying we shouldn't warn patients about effects of our meds or true withdrawal as we understand it, but we already counsel patients on side effects more than pretty much any other field. Warning about strange, unexpected side effects or effects that don't have decent evidence that our meds are actually causing them is just overkill.

I one hundred percent agree with you. I think the general public is invested in pinning somatic responses to medications in psychiatry because 1) somats have higher rates of psychiatric disorders, thus higher exposure to these medications, 2) because the popular understanding of when people talk about "withdrawal" has nothing to do with what we mean when we say withdrawal in our clinical trial data, and 3) they generally are suspicious of psychiatry or are generally anti-psychiatry.

As doctors, we are talking about withdrawal, but the general public is talking about "withdrawal" - and many of their side effects are ones we don't expect. I think there is a major knowledge gap between what we are doing in treatment of somats and somatic symptoms in our use and cessation of medications. I think the literature is clear that most people can stop our SRI medications cold turkey.