Latest / Radically Genuine / 154. Breaking Free From Psychiatric Drug Dependency w/ Pharmacist Dr. Shawn Gill

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154. Breaking Free From Psychiatric Drug Dependency w/ Pharmacist Dr. Shawn Gill · Radically Genuine

• Roger K. McFillin, Psy.D, ABPP (00:01.43) Welcome to the radically genuine podcast. am Dr. Roger McFillin in the shadowy corridors of modern psychiatry and it is shadowy. is dark lurks a silent epidemic when that's ruined countless lives while hiding behind the mask of help. Today we pull back the curtain on medical catastrophes that's been brewing for decades, the reckless over prescription of psychotropic drugs and a harrowing struggle. of those trying to break free from their chemical shackles. Imagine being told that a cocktail of pills would lift the fog of depression, sharpen your focus, and stabilize your mood all under the guise of scientific progress and safety. Now imagine finding yourself trapped in a nightmare far worse than one you sought to escape. For millions around the world, This isn't imagination, it's reality. These individuals have become unwitting victims of a system that prioritizes quick fixes and polypharmacy over long -term healing, where the cure has nothing more than a devastating disease in itself. The allure is undeniable, a pill for every ill, a chemical solution for life's complexities. But beneath this seductive promise lies a doctor. darker truth. What began as a single prescription often cascades into a dangerous dance of multiple drugs, each attempting to counteract the side effects of the others. This isn't healthcare. It's a perilous game of pharmaceutical Jenga with patients lives hanging in the balance. Yet in this bleak landscape, there is some beacon of hope. Many of my audience members have inquired about solutions. What happens when you are stuck in this cycle of despair and you don't know how to get off these drugs? Well, for today, it's the opportunity for me to interview a pharmacist. These often overlooked healthcare professionals stand at the critical intersection between prescriber and patient. They're the ones who see the full picture of a patient's medication regimen. Roger K. McFillin, Psy.D, ABPP (02:25.698) who witness firsthand the escalating cocktail of drugs many are prescribed, prescribed outside of any safety, any efficacy, any long -term evaluation. And as they these prescriptions, they're becoming increasingly aware of the dangers and harms of these practices. Our guest today is one such pharmacist. Positioned on the front lines of this crisis, he has witnessed a carnage wrought by careless prescribing practices and the pharmaceutical industry's iron grip on mental health treatment. He's seen patients spiral into debilitating withdrawal symptoms, their lives derailed by the very medications that are meant to save them. Roger K. McFillin, Psy.D, ABPP (03:06.68) through careful tapering, holistic approaches, and recognition of the human spirit, I think there is opportunities for us to reclaim lives from the clutches of chemical dependency. But we need more information, we need more research, we need ethical professionals of all healthcare specialties to speak out. Today, I'm hoping he not only exposes the hidden dangers lurking behind these prescription cocktails, but also illuminates the path to freedom. I want to welcome Dr. Sean Gill, was a pharmacist, writer, podcaster, and entrepreneur dedicated to sparking change in healthcare through de -prescribing. He's the founder of De -Prescribed Solutions, an independent consulting practice focused on the reversing of early stage chronic conditions in mental health, hypertension, and type 2 diabetes, which interestingly enough, all kind of coincide and work together. Dr. Gill hosts the Deprescribed Podcast and writes in the Substack newsletter, BUDS, B .U .D .S, where he explores topics in health, deprescribing, parenting, and personal growth. His mission is to inspire patients to take charge of their health by challenging conventional approaches and exploring topics. They range from mindfulness, resilience, lifestyle interventions, to reduce reliance on medications. And let's face it, where we're at now, it has to be a grassroots effort. Patients are going to have to take control of their healthcare because entering into the sick care system, you're going to get the same nonsense and you will be dependent on drugs that are trying to treat symptoms and don't certainly in any way under treat or work with the root causes of such of those conditions. Dr. Gill received his doctor of pharmacy from the University of Toronto. Leslie Dan faculty of pharmacy in 2015 with extensive experience spanning hospital, outpatient and community pharmacy. brings a unique perspective to his work in integrative healthcare where he combines traditional pharmacy practices with innovative approaches. I want to welcome Dr. Gill to the radically genuine podcast. Shawn Gill. PharmD (05:18.18) Roger, thanks for having me. Roger K. McFillin, Psy.D, ABPP (05:20.034) Well, many of my listeners have reached out. They are asking me to do an episode on deprescribing life after psych drugs. But let's just introduce you first to the radically genuine audience. Let's know about your background. And honestly, I want to learn more about pharmacy and how pharmacists can be part of the solution moving forward. Shawn Gill. PharmD (05:41.737) Yeah, well, thanks for the introduction. a little bit about my background, Roger. I started off in pharmacy when I was 16 years of age. So I've dedicated half my life to this profession. started off at my local community pharmacy, just stocking shelves. And I discovered a passion through the profession and this ability to really touch patients' lives and help them. So I decided to pursue the career of pharmacy. went to University of Toronto, graduated in 2015 at the tender age of 24. And I got my first experience in hospital setting at my local community hospital. Here where I was born and raised in Oakville, Ontario. It was there for about four and a half years, Roger. And I got to double dabble in a lot of different specialties, ophthalmology, cancer care, cardiovascular fractures and orthopedics. And then we also had outpatient mental health and neuropsychiatry. But then in 2019, I took a new position in a more integrative model where I work at a compounding pharmacy now. And we're attached to a pediatric urgent care and a family medicine walk -in practice. So it wasn't until the pandemic where I started paying more attention to this rising epidemic of mental health. And around that time in December, 2020, also welcomed the birth of my first son, my first child. And as you know, Roger, once you have children, your perspective really changes. And I just kept seeing more and more patients coming into the pharmacy around this time with the global pandemic, a lot of isolation, a lot of loneliness, and a lot of surge in anxiety and depression and saw more and more people getting prescribed SSRIs from all ages, teenagers, Gen Zs, millennials my age. And I thought I need to be doing more to kind of counter this onslaught of mental health. And deprescribing Roger really came into my radar when I was still in pharmacy school. It's a concept that's typically utilized in geriatrics. So I remember being in my third year geriatrics elective and We had a lecture series on polypharmacy and that's where I first discovered the term deprescribing. It was kind of like a light bulb moment in my head. thought we need to be utilizing deprescribing, not just in geriatrics where there are a variety of issues with polypharmacy, drug interactions, side effects that can compound in that patient population. I always thought that we should be applying deprescribing right at the onset of a diagnosis, right at the onset of prescription for anxiety or. Shawn Gill. PharmD (08:08.645) early stage hypertension, metabolic syndrome, diabetes, you name it. That is really the best time to have that conversation with the patient on what are your intended goals of medication therapy, how long do you want to be on this medication, and how can we prevent the progression of this condition. So that was where my passion kind of ignited. And I always thought about deprescribing and I tried integrating it into my practice when I was at the hospital and then when I was at the compounding pharmacy. But it wasn't until Like I said, when my son was born, I really had that change in perspective and started thinking I need to be doing more to counteract this problem that I'm seeing more of in my clinical practice, which is the rise of mental health affecting all ages and especially the youth. Roger K. McFillin, Psy.D, ABPP (08:53.496) Let me follow up on some definitions. Let's start with compounding pharmacy. You mentioned that is where you're currently working. Can you explain what that means? Shawn Gill. PharmD (09:01.219) So compounding pharmacy is a specialty pharmacy where we're able to make specialized dosages for patients. And compounding comes into play when patients need to access certain medications that are not commercially available or manufactured at a broad scale. So for example, our compounding pharmacy specializes in pain management. So the owner of the pharmacy is a brilliant guy and he actually created a compounded cream medication that we use for neuropathic pain and also arthritis as well. So we would take powders that we would order from USP grade pharmacopoeia wholesalers in the United States and putting them into a base cream, we would mix all these different powders into this cream formulation. And with compounding, it allows you to really become creative with dosing and also different types of formulations. So in the context of mental health, what I thought was maybe we could start compounding specific oral solutions to help facilitate tapers for individuals that are looking to come off their SSRIs. So compounding really allows you to be flexible and customizable with your dosing and your approach to tackling certain conditions. Roger K. McFillin, Psy.D, ABPP (10:13.644) Great, thank you. And you also mentioned polypharmacy, which is, think, really, really important. Before I start talking about my experiences with polypharmacy, can you just, again, a definition of what that means and what you are observing in your own practice? Shawn Gill. PharmD (10:30.809) So polypharmacy is defined as being on five or more prescription medications for a chronic condition. So typically we would see polypharmacy in the geriatric population. That's where you have grandpa or grandma. They're at later stages of their lives in chronic conditions like metabolic syndrome or metabolic diseases, cardiovascular diseases, cancer, neurodegenerative diseases. They begin to take a lot of toll on the individual. And oftentimes medications are often prescribed to address those concerns. But polypharmacy can also occur when you have things like prescribing cascades. That's when an individual is prescribed a medication, they experience a side effect. And from that side effect, they're prescribed another medication to address it. these are typical issues that can occur when you have multiple medications. And from the perspective of deprescribing, polypharmacy really is the enemy because it can lead to an array of different issues. For example, when you have certain side effects from certain medications, that may be causing similar side effects. For example, if you have an individual in their seventies or eighties and they're on say a medication for sleep, a sleeping pill like Zopaclone, it can cause sedation. They may be on another medication for something like overactive bladder, which is an anticholinergic medication like oxybutynin that can also cause sedation. And these side effects begin to compound and affect the patient negatively. Polypharmacy can also lead to issues of drug interactions as well. So that's where Roger K. McFillin, Psy.D, ABPP (11:58.84) Yeah, which is, which is my question because I want to stay focused on mental health and I am seeing polypharmacy becoming more and more the norm here in the United States, not just with the elderly population. I'm talking about with teenagers. I just got done with an evaluation of a 19 year old on seven psychiatric drugs, which included two benzodiazepines. So gone for me are the days. where somebody has just prescribed one, you know, like one SSRI. And I know we're going to talk about SSRIs today because people don't know how to get off of them and they need help to get off of them. But polypharmacy, I am seeing what start might start with an SSRI, might start with a stimulant, then becomes evolving into adding what's called a mood stabilizer or an anti psychotic, additional SSRI and SSNRI. And it is certainly like another drug prescribed for the side effect of another drug or what just looks like to me on the surface, a doctor is trying to emotionally blunt and sedate a person into a complete different state of consciousness, which ethically scientifically I haven't been able to ever identify where that is effective other than destroying the health of the individual. So what supports such practices? If these are becoming more commonplace, where is the science around this? And God, I've never found one study that evaluates somebody on five psychiatric drugs, but yet they're doing it. Why? And then what can a pharmacist do about this? Shawn Gill. PharmD (13:50.043) I totally agree. I saw I went off a little tangent. They're talking about geriatrics, but bringing it back to mental health. Roger, even two weeks ago, I had a case just like that. had an individual, she was a female in her teenage years prescribed an antidepressant SSRI. She was on Zoloft. was following up with her psychiatrist who then prescribed her the racidone, a second generation antipsychotic for adjunct for her depression. And I took the mother aside and we really had a conversation and I wanted to make sure that she was informed of the risks and the benefits of this medication potentially. And pointing to your question, I agree there isn't this really a paucity of information and research on the effectiveness of these medications, especially in the context of polypharmacy. Oftentimes I do see a lot of cocktails being prescribed to individuals when they're first initiating a medicine for anxiety, depression, we typically see like an SSRI or a medicine for sleep like Sopoclone or any other sleeping pill in addition to a benzodiazepine for PRN or as needed anxiety. So when individuals come to me with that prescription, I will typically put them aside and say, well, how can we trim this down and even avoid taking any of these medications to the point where we can focus on implementing more lifestyle interventions? And what have you tried? What have you not tried? And really trying to understand first of all, where their anxiety or depression or symptoms are coming from, and also having that sort of discussion with the patient about how can we approach this from alternative methods, because oftentimes I see these medications even being prescribed for very trivial reasons. For example, a lot of patients of mine, come to me and there may not be having severe depressive symptoms or severe and anxious symptoms. It could just be something benign as struggling with deadlines at work. You know, I see a lot of students, for example, in university, they're trying to cope with the pressures of achieving certain GPAs or getting into graduate programs. And when they tell their physicians, they open up to them the quick fix and the quick solutions to get out the prescription pad and prescribe that SSRI or prescribe that, you know, that benzodiazepine for PR and anxiety. And oftentimes, unfortunately, in my profession as well, pharmacists, which are really the gatekeepers for medications, we're really stewards of medication. I feel like we're not doing our due diligence. Shawn Gill. PharmD (16:07.057) and making sure and assessing the appropriateness of these prescriptions. It's often we get the prescription, we say take with food, off you go and see if for your refill. And there isn't much follow up. But what I've been trying to do with my practice is to really give my patients time and to really break down and understand why they're here in the first place and to find unique solutions to help them rely less on medications and more on lifestyle interventions and things that actually work over time, as opposed to just masking symptoms, blunting emotions, and really being put on that slippery slope of taking a medication for an undefined period of time, which may lead to more harm than benefit. Roger K. McFillin, Psy.D, ABPP (16:48.546) Yeah. And that was my next question is, there a conflict that ensues then with you as the pharmacist is providing these type of like education and intervention to a potential patient? I mean, I'm not seeing this at all locally here in the United States that pharmacists are intervening at all. In fact, I don't, they seem like they're completely overworked and they're just filling the prescriptions and sending them out. But like what you're talking about is you're on the front line of this and you're there to actually support informed consent. And where does that then become a conflict with their treating doctor? And is there an ethical code? Is there a standard here for pharmacists to be able to intervene when they see harm is being done? Shawn Gill. PharmD (17:31.631) Absolutely. And you know what, Roger, I think it just gets lost in all of the issues with the way our models are set up. For example, where I work right now, we're a compounding pharmacy, we're integrated with the family medicine practice. It's one big open area. So if I have an issue with the doctor's prescription, it's really easy for me to just literally go into their office and have that dialogue and conversation with them. So my practice helps facilitate that. But in community pharmacy, there's a lot of distance between the prescriber and the dispenser. Typically patients will go to their doctor's office, they'll hop in their car, they drive off to Walgreens or Shopper's Drug Mart, wherever have you, fill their prescription. And then it gets kind of lost. I think that distance creates a lot of sort of hesitancy amongst pharmacists because we're relying on fax machines to kind of relay information back and forth between the prescriber and the dispenser. So oftentimes, know, patients are in a rush, they have their lives to live, they can't just be waiting for you know, dialogue between the pharmacist and the physician to sort of discuss, you know, is this the right option? Is this not? So that's a major obstacle and barrier I find when I speak to some of my colleagues. And another thing, Roger, is when you look at it, it's basically comes down to the fact that the business model of pharmacy is rooted in dispensing. So when individuals find out that I'm a pharmacist and I'm interested in deep prescribing, sometimes they look at me like I have three heads and like, Whoa, you're kind of coming after our bread and butter here, but It's never about that. It really comes down to the fundamentals of our training and ensuring that the patients that we're seeing, we're doing right by them and that we're making sure that the medication that they're being prescribed is appropriate for their indication. Roger K. McFillin, Psy.D, ABPP (19:13.634) Great. We're going to spend some time on SSRIs, commonly known as antidepressants. We can throw SNRIs in there as well. Despite very known risks, we just continue to see these drugs being prescribed more and more. So what are some, in your opinion, what are some of the lesser known risks that are associated with these drugs, both in short term, long term? And what information are... Shawn Gill. PharmD (19:32.969) Thank Roger K. McFillin, Psy.D, ABPP (19:40.984) patients and families not receiving around antidepressants. Shawn Gill. PharmD (19:45.513) That's a great question and I ask that every single time I dispense one of these medications. Roger, the first question I ask my patients is, what has your physician told you about this medication? And it's not a knock on the physician. I really empathize with my colleagues who are MDs because they have their own set of issues that they're dealing with in their private practices and whatnot. They have lineups out the door. They have hundreds of patients to see. So oftentimes, time is the biggest constraint that they have. So they don't have much time to actually break down the risks, the benefits of these medications. So usually like clockwork, when I ask patients, what has your physician told you about the medication? What side effects should you expect? They'll typically respond with the exact same answer, which is not much, the medicine's safe. it may cause a little bit of difficulty sleeping or some upset stomach. And that's about it. It's really the tip of the iceberg with these medicines. Roger K. McFillin, Psy.D, ABPP (20:34.646) Yeah, let me ask you question. You said it was a time constraint issue. My experience is it's a knowledge issue that the doctors themselves aren't aware of the substantial risks. That they're just following some guideline that they were provided and they're assuming the drugs are safe or effective or they wouldn't be available for them to prescribe. Shawn Gill. PharmD (20:43.005) That too, that too. Shawn Gill. PharmD (20:47.858) I agree. Shawn Gill. PharmD (20:57.851) Of course, I definitely agree with that. then piggybacking on that, like when I have that conversation with the patient, I'm really usually not surprised because I've done so much now, but really what I tend to do then is kind of break down and we go and dive a little bit deeper into some of the risks of these medications. So we know that in the short term, when you start these medications, they tend to cause issues with the gut, whether it's nausea, diarrhea, constipation, and they can also throw off in individuals. circadian rhythm and sleep. So sometimes it can cause insomnia. Sometimes they can cause drowsiness. Typically what we'll see is in the first two to six weeks, those adverse effects typically may go away. Sometimes they can last. And that's usually the counseling points that we have as pharmacists and MDs about these medications. But what people are unaware of are the long -term implications with a lot of these medications. Now I know you're aware of this sexual dysfunction is a much more prevalent side effect that's becoming much more aware in the population that have been on these medications. And there's some suggestions that sometimes even sexual dysfunction can remain even after the medication is stopped. In the short term as well, we haven't even touched on in certain populations, specifically in pediatrics, the risk of suicide and self harm significantly can increase as well. And that's just a major red flag and a black box warning on a lot of these medications, which unfortunately is often overlooked. And then When I look at it from the long -term concept as well in context, I also tell my patients, we have to be very careful with if you are hard set on starting one of these SSRIs, you have to define the duration of the medication therapy. Because what we know is that the longer you're on these medicines, the more difficult it is to come off of them. Roger K. McFillin, Psy.D, ABPP (22:47.116) Yeah, I mean, that's the unfortunate thing about it. When you look at the research as I have, I've dug all the way into the original trials for Prozac being brought to market in the United States. I mean, you're talking about extremely short term evaluations, like six to eight weeks of this. we really have nothing long -term, but doctors are just saying you need to be on this drug for a year. That's outside any form of evaluation. mean, that's nothing more than drug companies trying to increase the amount of people. Shawn Gill. PharmD (23:01.857) Mm Roger K. McFillin, Psy.D, ABPP (23:15.288) that are on the drug for extended period of time to increase the amount of revenue off the drug. mean, that is, it's not science -based, it's marketing -based. And you brought up some really important points. Let's talk about the short -term response to these drugs. There's gonna be a percentage of people more vulnerable for young people, and that's what we're seeing. mean, under 25, still a period of adolescence, are being prescribed these drugs pretty routinely. And for a percentage of the population, it does induce a stimulating effect almost immediately for some people. which increases the likelihood of self -harm, suicide, and even homicide. And in my investigation and some of the podcasts I've done, I've come to realize there's about potentially seven to 10 % of the population that has this genetic mutation of a metabolizing gene that basically you provide them that drug right away. I mean, it builds up to a toxic level and that's, they're just more likely to experience these depersonalization, derealization, psychotic symptoms. And they are the ones who become most at risk for acting out with violence on themselves or others. But they're prescribing the drugs without even knowing if that person has that genetic mutation. So you as a pharmacist wouldn't know that either. Shawn Gill. PharmD (24:31.471) Absolutely. that's actually interesting that you brought that up. That's one thing that a lot of more pharmacists are trying to be implementing in their practices through pharmacogenetic screening. So that's although I'm not, I'm still kind of on the fence with the utility of pharmacogenetic screening and pharmacogenetic kits. I think in the context of initiating and prescribing medications, they definitely have a lot of utility because if you can identify an individual with a CYP2D6 Fast inducer or slow metabolizer that can help at least steer us in the right direction to prescribe a medication that's appropriate. In your context, like you said, if seven to 10 % of individuals are slow metabolizers of SIP2D6 enzymes and their prescribed fluoxetine or another SSRI that relies on that enzyme for metabolizing, then they can have sort of elevated levels of that drug in the body, which can then lead to adverse effects. I think that's one area that pharmacists can implement pharmacogenetic screening. to sort of streamline and improve the process of prescribing the right medication for the right patient. Roger K. McFillin, Psy.D, ABPP (25:36.066) Yeah, in my field, mental health, I've seen, I think that pharmacogenic screening is important to prevent harm. I'm not really sure the science around it supports that. That means that this particular drug is going to be effective for you. And then that's how it's, that's how it's being communicated. I think by from some psychiatrists. Shawn Gill. PharmD (25:52.059) Agreed. Agreed. Yeah. That's also where I kind of pump the brakes because I've had a few discussions with some of my colleagues that say, pharmacogenetic screening is the answer because then we can prescribe the right drug and we'll get the right efficacy. But specifically around SSRIs, I'm still very hesitant and I still kind of disagree because I believe what, like you mentioned, if you deep dive into the literature, a lot of the evidence suggests that these drugs are barely, barely better than placebo at best. And I know you mentioned diving into the papers. I've actually read a lot of research lately by Dr. Irvin Kirsch who talks about the placebo effect of the SSRIs and actually diving into the literature a bit suggests that these drugs really do cause a placebo effect in many to and back to kind of the acute stage of prescribing and dispensing these medicines. think that's where a lot of the benefits do occur when people start these medicines where they kind of had this intention, they're going to the doctors, they're kind of spilling their hearts out, they're sharing what troubles that they're going through, whether it's depression or anxiety, the doctor hands them a prescription and that is very powerful in the sense that it provides things like hope, provides some context and it can provide the patient with sort of a solution to their problems. So I think with that in mind, analyzing the research, it does suggest that they do have a very powerful placebo effect. And I think that's where a lot of times in the short term, A lot of patients will say, yeah, four weeks after I'm feeling great. But then when they kind of stay on the medicine six months later, eight months later, 12 months later, and you follow up and you actually had that conversation, how are you feeling? You start to see these other symptoms crop up, things like emotional numbness, blunting, low affect. I've had this conversation with so many patients, Roger, where they've been on SSRIs for three years, five years, and they'll tell me stories like my dog passed away three months ago and I couldn't cry. Or, you know, my son just graduated high school and there I was sitting in the auditorium and I felt nothing. And that just kind of shows you the potential negative impact that these medicines have when you're altering the neurochemistry in the brain and doing a lot of things in the central nervous system. It really has that impact, which is potentially negative in this, in the context that it can lead to emotional numbing. can lead to kind of this low affect. The analogy I like to use is imagine going to the Shawn Gill. PharmD (28:18.217) Sydney Opera House in Australia and we're going to watch the orchestra and you bring a pair of headphones with you. Like would you want to blunt out the highs and lows and the sound and just kind of be flat or do you want to experience kind of the highs and lows of life? So it's unfortunate adverse effect that I see that when I interview my patients at least who have been on these medicines for long periods of time, that's a common theme that I'm seeing. Roger K. McFillin, Psy.D, ABPP (28:42.902) Yeah, well said. You bring up really important points. Well, first is post hoc ergo proctor hoc fallacy. After this, therefore, because of this, and this is why I think clinical trials, why science is so important, because you begin to tease this out. We often in doctors are really at risk of doing this. So our patients is They assume because someone gets better after a medical intervention that it is the drug itself that is that mechanism of action and not all the other things around it. That's why we see such as a high placebo response rate in mental health and pain is there's this attention that's provided to the person and there's this expectancy effect. And the people are gonna be more susceptible to responding to the drug when it's not the drug itself are the ones who really do. buy into the medical authority and they have these beliefs around that there is that quick answer. Now this is a powerful psychotropic drug that acts on the brain and as you well said it, I think somewhere like 60 % of people or more who take the drug do report emotional numbing or bluntness as a response to the drug. Now the greater philosophical question and the scientific one is, is that anti -depressant? because that also numbs all experiences, including sexual ones, which you described earlier, but like the positive emotions of joy can be blunted. It's almost, you know, very much like taking away superpowers that exist for us human beings, where our emotions, our energy, and, you know, we're experiencing them on different vibrations based on experience. I mean, it's really profound negative effects. And then if... If you're in profound pain before that, certainly understand why some form of numbing or muting out that experiment could be seen as somewhat beneficial. But most people see it as aversive, to be honest with you. But if they don't know any better, like if they're taught or brainwashed to think emotions are symptoms of an illness, then I can understand the perception that that somehow is helpful. If there were no adverse reactions, if there was no Roger K. McFillin, Psy.D, ABPP (30:54.232) Terminates conditions that could take place from taking the drug if there were no fatal responses to taking the drug It didn't impact gut microbiome metabolic illness all these adverse health effects then might one might say it's worth it, right? But when you weigh out Costs and benefits under this and knowing that people get better prescribed a sugar pill Wouldn't it just be better than to tap into understanding that? And the other thing is that we're even, we're just relying really on the published literature when we say that there's a small effect of a drug over placebo. And, you know, we're not considering the totality of the research, which also includes those that did not demonstrate a positive response and those go into the file drawer effect. And we don't even talk about really how the drug companies have kind of manipulated the trials just to get that effect in the first place. So. Shawn Gill. PharmD (31:37.884) Of course. Roger K. McFillin, Psy.D, ABPP (31:47.51) We don't have a whole lot. We don't have a strong foundation of understanding what science is and understanding clinical trials. So we talk about things as if they're truth, like they are not because we understand them, but because someone else repeated them. Right. So it's like the norm, like, well, it does seem to improve some people outside of, of placebo, because there's some published literature that says it has a statistical difference. But I mean, really that difference is clinically really irrelevant. If we want to look at individual patients, is there someone who might have a stronger effect? Well, we don't know who they are. We don't know why. We don't know under conditions. And the same thing, if someone has a larger effect to the placebo, what do we know about that person? Not anything's are explored. And then we go long -term. Let's go past six months. Let's go past 12 months. Let's go past two years. I'm seeing people in practice been on the drug for 10 years. How's that justified? You know, how is that justified? And it's prescribed by Shawn Gill. PharmD (32:41.733) Yeah, same. Roger K. McFillin, Psy.D, ABPP (32:46.688) A primary care doctor who doesn't know shit about these drugs like absolutely nothing and I don't know how we've gotten here. Sean, you can see that you know I'm angry about it. I think we're pretty good at identifying the problem. I think we're probably on the same page of this. I'm more interested and I think my audience at this point is probably more interested in getting to solutions, but we can agree that's that's the problem, right? Shawn Gill. PharmD (33:09.929) Big time. agree 100 % because even in my practice, Roger, when I see a patient's profile, it's like 2009, they were prescribed an SSRI. So then instead of doing, when they're picking up their refill, I'll go into their profile and look and I'll say, I'll ask the hard question. What happened then? What happened in 2009 that led you to go into this medicine? And it's often, you know, a loved one passed away, divorce, tough times at work. And then what I try and do as a pharmacist, because I'm in that position, I'm handing them their prescription refill. I try and break it down. try and have a conversation with them and say, why are we still taking this? The guidelines say six to nine months is an adequate trial for depression or anxiety. And here you are 14 years later, eight years later, and you're still on this medication. Roger K. McFillin, Psy.D, ABPP (33:54.968) Can I ask you a question on that? The guidelines say that six to nine months are an adequate trial. What is that based on? I haven't been able to find anything. Shawn Gill. PharmD (34:01.752) I'm not sure either. I think it's just an arbitrary number because like you had mentioned as well, if you actually dig into a lot of these clinical trials, assessing X and Y SSRI versus placebo, a lot of times they are six to eight weeks, they're a very short timeframe. So I think it's just an arbitrary number, but if. Roger K. McFillin, Psy.D, ABPP (34:18.421) And that's important for people to kind of realize is that you're being told information that is made up. When I say it's arbitrary, it's absolutely arbitrary. I can't find any trial that goes six to nine months. Shawn Gill. PharmD (34:24.923) and Shawn Gill. PharmD (34:30.589) Yeah, and the thing is Roger as well is because, you know, as clinicians, know, pharmacists, physicians, we're inundated with so much information and we have to hold so much in our heads. It's feel guidelines are just a quick and easy resource for us to look to to say, okay, this is what we need to do in this context. We need to prescribe X, Y, Z for. Roger K. McFillin, Psy.D, ABPP (34:47.468) you know how guidelines are developed? Shawn Gill. PharmD (34:49.799) Not really. Roger K. McFillin, Psy.D, ABPP (34:51.254) So they're usually from major medical organizations. Let's say the American Medical Association, American Academy of Pediatrics. Do know who funds those organizations? Shawn Gill. PharmD (35:03.045) I can guess. Pharma companies. Roger K. McFillin, Psy.D, ABPP (35:05.654) Yeah, industries that would benefit from their product being safe, effective, frontline treatments and for people taking them longer than what it's ever been evaluated for. Shawn Gill. PharmD (35:15.997) Yeah, so that just shows you the kind of beast that we're facing. Roger K. McFillin, Psy.D, ABPP (35:19.148) Yeah. All right. Let's go into withdrawal and tapering. First, we were talking about polypharmacy. When you're on like five, six, seven drugs and someone comes to you and they want to get off this, how do you choose what goes, what drug is removed first and how you do that to like minimize horrible outcomes? Shawn Gill. PharmD (35:43.529) That's a great question, Roger, and something I'm still figuring out. I've been doing deep prescribing now for about 13 months. Most of my cases are monotherapy, luckily, so it's much easier, but I've had tried taking on a few cases of polypharmacy where there's two, three, or four psychotropic medicines, and it's very difficult because we have such a paucity of data or research. A lot of it is anecdotal. There are some papers out there where... some doctors and clinicians have taken on cases and published some case reports. My approach is always to identify kind of the sequence of which these medicines were prescribed. So that's step one is identifying what were you put on first, why were you put on it? And then usually other agents are added as adjunct therapy to boost the effects of the first one. So for example, I've had one case where I've had a patient on an SSRI. Going back to that individual, actually we talked about earlier. the female teenager, she was on an SSRI and then for adjunct therapy, her psychiatrist prescribed her a second generation antipsychotic. So typically, if I'm approaching it from a deprescribing context, really you want to try and minimalize the damage to the patient that may be induced from withdrawal during a deprescribing process. So what I'll typically do is we'll say, which of these is the lowest hanging fruit that we can kind of take you off? And we can mitigate some of the withdrawal by implementing certain lifestyle interventions or supplements. And then really the process I've discovered is that depending on how long the patient's been on the medication, how stable they are, how much intention they have and how motivated and driven they are to come off their medicines. Really it's a matter of picking one agent and kind of going through the process of slowly tapering and then going to the next agent and so on. So Really, it's very difficult to say we're going to stop all these cold turkey at once. Although I will say I've had a few patients tell me some success stories where they have been able to kind of do that or they're on an SSRI, they're on a benzodiazepine and they're on a medicine for sleep and they just kind of cold turkey all of it, which again, it comes back to a case by case individual basis, how driven they are, how motivated they are, how much support they have. Shawn Gill. PharmD (38:03.187) kind of the circumstances, the external circumstances in their life that they're dealing with. and then I've had some patients where even just coming off monotherapy, up one SSRI is a very challenging process and they're very sensitive to some of the withdrawal effects. And you have to go at a very slow pace to kind of wean them off using a hyperbolic taper. So it really comes down to the individual. And when there's polypharmacy involved, it just becomes much more complex. I think the fundamentals are first identifying the sequence of prescribing. figuring out why each medicine was prescribed, what it was indicated for, and trying to find the lowest hanging fruit to determine if you're using a benzodiazepine, for example, PRN as needed just for bouts of anxiety or panic. That's one that we can kind of take off right away and then implement certain lifestyle interventions. So when you do have situations of panic or whatever it may be, we can sort of have our mental health toolkit armed and ready. So when those situations arise, you can handle them. Roger K. McFillin, Psy.D, ABPP (39:03.608) All right, so let me give you some examples because I think this is more typical than not. Someone is on a benzodiazepine, not as needed, not as a PRN, but like was provided for sleep and they're on it for over a year or more. I've seen some horror cases. They're also on an SSRI over a year. They're also on an anti -psychotic medication. Not that they're psychotic. but for some reason they're prescribed an anti -psychotic medication, maybe under the idea that it's gonna boost the effectiveness or something else or help with sleep, who knows? And then they're on some other drug, like a stimulant, for example. So the common ones, SSRI, anti -psychotic. SSRI, antipsychotic, a benzodiazepine. When those are the most commonly prescribed drugs, simp stimulants as well, how do you make a decision about which one, if they've all been on them long -term, is there one that is easier to be able to get off of and then you start there or do you start with the harder one first? Like what's the logical thought process around? Shawn Gill. PharmD (40:22.663) Yeah, to be honest, like I said, I don't know. And I think in that situation, say they're on all four meds, I would probably go with the stimulant first because I've seen it in clinical practice where I've had individuals on long -term stimulants for ADHD, and then they just kind of stop it right away and there isn't much of a rebound effect in terms of negative withdrawal effects. So in that context, I would probably go with the stimulant first, but One thing I've also seen many individuals do is that they'll kind of initiate a taper for all three medicines at the same time. That's another approach you could sort of carry out. It's just a matter of identifying which withdrawal symptoms correlated with the medicine. So antipsychotics, for example, have a subset of withdrawal symptoms. SSRIs have a subset of withdrawal symptoms. And of course, benzodiazepines have withdrawal symptoms as well. The issue with benzodiazepines as well is that I'm not sure if there's any literature out there on this, but because they're medications that we use for a variety of other conditions, for example, seizures, you have to be very careful in the process of tapering off benzodiazepine because I'm not sure if there's any case reports out there. I haven't come across any, but I believe if you taper too fast and you have all this kind of going on with changes in sort of neurotransmitter levels, CNS and whatnot, potentially I'm not sure if they can induce a seizure or whatnot, but it's really in a matter of being very careful and being very slow. And the slower you go, the higher the chance of success. And that's unfortunately one of the main obstacles I find many patients face because when they're sort of, it's so easy to get on these medicines, know, the doctor prescribes it, they escalate the dose so quickly, but coming off of them is such an arduent process. You really have to be very patient and have to be very sort of, you have to approach it with the right intention. Roger K. McFillin, Psy.D, ABPP (42:18.392) So I appreciate you saying, I don't know when you don't know, because I think we're in a time period where doctors have to feel like they have all the answers. what I try to share with my clients is that this is experimental and it's an N of one and you are that one. So if we say something like, the best way to do this is slow with careful monitoring. individualize to you a trial and error approach for you and that we have other tools in place to help you deal with what might happen and that you have a support system and you have a team behind you to be able to reach out to if you're having some really strong adverse reactions, but slow and steady. That's really the way to go. Would you say that's true? Shawn Gill. PharmD (43:07.485) Yeah, absolutely. And going back to your point as well, in my situation and my clinical practice as well, like I'm very comfortable telling patients I don't know the answer because the fact of the matter is that we don't have any evidence or barely any thereof. There's no systematic reviews. There's no randomized trials on this process. There is actually a randomized trial that's going to be conducted at the University of Queensland next year for hyperbolic tapering versus linear tapering in SSRI. So at least we'll get a little bit of evidence there. But the problem Roger I see is that the fact is polypharmacy is so rampant, especially in mental health, it's so easy to initiate and prescribe these medicines without any foresight on the potential consequences of polypharmacy. So as a pharmacist, my approach now really is that when I, every time I see a prescription, especially a new one, is I always try and pump the brakes and make sure my patients understand what they're getting into. And that's part of informed consent because I think prevention, like the saying goes, an ounce of prevention is worth a pound of cure. And especially in this context, if we can really pump the brakes and prevent these cases of polypharmacy, it would save a lot of patients, a lot of suffering. Roger K. McFillin, Psy.D, ABPP (44:23.202) Yeah. Well said. All right. Let's some definitions. know a lot of people want to know how to get off antidepressants. They never thought it would create this degree of dependency and they just can't get off of them. They've been on this drug a lot longer than ever evaluated. The doctors don't know what to do. And you brought up something, a word, a name that's quite new, somewhat new. Many people haven't even been exposed to it yet. And the doctors, prescribers who I am interacting with don't have even some of the basic knowledge of this. So please define for us what hyperbolic tapering means in comparison to what you said, was linear tapering. Shawn Gill. PharmD (45:01.897) So linear tapering is the thought process that say you're on, we'll give an example of an SSRI, you're on Lexapro 20 milligram. So it's written in the guidelines, again, not backed by much evidence at all, that to taper off that medication, you'll follow a linear approach. So you'll go very intuitively from 20 milligram to 10 milligram to five milligram, and then maybe five milligram every other day. And the guidelines do stipulate that this process should occur over two to eight weeks. So very fast, very quick. But then, you know, from a patient perspective, eight weeks sounds like a lot of time, you know, I mean, to start the medicine, takes one day, but to come off of it eight weeks and four dose reductions, it sounds like a lot hyperbolic tapering on the other hand was coined by Dr. Mark Horowitz, who's the co -founder of outro health. Shout out to them, but they're doing a lot more research and pushing the boundaries with getting hyperbolic tapering into the mainstream. And I think it's a much more suitable approach. So hyperbolic tapering looks at what's actually happening at the receptor level of the drug and correlating that with the reductions in the dose. So as to facilitate step -by -step approach of coming off the drug. So hyperbolic tapering, think of it as micro dosing off your SSRI. And what that's doing is going back to the pharmacology and the pharmacokinetic of these drugs and how they're actually interacting with the receptor. So let's break it down and we can dive a little bit more into pharmacology. So SSRIs, they work mainly on a receptor called the serat receptor, serotonin receptor, S -E -R -T. And looking at PET scans, Dr. Mark Horowitz and a few other researchers have identified that these drugs don't follow a linear sort of relationship with the receptor. So theoretically, when you're prescribed these medicines, doctor may start you on Lexapro. 10 milligram or five milligram. You'll double the dose to 10 milligram after a week. And then they can go up to 20 milligram. And the thought process is, I'm doubling the effect of the medicine. But what we see is that that is not the case at all. Some reviews have actually come out that suggest that most of the effect of these drugs on the receptor, more than 50 % of the effect on the receptor, occurs below the minimal therapeutic manufactured dose. Roger K. McFillin, Psy.D, ABPP (47:24.994) Well, so does I just want to clarify, does that mean we're just prescribing too much of this? Shawn Gill. PharmD (47:30.505) Well, what happens is that you have a plateau effect at the top. if you remember your grade 12 math or calculus, a hyperbola as opposed to a linear line, which goes from the bottom left to the top right, a hyperbola follows kind of a curve. So most of the effect happens below the therapeutic dose at very low doses. And as you increase the dose, it levels off. So essentially. Roger K. McFillin, Psy.D, ABPP (47:54.488) And so what's happening to the body at that point? Shawn Gill. PharmD (47:57.865) Well, that's why I think it explains Roger why typically if I have a patient who's on lexaproton milligram and it's been eight weeks, they're still feeling awful. Their anxiety is still prevalent. They're still around. Their depression is not cured. They go to their doctor and the doctor says that we're going to increase the dose. think that explains why typically we don't see a two X in effect of the medicine. And all of a sudden when you increase the dose from 10 to 20 milligrams, it's not like you see a huge jump in the effect as opposed to something like, for example, if we're talking about thyroid medication. blood pressure medication, when you increase the dose, can kind of project and see what the response will be from an objective measure. But I think that also explains why most of these drugs, no matter how I've seen this often, so, so often in my practice, Roger, where patients will start on a dose of any medication like SSRI and SNRI, antipsychotic, and we're just leveling up the dose, leveling up the dose, and there's no impact on the actual condition. And that's what then leads to the prescribing cascade. Another one is added. we increase and increase. But when you look at it from the hyperbolic relationship, it explains why at below therapeutic doses, most of the receptors being occupied. And that also explains why when we taper patients off these medicines, a lot of times they'll fail the linear taper because they taper too quickly. If you imagine the hyperbola, we can definitely link to some graphs as well for patients to visualize this. Say you're at a dose of Lexapro 10 milligram and you go to five milligram. I don't have the numbers off the top of my head, but imagine you're occupying 75 % of the receptor at 10 milligram jumping to five milligram. You're thinking you're going to cut that in half. You're to go to 37 and a half percent, but you actually, in reality, maybe go to 60%. And then from five milligram to zero, where you stop the medicine, you think you're going to go, maybe, you know, it's going to be a straightforward process. I'm at five milligrams, not a high dose, but then what happens at the receptors, you're going from 60 % occupied receptor to zero. It's like at first you're going down a flight of stairs from 20 to 10 to five, then you're jumping off the ninth floor to the bottom. And that's oftentimes what happens to these patients, which is why my practice, I see it over and over again when they go through the linear taper, they're back in clinic for eight weeks later and they're experiencing negative symptoms. They're anxious. Their depression comes back and the doctors will then say, it's a rebound effect. It just kind of reinforces that chemical imbalance, that diagnosis that you need this SSRI and that's Roger K. McFillin, Psy.D, ABPP (50:24.0) withdrawal. Shawn Gill. PharmD (50:25.243) Exactly. And it comes down to the fact that the patient's experienced withdrawal. Roger K. McFillin, Psy.D, ABPP (50:29.04) So you know, the question that a lot of people have and I can't answer it and I don't know if you can answer it either. So these drugs came to market under the theory that there is some deficiency in serotonin, that those drugs in itself are going to increase the availability of serotonin in the nerve cell. But what we know now is that doesn't exist, right? There's no real correlation there. So what happens when we artificially Increase the availability of serotonin in the nerve cell with a chemical compound made in a factory. Shawn Gill. PharmD (51:05.141) I'm not too sure and I guess that's why these drugs are so kind of sporadic and they can cause a variety of different effects in different individuals. And personally, like that's why I think the serotonin is not just in the central nervous system as well. Much of the serotonin produced by the body also occurs in the gut. So that explains why sometimes these medications can cause very severe side effects in the gut. But it really does break down to the fact that Even if you look at the product monographs, of a lot of these compounds, if you just go on Google and search Lexipro monograph, Zoloft monograph, that's the legal document that the drug company has to provide. And in there, they'll have a paragraph on the mechanism of action. And usually most of them will stipulate in one sentence that they don't fully understand the mechanism of these drugs. And I think that just kind of shows you that, you know, we don't fully understand how these drugs work. And I'm aware of that fact that the chemical imbalance theory has debunked or has been at least criticized a lot in psychiatry. Yeah. Roger K. McFillin, Psy.D, ABPP (52:10.456) debunked, never supported in the first place. I mean, there's no scientific data that you can find that would have ever supported it. I mean, it was just a hypothesis that turned into a marketing campaign. But I mean, unfortunately, you'll still see doctors talk about it today. Shawn Gill. PharmD (52:23.388) There's a Yeah, there is a really good paper by Dr. Joanna Moncrief, where she talks about and breaks down a new way of looking at psychoactive compounds. She calls it the drug centered model versus the disease centered model. I think a lot of your listeners would be very interested in reading that because it kind of breaks down that when you look at drugs from a disease center mall, that's like looking at, for example, antibiotics, we understand the pathology of an infection. We understand what the antibiotic is working on in the pathway of that bacteria. And we can almost begin, can extrapolate from that what the outcome will be. The antibiotic kills the bacteria. Whereas a drug center model, these medications, come in, they fluctuate and change our neurotransmitters or serotonin or neuro epinephrine or dopamine. And they're inducing kind of like a psychoactive effect on the entire body. Emotional blunting, numbness, euphoria, just like how alcohol reduces social anxiety. We don't prescribe alcohol for that case, right? but that's kind of the effect of the drug on the body and the symptoms that, or sorry, the effect of the drug kind of overlays with some of the symptoms of these conditions like anxiety or depression. So shout out to Dr. Joe and Amon Kreepe. I'd highly recommend, we can link to that paper. I'll send you the paper as well, Roger. You can link it maybe in the show notes. Roger K. McFillin, Psy.D, ABPP (53:42.562) Yeah, definitely have spoken about that on my, podcast before. And I think it's safer to say that these drugs are going to induce a chemical imbalance. They are not correcting one. And, that's the ethical challenge that exists for me. So when you have something that is theoretical, like the serotonin hypothesis, and then you in the United States, we're one of two countries that have direct to consumer drug advertising and you flood the entire market with this idea that what they feel is related to chemical imbalances. Shawn Gill. PharmD (53:54.737) Agreed. Roger K. McFillin, Psy.D, ABPP (54:12.482) then you create a drug that you still say you're not really sure about the mechanisms of action. The science behind its effectiveness, at best you say is controversial. I would say that it is fraudulent. So you have these doctors who are saying, it may not be due to low serotonin, but we know the drugs work, we just don't know why. Which again is another lie, right? And it only does so. the continued justification of those drugs? Because what else are you going to say? You you've been practicing this way for 15, 20 years or longer, your entire family is supported by it. You've prescribed countless drugs to countless people. Are you really going to sit there and say, yeah, I harmed people over my entire career based on faulty evidence and I've been a spokesperson for the drug company. They don't really work. They were really brought to market off of fraud and scientific misconduct and we know they're harmful from the moment you take them. Like no one's going to say that, right? And that's the difficult place that we're in. I can say it. I'm a clinical psychologist who doesn't prescribe it. I just study it and I'm my own boss. But most people aren't in this position. Even if they think it, even if they know it, it just seems so much bigger than them. You know? What can I really do? And some have pulled themselves out of the system very creatively, you know, now focusing on metabolic illness. So some of the doctors that I've had, psychiatrists I've had on my podcast, like Dr. Christopher Palmer or Georgia Eady, you know, who kind of pulled themselves out of this and now they're using nutritional psychiatry, I think is brilliant. But I would love them both to be more open about the harms of the drugs that are prescribed, but they really can't do that. I mean, they would be really taking down their entire profession. Shawn Gill. PharmD (56:05.129) Yeah. And I struggle with this too, Roger, like in my, you know, adventures here with the prescribed solutions, I try and make connections and sort of build a network of doctors in my area and having conversations with psychiatrists is extremely difficult because I try and look at it from their perspective as well. I understand it's such a sunk cost fallacy. Imagine dedicating, you know, 50, like decades of your life to, you know, the study of psychiatry and, you know, sure there's obviously involvement with, know, partnerships with pharma and whatnot. But it comes back to your point. Now kind of the cat is out of the bag. And we understand that these medicines aren't what they were tethered out to be. And in my opinion, they do definitely cause a lot of harm and more harm than benefit. But I've seen you kind of write about this and also post about it on social media. It's almost like a house of cards. So where I see things in terms of how I want to dictate my practice is focusing on prevention, focusing on How can I stop, my mission is to stop patients from going on this sort of pathway that can lead to debilitating withdrawal because like you as well, I've heard dozens of horror stories and have had conversations with individuals who were prescribed these medicines for postpartum depression, you name it, anxiety, loss of a loved one. And it's almost like a set and forget mentality where their GP prescribes it, their psychiatrist prescribes it. The psychiatrist then lays it off to the GP. The GP doesn't want to play with the dose or anything because it's from the psychiatrist. And then patients get caught in this mix where three months, which was the intended duration of therapy, turns into three years, which then turns into three decades. And then they're at a point where they're trying to come off. And then the debilitating withdrawal, the difficulty of reversing that decades or years of neuromodulation can be quite a challenge. It's heartbreaking when you hear these stories. So my MO now is to try and stop people from going on that pathway, instead focus on alternatives, focus on studying philosophy, physical exercise, breath work, building resilience, things like that. So that's kind of my focus now in my practice. Roger K. McFillin, Psy.D, ABPP (58:20.34) Yeah, you brought up such a good point that I don't think I discussed enough. The set and forget. And what happens is you make that prescription and you just forget about who that patient is. and this is what I see all the time is that another prescriber becomes involved with the case because they've left their psychiatrist for whatever reason. And then the fear of making that change or a psychiatrist doesn't want to make a change on the drugs that were prescribed in the hospital. You know, it It's such a broken system and the patient is really the one who is the victim of all this because before you know it, they're five years in, there's 10 years in, no one wanted to make a change with their Seroquel and their Prozac and their Trazodone and their Xanax, you know, despite the concerns. It feels like it's too risky for them to oversee it, especially if you're a primary care doctor. Shawn Gill. PharmD (59:17.959) Yeah, absolutely. And I think that's where pharmacists have to step up a little bit more. At least I'm trying to take that initiative in my community because it comes back to the fact that we are stewards of medicine. one thing that many people don't realize is within our practice, we have the ability to say, no, we're not going to dispense this medicine. It's not appropriate. It's not safe. It's just a matter of having that courage and taking that step to of implement sort of a plan for the patient. doing the hard work of actually getting patients off. And unfortunately though, like I mentioned earlier, it's not incentivized. Our business practices are kind of against de -prescribing. And my goal is to try and kind of change that rhetoric and try and change the dialogue and sort of revolutionize the industry of pharmacy to focus more on actually helping our patients, actually working with our patients. And I think that's one of the best things with medicine 3 .0, the shift towards chronic disease prevention, shift towards longevity, putting patients in the driver's seat and having a team around them with the pharmacist, their psychologist, their GP, so that they can be in charge and they can have more sort of agency in dictating their health outcomes. Roger K. McFillin, Psy.D, ABPP (01:00:32.098) Yeah. So I pulled you off the specifics of hyperbolic tapering. apologize for doing so, but you made so many good points. Let's get back to some of the specifics, like what hyperbolic tapering for an SSRI would actually look like in practice for the, know, the person who's been on the drug for over a year, most likely it's longer and they want to get off of it. And they recognize to you that their attempts to get it off, get off in the past have just brought misery. Right? So, I mean, they had severe mood changes, sleep difficulties, agitation, sometimes like even akathisia, and they're scared to death of getting off of it. Some of them are actually kind of convinced to believe that it's their depression returning and they need to be on it for life. They might've even been told that. So what would hyperbolic tapering look like in practice? Shawn Gill. PharmD (01:01:23.689) So there's a great set of guidelines called the Maudsley Deprescribing Guidelines written by Dr. Mark Horowitz and Dr. David Taylor. And in the guidelines, they actually provide dosing tables and guidance on how to actually facilitate a hyperbolic taper. So that's step number one, is having the right resources and the right information and presenting that to your GP to actually prescribe the hyperbolic taper. And essentially with hyperbolic tapering, like I said, it goes back to... looking at what's happening at the receptor level of the drug and following a stepwise approach to reduce the concentration of the drug at the receptor in a stepwise approach. So what we'll do is when we facilitate a hyperbolic taper, we'll look at the dose you're on. So you're on 20 mG of Lexapro and say you're occupying at that dose 75 % of the receptor. The goal would be to reduce the dose at a rate that produces a five to 10 % reduction in the receptor. So you're Alexa pro 20 milligram, maybe to go to 5%, sorry, let me rephrase that. Say you're Alexa bro 20 milligram and the receptor occupancy is 75 % to get to 70 % maybe from 20 milligram, go to 17 and then Roger K. McFillin, Psy.D, ABPP (01:02:38.038) So for that, they would have to then find a compounding pharmacy, right? Like that's another part of this issue is that they're like, how do I do that? You know, how do I get to that percentage? Shawn Gill. PharmD (01:02:44.553) correct. Shawn Gill. PharmD (01:02:48.999) Yeah, so we haven't even touched on that topic. So Acetalapram, which is the generic equivalent of Lexapro, I believe it is available in a liquid formulation and manufactured statewide. It's not available in Canada, but I believe it is available in America and the United States. So that's one way you can facilitate and actually, you know, to get patients more insights, that's an SSRI that might be more accessible for them to facilitate a hyperbolic taper. Fluoxetine is also available in liquid formulation as well. So when you look at the custom doses needed to facilitate the hyperbolic tapering, you don't necessarily need a compounding pharmacy if you're on those two agents. But for every other SSRI or every other antipsychotic, compounding pharmacy provides those options where you customize the dose. And I don't have the dosing tables in pharmacy, so we'll just say arbitrarily, say for Lexapro, for example, it's 20 milligram. 17, 14, 11. Roger K. McFillin, Psy.D, ABPP (01:03:48.024) long though, how long would you go down that, say you do that initial dose reduction, you know, around 10%, how long would you then stay on that? Shawn Gill. PharmD (01:03:56.137) So with my patients, like when I build these custom taper plans, I'll typically say each dose reduction phase will be four to eight weeks. Depending on the individual, there's so much in context here as well, Roger. So for example, one kind of rule of thumb is that we'll say that for example, if the patient's been on the medicine for 14 months, we'll say that the taper would generally last potentially up to 14 months. So that's kind of a rule of thumb. However long the patient's been on the medication, you can expect them, it might take up to that point to come off the medicine safely. so. Roger K. McFillin, Psy.D, ABPP (01:04:29.272) Wow. So if someone's on a drug for 10 years. Shawn Gill. PharmD (01:04:33.193) I'm not sure about in that context, like 10 years, I'm sure there's a lot of success stories on like surviving antidepressants .com, which is a great forum for individuals looking for insights. In that case, it might not take 10 years, but it could take three, four or five years of this hyperbolic taper and micro dosing. Because what we typically see Roger is that an higher dose is 20 milligram, you're at 75%. But following the hyperbolic nature of these drugs, the closer you get to zero, the harder it is. Roger K. McFillin, Psy.D, ABPP (01:05:01.836) Yeah. If we see that. Shawn Gill. PharmD (01:05:02.441) It kind of creates this phenomenon in my patients. I've had situations where we're facilitating the hyperbolic taper, we're making great progress, we're at like five milligram, four and a half milligram, and it's almost like patients can taste the finish line. They see, four to zero, that's nothing. I was on 20 milligram before. Can I just jump down? But they don't really understand what's happening at the receptor is that four milligram, you're maybe still occupying 25 % of the receptor or 30 % of the receptor. So if you jump from zero, it's 30 to zero, that's a big jump. So that's why, you know, with compounding pharmacies, they provide that sort of custom solution where doctors can prescribe, you know, micro doses off of it, you know, 4 .5 to 4 .4 to 4 .2 or whatever have you. And then when you can compound the medicine, it just helps facilitate that so that you, at least you can assure that you're getting the correct dose as opposed to, you know, there's a lot of forums online, like I said, surviving antidepressants, there's Facebook groups dedicated to. specific molecules like acetalapram tapering groups and surgery and tapering groups, whatever have you, but people have cut up tablets, crushed tablets, measured them themselves with a weighing scale. So it's, it's very difficult process, but it just shows you that there are options out there and there are a lot of success stories. But what I always tell my patients is that if you're going to come off your antidepressant, you have to one do so with intention and you have to be very patient. And some cases. To be honest, Roger, like I've had some cases where people are able to make the jump, where they're able to kind of even go from five milligram or 10 milligram and just kind of cold turkey it. And they really focus on what they can control in their lives. For example, I had one gentleman who I was kind of having conversations back and forth with deep, with deep prescribing. was on a single SSRI. It was a sertraline 50 milligrams and he was on for about four years, three and a half years dealing with those things, I and stress from work. And I've been having conversations with him every time he pick up his refill for about 12 months, trying to get him to sort of consider de -prescribing. then one day he came in with his wife and he shook my hand and said, Sean, thanks so much for all your help. I'm off the medicine now. And I said, well, how'd you do that? And he just said, and he mentioned about two or three months prior, him and his wife, they bought a new puppy. It was springtime. So they were going out every single day, three or four times a day, walking the dog. He's being more physically active and he was able to cold turkey it. Shawn Gill. PharmD (01:07:28.357) And he said he went through about four or six weeks of hell where he had a lot of significant symptoms, withdrawal, anxiety, flooding back, but he was able to manage and control what was in his power. And he was able to get outside, be physically active, focus on his sleep, focus on having some support from his wife and his family. And he was able to kind of walk the bridge and get off the medicine, but it really depends on the individual and the case by case basis. Roger K. McFillin, Psy.D, ABPP (01:07:52.676) Yeah, those stories exist, but then there's always there's the story where somebody then commits homicide, you know from the same reaction So yeah, I want to be very, you know mindful the fact that some people cold turkey a drug and it has an effect that leads them to kill themselves or somebody else and there are Product viability cases around this. So let's just you know, so just what I want to say to Shawn Gill. PharmD (01:08:00.507) Wow, yeah, I'm sure. Roger K. McFillin, Psy.D, ABPP (01:08:18.454) the audience listening. So people are considering this. We're certainly not suggesting the cold turkey, the drug. We're saying that there is safe ways to attempt to do so and beware of the significant risks that occur. Like I've met people who just weren't able to get their prescription filled and, you know, they were in an acute crisis. So we want to be careful about that. And it depends on the drug too. So from my understanding, there are drugs that are just easier to get off of. And there are. drugs that are very difficult to get off of. The one that I think is most notorious for that is afexor. Could you explain why that would be? Shawn Gill. PharmD (01:09:00.797) Yeah, first off, do apologize, Roger. Yeah, we're not advocating for the cold turkeying or stopping antidepressants abruptly. I just wanted to give that clinical context and a case example. But back to the question on the effects, sir. I believe it has to do with the fact it's half life is shorter, but I haven't been able to find much evidence on why or any sort of commentary on why then the vaccine effects are as as able to cause more issues with de -prescribing and discontinuing. I know paroxetine is also, or Paxil is also one of the major agents that can be more difficult to come off of. And some of the thought process behind Paxil is the fact that it's what we call much more anticholinergic in terms of its neurochemistry and pharmacology. So it induces much more side effects related to sort of the anticholinergic system in the body. So dry mouth, constipation and whatnot. So it's thought that withdrawal from paroxetine is a much more unpleasant. But back to the question of why venlafaxine is more difficult, why peroxidine is much more difficult, I don't think we really have the answers or elucidated the exact mechanisms. I think it just based on the minimal data that we have of tapering patients off antidepressants or SSRIs, those two, venlafaxine, peroxidine tend to be much more difficult. And based on what I've read in some of the literature, it suggested that with peroxidine at least, it's much more anticholinergic in its sort of pharmacological profile. Then the vaccine, I'm not sure. think it might be related to Half Life, but to be honest, I don't have the answer. Roger K. McFillin, Psy.D, ABPP (01:10:34.07) Yeah, I think what I've read and what other experts have said on this show is it does have to do with the half -life. But still, I think the withdrawal effects and the damage from these drugs tends to be underestimated and minimized by many prescribers. And I can't even tell you how many young people were inappropriately prescribed effects or I think everyone's inappropriate prescribed effects or to be honest with you, but then they're tapered off in like two weeks and they go through hell. And then the doctor justifies this as the reason for being on effects or for life. See, this is your mental health returning. And, boy, I still can't believe that somebody's willing to make such a statement today. I mean, talking about the level of incompetence that exists to be able to make such a statement. mean, someone to still make that statement today, you have to be, you have to be working out of a bubble. You have to be completely isolated. and detached from culture and the science of your profession. And unfortunately, you know, in my experience, that is exactly the case. Would you be able to define for us what protracted withdrawal is? mean, it comes up in forums and so forth, the iatrogenically harmed patients across the globe will talk about being placed into protracted withdrawal. So I think a lot of what we're talking about today with hyperbolic tapering is to try to prevent that. Shawn Gill. PharmD (01:12:00.559) So my understanding of protracted withdrawal, that is a withdrawal that occurs typically after or months after or weeks after a dose reduction has been done or when the medication has been stopped. So there is some commentary on sort of the thought process and why protracted withdrawal may occur. There was a systematic review in nature that looked at, really dived into the relationship between SSRIs, their dosing and their serotonin receptor occupancy. And there was a little bit of evidence that suggests that with medications like for example, acetalibram, acetalibram, the serotonin receptor occupancy, it tends to decrease at a slower rate compared to the plasma concentration of the drug. So what that means is that when we look at kind of pharmacokinetics, when an individual is on a medicine like for example, a stick with acetalibram, when you reduce the dose, theoretically more drug is being cleared. from your blood plasma concentration circulating throughout the body. But the paper was kind of suggesting that for some reason, these medicines may accumulate at the actual serotonin receptor site and it's cleared much slower from potentially the central nervous system. Again, we don't really understand why, but that can sometimes explain why even when patients are, and I've seen this phenomenon quite often, Roger, where in the early stages of a hyperbolic taper, we're coming off the medicine, We're going through each phase. There may be a little bit of withdrawal here. And I always like to use the analogy of being a surfer. There's gonna be kind of these waves of anxiety or these waves of depressive symptoms and these waves of withdrawal that are going to occur. They are inevitable. And you just have to kind of ride the wave because the onset happens, they peak, and then eventually they kind of subside. But what I would see in some of my patients is that they would have absolutely no withdrawal for the first three or four phase reductions. everything's going smooth, but then all of a sudden it's like they get hit by a ton of bricks. And diving a little bit deeper, I did come across this paper, I'm happy to share it with you. It's a systematic review in the Journal of Nature. And like I said, it suggests that for some reason, occupancy, the receptor occupancy, the concentration of the drug tends to decrease at a much slower rate compared to what's happening in the plasma concentration. So I think that's one of the reasons why protracted withdrawal may be occurring. Shawn Gill. PharmD (01:14:25.555) Again, we don't really fully understand the mechanisms, but I think that's one area to further investigate. But it can give some patients some insights because oftentimes when I'm going through or helping patients through the taper process, like I mentioned, we have to be surfers, we have to kind of ride the waves of withdrawal. But it can be really discouraging for a lot of patients when they're following the hyperbolic taper, they're tapering at an extremely slow pace, then all of a sudden, maybe it's the fifth phase reduction or the sixth phase reduction. the sudden onset of withdrawal comes and it feels like they can't go any further. And when I try and stipulate with my patients as well, it's never a process, it's never a race to get to zero. You have to really come at this with intention, with patience and understand that there's a lot of underlying mechanisms that are happening inside your brain and inside your body. And we don't fully understand and we can't fully anticipate what's gonna happen, but... If you can understand that it's due to withdrawal, it's not due to the fact that you're broken, you're chemically broken or whatnot. If you can understand kind of what's happening at the pharmacological level, it can bring a little bit of solace and it can also bring some insight that this will rise and this will occur, but it will also dissipate over time. Roger K. McFillin, Psy.D, ABPP (01:15:41.112) set. Just to take a step back review a little bit, you know, here we are. Honestly, with where we are in 2024, the best way to prevent protracted withdrawal, withdrawal symptoms, drug dependency is to not get on the drugs in first place. And that's my answer to a lot of people when they say they want solutions is Shawn Gill. PharmD (01:15:50.021) Thank Shawn Gill. PharmD (01:15:58.043) Agreed. Roger K. McFillin, Psy.D, ABPP (01:16:04.404) That's what I'm trying to do. I'm trying to prevent people going down this road in the first place through education, through science. It's a lot of bad science and industry influence that has put us in this position. So if we can educate the next generation and prevent from happening, then we don't have to be in these positions. For those who are, we have to move away from misinformation. We have to use evolving developing science that exists to be able to safely get you off the drug or drugs that you are. taking and be aware of the risks associated with trying to do this on your own. And we're learning more about hyperbolic tapering, which we talked about today, the Maudsley method, it's out there. You can look at it. Unfortunately, you're probably going to be the one who's going to have to educate your physician in the first place. If your physician's a good person, they're going to welcome that education. If your physician is a narcissist, they're just going to be offended by it and they'll probably take it out on you. And that's the reality. I say this because this is what we see. So many people are are into this profession, they just want to be right all the time. They're the doctors, shut up, listen. You do what I tell you to do, right? And that doesn't fly anymore because, your identification as an authority has been very devalued over at least the past four five years as we start to awaken. So the medical establishment and your authority, we are taking you down from that perch that you've been arbitrarily artificially kind of propped on just by the name of a doctor, right? So if a lot of your training in yourself has put you in a bad position to harm patients and you haven't been able to think critically yet yourself and you're just following guidelines, we need to pull you away from that line of thinking and it's gonna be done by the patients themselves. So you're harmed as a patient, you're not gonna harm a child, you're not gonna harm another family member, you're gonna stand up for your rights and you're gonna be aware of this information and you're gonna educate the doctor. If you have to shame the doctor, we're in support of that because sometimes that's the only way to get... Through to some people because they're going to repeat the same damn narrative to you whether it's a vaccine whether it's another drug They're just gonna repeat it over and again. It's like robotic they've been trained to do so you can slap them up and with some logic and some information and that's some papers and Let them know that there are risks to the decisions that they are making even though they think that they're protected from liability and generally some Respects they are if they're following guidelines Roger K. McFillin, Psy.D, ABPP (01:18:24.588) We have to be able to some way just kind of tap into that ethical side of them, that human side of them. It's going to be up to us folks. Like, I don't know what else to do anymore. I mean, I'm still looking at the data. It seems to be increasing. I don't think enough people are listening to podcasts. I think you're still, you know, the establishment that is funding of this narrative is still what is influencing you. I don't think that's necessarily my audience. So you wouldn't be listening if that's the case, but It is your responsibility, I think, to share an episode like this for people who are on these drugs, right? Like how many of your friends, neighbors, or family members are saying, well, I felt horrible when I was off it, which then they use as a reason to continue being on it. No, it's withdraw. You were inappropriately prescribed. You're harmed. And, Dr. Gill said it earlier in in the podcast, the longer that you're on the drug, the more harm that's going to be done. So I want to give you the last word, Dr. Gill, just anywhere my audience can find you and the work that you're doing, seems like you're going to continue to evolve in your career and learn more. You're dedicating yourself to this and you're also using your own entrepreneurial skills to be able to help change the system. So I feel like I'm getting you very early on in a process that maybe three, four, five, 10 years down the line, it's going to be really advanced and this might be the first of many conversations. Shawn Gill. PharmD (01:19:46.163) I appreciate that, Roger. Yeah, people can find me at drseongill .com. I also write on Substack and I'd appreciate anyone to support me on there. My Substack you can find at seanill .substack .com under the title Buds, B -U -D -S. And I also have a podcast, Deprescribed with Sean. If you just Google me as well, you'll find me there. But I really enjoyed this conversation, Roger. It's been a real pleasure of mine. Thanks for having me. Roger K. McFillin, Psy.D, ABPP (01:20:12.002) Yeah, it's an honor to have you and I want to thank you again, Dr. Sean Gill for a radically genuine conversation.