Latest / The Dr Louise Newson Podcast / 47 - Rethinking mental health and antidepressant prescribing

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47 - Rethinking mental health and antidepressant prescribing · The Dr Louise Newson Podcast

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Mark Horowitz is on my podcast today, and this is actually
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going to blow your mind. You might have to listen to it
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more than once. We talk about antidepressants,
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we talk about benzodiazepines, we talk about gabapentin,
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pregabalin, these highly addictive drugs that are
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prescribed more commonly than HRT and have more risks with
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them. We need to be thinking
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differently about mental health and his perspective on things,
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including his research. It's really interesting and I
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just hope it makes you think of it differently.
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So Mark, this is great that you've come in today.
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I know it's going to be a very interesting podcast.
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It's going to resonate with a lot of people.
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People might be wondering why I'm holding such a big heavy
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book that I slugged across London, but it's the Modesley D
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prescribing guidelines. Antidepressants,
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benzodiazepines, gabapentinoids which is gabapentin and
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pregabalin and Z drugs which are the sort of zopiclone sleeping
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tablets. And you are a co-author of this
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and you've written so many papers.
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Your knowledge is huge and I just wanted to get as much out
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of your lovely brain for the next half an hour.
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So just before we start though, just explain a bit about your
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background if you don't mind. Thanks for having me on.
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And if the book is heavy to carry, imagine how hard it was
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to rise. So thank you.
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So I'm, I'm Mark Horowitz, I'm a training psychiatrist and
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researcher. I'm in a associate professional
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psychiatry at Adelaide University and I'm a visiting
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lecturer in psychopharmacology at King's College London.
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And I run a de prescribing clinic that's specialized in
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helping people to stop antidepressants, pensodizepines,
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all the drugs you mentioned in the NHS in Northeast London.
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And I also work with Outro Health in America that does
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similar things to help people come off antidepressants safely.
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And I've done a lot of work exactly dealing with half of
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psychiatry, I think, which is how to safely stop medications
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because so much of psychiatry is about how to start them.
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And I, you know, sometimes I think it's a little bit like
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having cars without brakes on the on the on the road that I'm
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looking at how. To safely stop these things.
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It's really interesting actually.
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So it's reflecting a lot coming here today because I qualified
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in 1994. Antidepressants, the SSRIs were
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just sort of coming out really. Before that we had
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antidepressants like amitriptyline, dithioprine, but
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they had more side effects. So we were a bit more careful
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and they were quite immediate side effects.
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People had, you know, the dry mouth, sometimes blurred vision.
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So when they came out, I remember because I, when I did
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my training in general practice, there were more drugs than when
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I did my psychiatry training, if that makes sense.
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The adverts were very, oh, it's very easy, it's very safe, it's
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very low and low risk. Just just prescribe them.
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And you know, as a doctor we don't really get trained much
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about lifestyle medicine at all. So when you want someone in
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front of you, 10 minutes, it could be really difficult to
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tease out firstly, whether they are clinically depressed or
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whether they're reacting to a dreadful situation or whether
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there's something else going on. But also like, how do you take
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responsibility? How do you manage them?
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It's, it's, there's a lot, quite a lot of pressure as, as AGP.
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So I do feel bad for lots of reasons.
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But I've, I've prescribed a lot of these drugs.
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I've prescribed a lot of sleeping tablets to a lot of
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women thinking back who really couldn't sleep.
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And I was just on this sort of hamster wheel like a lot of
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people are, because they thought what I was doing was, was right.
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And I think it was at the time, but there's a couple of things
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really. One thing is obviously now I
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know about the world of hormones in the brain.
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And when I think back to the women who I've prescribed to, I
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didn't ask about their periods. I didn't ask if they had any
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change throughout their cycle. I didn't ask about post nasal
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depression, which is often a sort of sign that they might
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have worsening mental health when they hormones change as
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they age. And now obviously I prescribe
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hormones, but I de prescribe a lot of these drugs.
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I'm constantly thinking how can these people come off those
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drugs because there are harms with them, there are long term
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risks and I'm thinking so much more about how to not prescribe
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them in the first place. And the last 6-8 years probably
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I haven't prescribed any of those drugs.
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And I would say my patients that I look after now are healthier
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than patients I've had before. Yeah, I mean, I guess there's a
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lot to dig into there. I mean, number one, I think it
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it does impose on GPS a very big pressure that I think is, you
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know, people have all sorts of problems, physical health
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problems, social psychological problems, and GPS are there with
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eight to 10 minutes to try to solve them.
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I think there's a lot of pressure on them to to deal with
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that. We know that most people's low
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mood is is because of their life circumstances.
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You know, study after study shows the number of stressful
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life events you experience in a year correlates very strongly
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with whether you're depressed or not.
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You know, the, the sort of things that before the kind of
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biomedical era, people would have said causes depression, job
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loss, divorce, death of a loved 1.
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You know, those are the, are the big risk factors.
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We have, you know, hugely medicalized these conditions
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over the last few years where everything is now has capital
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letters. It's major depressive disorder,
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journalized anxiety disorder. But you know, these things are
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responses to our lives. Lots of people get better
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naturally. You know, we know that after
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that the process of natural recovery is very efficient.
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Most people who are depressed six months later will not be
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depressed because things change in people's lives.
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We are, we have this sort of intervene quickly mentality.
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So GPS, you know, with you know, want to do something useful.
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They want to be helpful, that part of their training, they
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want to get there and do something.
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But we know that people that are not prescribed antidepressants
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have the same sort of outcomes as people that are prescribed
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antidepressants. So there's not huge evidence for
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their effectiveness, especially in the long term.
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So a lot of studies on these drugs are done for a few weeks.
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There's very small differences. You need a sort of magnifying
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glass to see it on these, on these studies and there are very
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few studies on long term effects.
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So I think a lot of people are being prescribed these drugs too
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quickly for too long without reference to the long term
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consequences which we can talk about, including how hard it is
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to stop these drugs. Yeah, and some people really do
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feel worse when they take the drugs.
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And I know looking at some of the studies, people were saying,
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well, it's because these people have mental health issues
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anyway. So there's suicidal thoughts or
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whatever that happen are not because of the drug, they're
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because of how they are. But there has been increasing
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evidence that there is a cohort of people whose mental health
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has viral doubt of control on these drugs, which, yes, is a
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concern, isn't it? So I find that very irritating
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when people blame the underlying condition because it's very
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clear. The FDA did a very big meta
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analysis now 15 years ago. They looked at double-blind
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randomized controlled trials. That means that the people in
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both arms of these trials have the same mental health
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conditions. So you can't blame the mental
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health conditions. That's the whole point of doing
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these trials. In the group of people given
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antidepressants, there was more suicidality than the group given
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placebo. That was particularly true for
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young people. And that's why in America
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antidepressants come with a black box warning that under the
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age of 25 these drugs will increase, can increase your risk
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of suicidal thoughts and acts. There are there's been a lot of
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shifting around words by the MHRA and different drug
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companies to make it sound like it's because of the underlying
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condition, but that is just not true.
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The double blinded studies show that it's the antidepressants
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that are causing that increase in suicidality.
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So you're quite right, it's something to be concerned about
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when you talk about older adults between the ages of 25 and 65.
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There is more debate. Some analysis show that
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antidepressants increase suicidality, some show they have
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no effect, but no studies show they decrease suicidality.
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So when people say that these drugs are life saving, it really
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is a marketing line because, you know, that has not been shown in
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any studies. People might say that about the
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drugs that they take. People might say that about, you
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know, anything they do in their lives.
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But looking at the evidence as we have to as doctors, the
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objective evidence doesn't show that these drugs reduce
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suicidality. That's not not what the studies
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show. And that's really important, I
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think, for people to know when they first came out, we could
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prescribe them to children. They're still prescribed to
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children. And they are still prescribed,
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but not so much as from GPS, but we that.
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But because mental health services are so stretched,
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there's more owners than on the GP.
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If you've got someone in front of you that's got mental health
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issues and you know, it's a really long wait for cams or for
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a referral and you see these people, it's really hard.
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I was, I was very fortunate. I had a really good trainer when
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I was AGP. And he kept saying to me,
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Louise, you can't change people's home circumstances, but
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what you can do is change the way they think about them.
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And so we, I spent quite, and he did quite a lot of cognitive
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behavioural therapy actually. And it was quite a lot about
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what you can accept and what you can change.
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And it's the mindset. And you know, it can take a bit
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of time. You can't just do it all in 10
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minutes. But I was very fortunate because
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where I worked as AGPI really got to know my patients and
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their families. So you knew like sometimes it
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was a breakup of a relationship and then next time they'll be
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with someone else and something would happen.
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Or it might be an abusive partner and it's working how you
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remove yourself from the violence or something rather
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than being medicalised for it. Exactly.
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I think, I mean, you know, this is what happens with
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medicalization. You swap problems.
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So you're talking about all sorts of whatever domestic
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abuse, relationship problems, job issues, you know, the way to
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solve those problems. You might need social workers,
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you might need to change, you know, financial services.
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There might need to be things that have changed.
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If you turn it into an issue with chemicals in someone's
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brain, then you're thinking about which drug works and side
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effects and doing research on brain chemistry.
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And I think you're missing the problem.
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You can't. So I think that's what, you
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know, medicalizing has done is it's confused people.
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I remember reading in an article saying there's rates of
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depression that are rising in teenagers because of bullying
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and financial stresses. And what we want to do is do
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more research into the brains of these people to work out why
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it's happening. It's such an absurd response.
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If the issues are bullying and financial pressures, then of
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course the solutions are school dynamics, you know, and
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redistribution, supportive of people that with low incomes,
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not looking at what goes wrong in their brains.
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Because we live in such a sort of technophilic age where
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understanding how brains work is the answer, we've forgotten the
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sort of basic social factors that push these things.
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I think it's hard for GP because sitting there, as your trainer
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said, how can you change people's lives?
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It's very hard, which is why I don't think it's best seen as a
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medical problem because GPS are very good at managing blood
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pressure and diabetes. But when you're talking about
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social problems, they may not be the most appropriate people to
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deal with these things, but medicalizing it has put it in
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their laps, which puts them in a very difficult position, which
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is why it's so easy to prescribe a medication because you can do
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that in 8 minutes. Yeah.
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And The thing is also with psychiatric diagnosis is all
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this DSM criterion. And as doctors, we'd like to
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make a diagnosis because it helps dictate treatment.
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And also it it can be, not always I think, but it can be
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validating for a patient to know they have a condition.
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You know, if you were feeling really tired and lost weight and
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I did your blood sugar level and your glucose level was really
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high and I told you had type 1 diabetes, you'd be quite
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relieved with the diagnosis and the treatment that was
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effective. But some of these criteria are
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firstly very rigid. Secondly, you can talk about
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some of the politics maybe behind them, but then as soon as
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you've got that, then it triggers the medical treatment,
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doesn't it? So I.
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I exactly, I think the, the route into medicalisation of
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these conditions is diagnosis. And you know, as you've alluded
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to diagnosis, when you talk about type 2 diabetes, you talk
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about blood sugar levels, you talk about instrument responses,
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there's biochemical findings, talking about mental health
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conditions, of course, there are no biochemical findings.
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These things are social constructions.
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They were, you know, the the modern age of psychiatry was
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unleashed in 1980 in the North East of America by the DSM three
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committee. So, you know, I think it's
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worth. So in the 1970s, psychiatry was
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under attack by psychologists who said, you know, we're better
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at therapy and we're cheaper. What are you guys doing?
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And their response was, you know, we're doctors, we have
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medical degrees, we understand the way the brain works.
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And DSM 3 was the response to that.
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Before that, DSM One and DSM Two had been very psychoanalytic in
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orientation. They had different chapters on
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reactions, depressive reaction, anxious reaction, even psychotic
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reaction. And the reaction was to people's
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lives, things that go wrong. Some people respond by becoming
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hopeless, some people by becoming very anxious, very
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common responses. DSM three, those categories were
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changed. Depressive reaction became major
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depressive disorder capital letters.
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Anxious reaction became generalized anxiety disorder
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capital letters. Was that because of new
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biochemical findings, neuroimaging, epidemiological
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studies? No, it wasn't.
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It was because they wanted to enforce that these are medical
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conditions like anything else. And so they sat around.
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There's these, there are these interviews done by James Davies
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where he asked the committee members, how did you come to
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these diagnostic criteria? And they said things like, it
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was a bit like a group of friends ordering, going out for,
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for dinner. And in the end we would vote on
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the right criteria. And they said things like 6
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criteria was too many, 4 was too few.
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So we decided on five criteria. And also they said things like
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you can't put that symptom in the diagnostic criteria because
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I do that. It was very much shaped by their
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own notions of what is normal, what is abnormal, based on
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middle-aged white men. Professors of psychiatry in the
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1970s, sort of famously, of course, in previous versions of
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the DSM, homosexuality was a diagnosis that then became out
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of favour as social mores changed.
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So you can sort of see how socially determined these things
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are. And so you're right.
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Now you have this diagnostic set of criteria, a capital letter
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diagnosis, it sounds like diabetes.
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And now you're in the realm of the medical where, of course,
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there are guidelines that say if they have this diagnosis, give
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this medication. And so now you've been shunted,
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you know, all these different life problems have been shunted
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into, you know, a diagnostic lane.
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Maybe the other thing to say along with this is how common
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depression is. You know, people, you know say,
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oh, it happens to one in four or it's this by the age of 4570% of
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us will meet criteria for clinical depression or anxiety.
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70%. So, you know, it's the idea that
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there's something wrong with the brains of 70% of people is
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implausible. You know, it's, it's a sort of
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natural response a lot of us have to overwhelming stress, you
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know, or, or not having our emotional needs met.
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It's the response of a normal person to circumstances.
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That's what a lot of these studies show.
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And of course, if you do medicalize that there's a huge
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market to to give people medications.
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And I think that's what's happened over the last few
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years. What, what was considered, you
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know, normal has now been, is now, you know, jumped on
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diagnosed and you push down a, a, a treatment path.
15:21
And of course, because the antibodies are not so effective,
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a lot of people go through cycles of, of medication.
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They try an antidepressants, they're told that this one's not
15:31
for you. Try another one.
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It can lead people down this route of being given multiple
15:35
medications because the medications especially, you
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know, if you're in a situation of domestic abuse, relationship
15:42
conflict and the issue's not being solved, but you're being
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medicated, you know, if these medications are not going to
15:47
solve those problems, they're not particularly effective.
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And so you end up giving, getting multiple cycles of
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medication. You're then sometimes called
15:56
treatment resistance, which then makes you eligible for further
15:59
treatments that people are given.
16:02
Pregabalin, quetiapine, you know, you people can end up
16:06
getting lithium or allergic evulsive therapy.
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You go down this sort of route. Yeah.
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Of medical treatment, Yeah. To find something until it's
16:12
effective, yeah. And.
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I see this a lot because we do see a lot of people with mental
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health issues. You know, one of the commonest
16:18
symptoms of hormonal change is low mood, brain fog, anxiety,
16:23
irritability, poor sleep, lots. There's a big overlap of course
16:27
with symptoms of depression. So most people, and I was really
16:31
surprised when I started my clinic several years ago, but
16:34
most people I see have been either offered or given
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antidepressants. 68% of people come to the clinic and I thought
16:41
with time things would have improved, but actually they
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haven't. But I'm seeing people that are
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on antipsychotics like you say, like quetiapine, lithium, the
16:53
gabapentin for Gabilin for their moods.
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But also I have been seeing increasingly people that have
16:58
had electroconvulsive therapy and ketamine infusions, which
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really scares me because no one's been thinking about other
17:08
causes. You know, like you say, some of
17:10
them are social causes, but some of them are hormonal changes.
17:13
And then what really sort of concerns me is that if someone's
17:18
on hormones, we have a long discussion about the difference
17:21
between the natural and the synthetic ones, about the risks
17:24
and the perceived risks. I don't know any of my patients
17:28
that anyone sat down and told them any perceived risks or
17:31
problems with any of those drugs, including
17:34
antidepressants. If you've ever felt confused,
17:38
dismissed, or just left to figure out your hormone health
17:41
on your own, that's exactly why I created my free Balance app.
17:46
It's designed to educate women about their hormones at every
17:50
stage of life. You can track your symptoms and
17:53
periods if you have them, read evidence based articles and
17:57
connect with a community of women who are asking similar
18:00
questions that you might be asking.
18:03
I see everyday how powerful knowledge is.
18:06
When you understand what's happening in your body, you can
18:09
make informed choices about your health and your treatment, and
18:13
you can advocate for yourself when you speak to healthcare
18:15
professionals. If you want clear, trustworthy
18:18
information without the noise or the misinformation, then
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download My Balance app today. It's there to educate, support
18:27
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18:32
There's so many things to say. I think #1 even before we talk
18:35
about side effects is how these drugs work, I think it's also
18:37
worth talking about because, you know, people have presented
18:40
these drugs as sort of solutions to their problems.
18:42
And I think they're, they're anything but.
18:43
You know, I, there's the work of.
18:45
Joanna Moncrief is a professor of psychiatry, I think who makes
18:47
these things very clear, which is, you know, there's two ways
18:50
of thinking about psychiatric drugs. 1 is what she calls a
18:53
disease centred model where these drugs where where drugs
18:56
can reverse the underlying cause of a condition.
18:59
So for example, an antibiotic is a good example, a valid example.
19:03
You've got a pneumonia, you're coughing up blood, you feel
19:05
terrible. Antibiotics go in, they kill the
19:08
bug and you're coughing in your fever, go away.
19:10
You know, fantastic solution. People present psychiatric drugs
19:14
as if they're similar. You know, even the word
19:16
antidepressant sounds a bit like antibiotic.
19:18
I'm just going to go in there, get the depression, kill it and
19:20
you'll come out the other side. And, and, and these sort of
19:24
explanations are often based around this idea of a chemical
19:26
imbalance. People's depression is caused by
19:28
a neurotransmitter imbalance in their brain.
19:30
And antidepressants will fix it. They'll increase serotonin is
19:33
the drug is the, is the transmitter most talked about.
19:36
People will feel better. And that sounds like a very neat
19:38
solution. You know, who who wouldn't take
19:41
a a transmitter that you're you're lacking?
19:44
It sounds very plausible and safe.
19:46
But of course, you know, that explanation is not based in in
19:49
good evidence. We don't have evidence that says
19:51
that depressed people have low serotonin in their brains or,
19:54
or, or in anxiety. It was really an idea.
19:58
It was put forward by scientists 60 years ago, amplified by drug
20:01
companies. So it's sort of, you know,
20:03
everybody in the street thinks that but it, but there is not
20:06
evidence for it. So there's another way of
20:08
thinking about how the psychiatric drugs work, which I
20:10
think makes a lot more sense, which she calls the drug centred
20:14
model. Antidepressants, pregabalin,
20:17
gabapentin, antipsychotics are psychoactive chemicals.
20:21
They cross the blood brain barrier.
20:23
They affect the way that you think and feel, and that means
20:26
that they those effects are superimposed or whatever you're
20:29
feeling. An analogy would be to alcohol.
20:32
If you're an anxious person and you don't like parties and you
20:35
drink alcohol, you feel less inhibited, more calm.
20:39
Nobody would say that social anxiety is caused by an alcohol
20:43
deficiency. You know all that.
20:44
Everyone understands that alcohol is being superimposed on
20:47
whatever anxieties you have. And also, when you stop alcohol,
20:51
it'll leave your blood, your anxiety will come back.
20:54
And if you use alcohol in the long term, you'll become
20:56
tolerant to it. It'll have less and less effect
20:58
on your body, or you'll need more and more.
21:00
And also alcohol is going to have toxic effects on your
21:03
liver, on your brain, and it might be very hard to stop.
21:06
You'll get withdrawal effects. If you think about psychiatric
21:09
drugs through that lens, everything makes much more
21:11
sense. You know what do antidepressants
21:13
do, for example? When you ask most people on the
21:15
drugs, they say they feel numb. Yes.
21:18
And what they're. Saying is the range of their
21:20
emotions from very positive to very negative has been
21:22
compressed into the middle. And if you're very panicked or
21:25
anxious, you know, or low in mood, having the volume turned
21:29
out from A10 to A4 can be a relief.
21:32
But it's not the same thing as fixing the underlying problem.
21:34
And you have to expect all the issues that come with
21:37
psychoactive drugs. You're going to get tolerance
21:39
effects over time. It'll wear off.
21:41
There's going to be toxic effects, which we can talk about
21:43
in a second. When you try to stop them, you
21:46
get withdrawal effects because your body gets used to it.
21:48
We try to stop it sort of scraping out for it.
21:50
And we now know that antidepressants and pregabalin
21:53
and gabapentin and quetiapine and all of these drugs can have
21:58
severe withdrawal effects that can last for some people for
22:01
months or even years, you know, not not just a week or two.
22:04
That would be a kind of, you know, small hiccup, but serious
22:06
problems. And then talking about all the
22:08
side effects of the drugs. I'll start with antidepressants,
22:11
then talk about pregabalin and quetiapine.
22:14
Well, there's a lot of overlap. You know, antidepressants cause
22:17
emotional numbing, you know, that's that.
22:20
I think that might be their main effect.
22:21
But that's one of the main reasons people come to my clinic
22:24
in America, Outro Health and, and, and in the NHS, they say, I
22:28
don't know who I am anymore. I don't know what I think about
22:31
my partner or children. I used to like art, music,
22:33
sport. I've lost interest.
22:35
And So what might have been useful in the short term, 5
22:38
years, 10 years later, you know, is causing them significant
22:41
problems in their life. There's sexual trouble.
22:44
We know those things actually correlated emotional numbing and
22:46
sexual numbing. You know, more than half of
22:49
people on antidepressants experience diminishment of their
22:53
libido, desire, ability to ejaculate to to have sexual
22:57
pleasure. We also know that some people
22:59
will have that even after they stop.
23:00
There's a question. This is called post SSRI sexual
23:03
dysfunction. There's a question, does it come
23:05
back? You know, some people it can
23:07
take years, but it's a really a concern.
23:10
Weight gain is a big issue. Not in the short term studies.
23:12
In the long term studies that comes out as a clear signal.
23:15
There is daytime fatigue, trouble sleeping, concentration
23:19
problems and memory issues even in healthy volunteers.
23:22
There are not great long term studies on the physical health
23:25
consequences of the drugs, but there are cohort studies that
23:29
find they will. In all the studies they find
23:31
similar findings. People who take antidepressants
23:34
are more likely to have strokes, falls, have bleeding risks,
23:39
osteoporosis, cataracts, heart disease, and in some studies
23:43
they will die earlier. There's a big debate about the
23:46
degree to which that is based on their depression or the
23:50
medications themselves. In studies where they try as
23:53
much to control for those issues as possible, these signals still
23:56
come out. So there is a concern that we
23:58
know that these drugs, for example, affect platelets and so
24:01
bleeding risks make a lot of sense, as do strokes.
24:03
So there are, you know, these are not just benign drugs when
24:06
you're talking about pregabalin, gabapentin.
24:09
I mean, those drugs have been referred to one professional
24:11
psychiatry as benzodiazepines, steroids.
24:14
I think that's a very good description because they have
24:17
they work on a slightly different pathway, but you can
24:20
block their effects by giving an opioid blocker, which means that
24:23
if something similar to opioids, they're obviously a drug of
24:27
abuse. They have money, they have a
24:29
street value on the on the black market.
24:31
So they are, they are addictive substances.
24:33
They cause dependence. They also cause memory
24:36
concentration issues, they cause tiredness during the day, they
24:39
can cause weight gain. They all 'cause withdrawal
24:42
effects. So many of the issues with
24:44
antidepressants are probably even worse for pregabalin and
24:46
gabapentin and there and there's a sort of catch up that happens
24:51
where you know, benzodiazepines have a fairly bad reputation, I
24:55
think appropriately amongst doctors.
24:57
One because a lot of doctors were sued a generation ago and
25:00
they don't prescribe them very well.
25:01
I think, I think in fact GPS are quite sensible with
25:04
benzodiazepines here. It happened for a few days, not
25:06
a solution to your problems. Then a new drug comes onto the
25:09
market that has the exact same issues.
25:11
In this case it's pre gabulin and gabapentin.
25:14
And it takes independent researchers 20 years to catch
25:17
up, to say, actually, these drugs that are presented as
25:20
having no major issues, are addictive to cause dependence,
25:24
can be hard to stop, aren't that effective.
25:26
By that time, the next. Yeah, drugs are coming out.
25:29
And, of course, we have ketamine coming out now, which is sort of
25:32
even more obviously a street drug.
25:33
I used an analogy to alcohol before, but now I don't need to
25:37
use an analogy because ketamine, you know, is a street drug.
25:39
It's a horse. Tranquilizer as well.
25:41
You know we. Have a There's an issue every
25:43
every few weeks in the BBC, there's a, an article about kids
25:46
using ketamine more and more and at the same time representing it
25:49
as a medical treatment. And of course some people high
25:52
because that's what ketamine does.
25:54
But there are all sorts of consequences.
25:56
It causes your bladder as walls to stick together, your ketamine
25:59
bladder, the effect wears off. Some people become very
26:03
disorientated by the drug they're going to, you know,
26:06
bigger doses cause the K hole, but even smaller doses cause
26:10
disorientation. It increases your risk of car
26:12
accidents, of heart troubles. In the original studies that,
26:16
that they got the drugs approved on, there was more suicides in
26:19
the group given ketamine because some people obviously it's a
26:21
very unpleasant experience. So we are giving out drugs with
26:25
psychoactive properties to a whole lot of people, older
26:29
people, young people and some people may find it pleasurable
26:33
and a lot of people will find it unpleasant.
26:36
It'll wear off. It'll cause a whole lot of
26:37
physical health problems for them and it'll be very hard for
26:40
many of them to stop. So I, I think we are, you know,
26:43
handing people out medications without huge evidence of their
26:47
effectiveness with significant issues down the track for long
26:51
term physical health problems and withdrawal effects without
26:54
being told exactly what they're what they're taking.
26:56
It's really scary and and. People this thing might be
26:59
wondering why we're talking about pregabalin and gabapentin
27:01
and ketamine, but but a lot of women with hormonal issues have
27:04
prescribed these. And I was actually horrified the
27:07
first time I read some menopause guidelines that say, oh, they
27:11
talk about non hormonal treatments.
27:13
And, you know, there are lots of non hormonal things we can do
27:18
that aren't medicalised. You know, I do a lot of yoga.
27:22
That's irrelevant, whether I take hormones or not.
27:24
There's lots of mental health issues, you know, improvements
27:27
that can occur with regular exercise or going outside or
27:30
whatever, eating all sorts of really important things.
27:34
But actually in the guidelines, it says that gabapentin and
27:37
pregabalin can be given for fleshes and sweats.
27:41
Now, firstly, fleshes and sweats are not the most common nor the
27:44
most severe symptom and actually why would you give those highly
27:48
addictive drugs? I, I was shocked, but we see
27:51
people that have been often given them because they've been
27:52
scared away from their natural hormones.
27:55
It's. Just that you don't.
27:57
Replace one thing for another, but nothing that has all these
28:01
awful side effects and risks. I can't speak to the.
28:04
Exact studies in menopause because I'm, I'm more aware of
28:06
the studies in depression and anxiety, but the sort of
28:08
approach the drug companies normally take with these sort of
28:11
things is they do short term studies.
28:13
It goes for four weeks or 8 weeks.
28:16
And sometimes you see a small effect and if you see a small
28:18
benefit, you don't know, there's lots of reasons why you could
28:21
see a benefit. Maybe you're a little bit high,
28:23
you know, maybe you're a bit euphoric because you've been
28:25
given these drugs that can make people a bit high.
28:27
Maybe you're a bit numbed and so you don't feel things as much as
28:30
you used to. Maybe you're unblinded by the
28:32
treatment. You've got side effects that
28:34
makes you think I'm on the treatment.
28:36
We know that expectation effects make people feel better.
28:38
That's a very big effect in antidepressants.
28:40
It's going to be an effect with precable or any other drug.
28:43
And so you get these small effects and then they, they
28:46
Polish the trials and they get their drug approved and enters
28:48
guidelines. But of course people don't take
28:50
drugs for eight weeks. They take drugs for years or
28:52
decades. So you don't know what's going
28:53
to happen down the track. And what we can see with people
28:56
on these drugs long term, it's a very different story.
28:59
The drugs wear off. Sometimes they cause negative
29:01
effects. You know, just using the analogy
29:02
of alcohol, you might think you're quite happy on a, on a
29:06
couple of weeks of alcohol down the track.
29:07
You know, that's not the case. People end up being miserable
29:10
and anxious. I see that a lot people getting
29:12
worse on longer term treatment, mood and pain get worse on
29:16
longer term treatment because, you know, what happens in the
29:19
short term isn't necessarily affected in what happens in the
29:21
long term. And then all these physical
29:22
health consequences build up. And, and also you're also not
29:25
getting to the root cause of what's happening.
29:28
You're putting a sort of sticking plaster on top of it.
29:30
And so, you know, if they're doing studies in menopause,
29:33
there's anything like they do it in, in mental health problems,
29:36
they're gonna be doing all these kind of tricks of the trade to
29:38
make the drugs look effective in the short term whilst ignoring
29:42
long term effects. The side effects, you know,
29:44
often how small the effects are. I, I had a quick look at
29:47
antidepressants and menopause. You know, the effects are very
29:50
minimal. You know, I think they, you
29:51
know, you can sort of, again, you need another magnifying
29:54
glass and yet, but they sort of get over the line of statistical
29:57
significance at 8 weeks and that's the trigger for getting
30:00
approved. And suddenly you have a whole
30:02
lot of drugs being given to a very wide group of people based
30:04
on very scared evidence because more women are prescribed.
30:07
Antidepressants than they are HRT just tell me the stats
30:11
before we finish about antidepressant use in adults in
30:15
England and. Australia and America, about one
30:17
in six adults are on antidepressants, so in England
30:21
this year, 9 million adults will use antidepressants.
30:24
It's more common amongst older people and women.
30:27
So women are prescribed antidepressants 50% more than
30:30
men. As you get older the gradient
30:31
goes up. So it means that middle-aged
30:34
women between I think that's, I think it's defined as 40 and 60.
30:37
About one in three in England are on an antidepressant.
30:40
So it's very high levels, one in three I think.
30:42
In areas of deprivation. I think in North England it's
30:44
even higher and it's increasing every year.
30:47
So every year there's a few percent going up, in part
30:50
because people are on these drugs longer and longer,
30:53
probably in part because it's very hard to stop them because
30:55
of withdrawal effects. So people end up getting, I
30:57
think that's another issue. It's very easy to start these
30:59
drugs, much harder to stop them because you get to get dependent
31:02
on them. Yeah.
31:03
And so there is escalating use all, all throughout the world.
31:07
So we need to wake up. We need to think about it.
31:09
We need to think differently before we start.
31:12
And when I say we, I mean us as doctors, but also we, I mean us
31:16
as potential patients as well, or, or friends or relatives as
31:20
well. I think it's really important
31:21
that we look at mental health with a different lens actually,
31:24
and look at some of these medications and wonder what
31:27
we're doing. But also, you know, we just need
31:31
to be thinking about other ways of managing any mental health
31:36
issue. I think, you know, we're not
31:39
talking in this podcast that everyone needs to come off their
31:41
antidepressant overnight. And actually, please don't,
31:43
because, you know, I should say that it's important.
31:45
You know if you do. Decide that.
31:46
Medications are not not for you. It's worth talking to your
31:49
doctor. And coming off your drugs
31:51
quickly is the worst possible thing to do.
31:52
Yeah. Terrible withdrawal effects.
31:54
Yeah. Do it carefully.
31:55
Yeah. And that's why, you know.
31:57
Deep prescribing guidance, that's why we're joking about.
31:59
It's very important that people do it in conjunction with people
32:01
who are experienced, you know, of deep prescribing because the
32:04
response is can be very different and it can take a long
32:06
time, but it's worth persevering.
32:08
I've had some very good responses, but sometimes it can
32:10
take years and years. So it's great.
32:14
This conversation is just the start of many really for people
32:17
to be thinking differently and, and making choices really.
32:21
So before I finish my, I always ask for three take home tips.
32:25
So three things that people will be listening to this and
32:28
thinking, gosh, maybe I don't need that antidepressant.
32:32
What are the three things that they could be doing?
32:36
You mean instead of? Taking antidepressants, yeah.
32:38
Or just in general if they think.
32:39
Or maybe I need to stop because I think there's two things
32:42
really. There's the D prescribing side,
32:44
but there's also like what to do instead as well because the two
32:47
should work in parallel. So I'll say I'll say a few
32:49
things. I'll try to keep it to.
32:50
Three, I think #1 you know, even before you get to alternatives,
32:54
you know, is the drug helping? I think, I think, one, a lot of
32:56
people drug, the drugs are not helping.
32:58
And for some people, they're making it worse.
33:00
And so in that case, you don't even need a replacement.
33:02
Just stopping something that's not helping you or making things
33:04
worse is a good step. So I think it's worth, you know,
33:06
really sitting down. I've seen people who think
33:09
through, am I better than I was before I started all these
33:11
treatments? A lot of people conclude,
33:13
actually, I think that I'm doing worse after all these
33:15
treatments. I think that's the first thing
33:16
to think about. Two, you know, I think a lot of
33:19
people mistake the trouble they have coming off antidepressants
33:23
with the fact that they need antidepressants.
33:25
So people stop. They feel terrible, anxious, low
33:28
in mood, panic. They think I must need this
33:30
drug. The GP reinforces that idea.
33:33
So I think people should be aware these drugs cause
33:35
significant withdrawal effects. They can feel like someone's
33:38
condition coming back. They're often not.
33:40
We know withdrawal effects are very common.
33:43
They're not to fall into that trap of mistaking withdrawal for
33:46
you. The fact that you need the
33:47
drugs. I think it answers your
33:49
question. There are lots of other things
33:50
people can do that that can help mood.
33:53
I mean, I think #1 you know, I can.
33:55
I'll rattle off all the things that the NICE guidelines say.
33:57
But before you get to that, most important thing is, you know,
34:00
what has caused you to be in that position?
34:02
Because, you know, to say that you need a drug, there's a
34:05
chemical balance. It's a bit of A1 size fits all.
34:08
You know, some people are in, you know, bad relationships.
34:10
Some people are in difficult jobs.
34:11
Some people have physical health problems and to sort of say it's
34:15
all the same thing, we'll give all the same treatments doesn't
34:18
make sense. I think the first thing is to
34:19
work out, you know, why is there a physical health problem?
34:22
Is there is it a relationship problem?
34:24
Doesn't mean it's easy to solve. I don't, I'm not going to be a
34:27
glib and say, well, then you can just, you know, wave it over the
34:29
wand. But if you don't understand
34:31
what's causing, it's very hard to work out how to fix things.
34:34
Then to get to things like the NICE guidelines, there's a whole
34:36
lot of non medication things that are just as effective as
34:40
antidepressants in the short term.
34:41
Some of them are more effective in the long term and they're all
34:44
safer. And it includes, you know,
34:46
exercise, mindfulness, various forms of therapy.
34:49
And I always like to point out is NICE says the most cost
34:53
effective treatment for severe depression is problem solving
34:56
therapy, which means writing down your three most significant
35:00
problems, the first step to take for each one and report back on
35:04
progress made or barriers encountered in two weeks.
35:07
I think that really brings home those people's problems that are
35:10
causing their mood. And I think we've lost sight of
35:12
that. So I would put that sort of in
35:14
people's minds to sort of demedicalize their their
35:17
conditions. That's so important and such
35:19
great. Advice.
35:19
So thank you so much for coming today.
35:21
Thanks. Thanks Louise, I've got
35:24
something. Really exciting to.
35:25
Share with you every Thursday I'm going to be releasing an
35:28
extra episode for those of you that sign up.
35:32
It's an opportunity that I can have more guests, share more
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