Have the quick fixes provided by psych meds caused us to overlook the real, underlying causes in our mental health struggles? Psychiatrist Dr. Josef Witt-Doerring joins host Leslie to explore the current treatment model that puts profit before patient well-being and encourages the overprescription of drugs in mental healthcare.
Have the quick fixes provided by psych meds caused us to overlook the real, underlying causes in our mental health struggles? Psychiatrist Dr. Josef Witt-Doerring joins host Leslie to explore the current treatment model that puts profit before patient well-being and encourages the overprescription of drugs in mental healthcare.
Dr. Josef shares how the psychiatric care system resembles more a conveyor belt of treatment - quick evaluations and prescription solutions - rather than a holistic approach to understanding and addressing the root causes of mental distress. A passionate advocate for deprescribing, he also shares heart-wrenching stories and expert insights on the urgent need for a tailored approach to mental healthcare. He peels back the curtain to expose the pharmaceutical industry's influence on the industry and questions the wisdom of a system that frequently overprescribes antidepressants.
Dr. Josef also shares the risks of long-term medication use, such as emotional blunting and post-SSRI sexual dysfunction (PSSD), and the daunting journey of medication tapering. The conversation wraps up with an honest reflection on the journey of understanding depression in the context of our environment and the challenges faced by those navigating the daunting process of antidepressant withdrawal.
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Show Credits:
Leslie: Welcome to The Nature of Nurture with Dr. Leslie Carr, a podcast for your mental health. I'm your host, Leslie. If you're watching this podcast right now, you can find the audio version in any podcast app. And if you're listening, you can also watch this episode on YouTube at The Nature of Nurture. You can find that link in the show notes.
Today, I'm here with Dr. Josef Witt-Doerring. Dr. Witt-Doerring is a psychiatrist who specializes in helping people to get off of psychiatric medication, and he has a wealth of information when it comes to the harm that psychiatric medication can sometimes cause. Like me, it is not his intention to get everyone to quit taking their meds, but we both believe that people need to be able to give their informed consent to treatment, and this is not always what's happening in the United States.
There's a growing body of people, for example, who feel strongly that they've had an adverse reaction to antidepressants. And that the side effects have had a measurable negative impact on their lives. I think it's time for those stories to be told. More than anything, we live in a culture of overprescription in the United States.
And that's what this conversation is about. Dr. Josef Witt-Doerring has previously worked for the FDA, as well as a few pharmaceutical companies. His current medical practice, which he runs with his wife, mainly focuses on safely deprescribing patients from all over the U. S. This interview took place via Zoom, so in a moment you'll see me in my home office, but it is my great pleasure to introduce you to Dr. Josef Witt-Doerring.
Hello, Josef.
Josef: Leslie, it's great to be back again.
Leslie: Thank you so much. Yeah, we might as well tell people. I thought we already had this conversation and the video got corrupted, so I am extremely grateful that you are willing to redo this with me.
Josef: Hey, another chance to catch up and talk.
I'm welcoming the opportunity.
Leslie: Me too. Thank you very much. So, just to set the stage for everybody and perhaps, um, take things, take things back a little bit in your timeline. How did you get into this whole crazy business of deprescribing?
Josef: Oh, wow. Okay. Yeah. Um, so, I mean, I think it, It happened, it happened gradually.
So I think the real realization hit when I joined psychiatry residency. So, I mean, I had been going through medical school, interested in psychiatry because I was interested in, um, really psychotherapy, philosophy, just different Understanding why people were unhappy. And I said, this is great. You know, I'm going to go in psychiatry and help people figure these problems out.
And then when I got there, I realized that's really not the way the system was set up. And it actually took me years to realize, um, what I was really seeing, you know, because. I think intuitively we understand that when someone is sad or upset, most of the time it's because of a reason, you know, maybe there's a very concrete reason in their life, maybe they have a lot of maladaptive traits.
Some of them are just things they've grown up with. Maybe some of them are in response to trauma and they're, uh, they're affecting their life. Um, and so you would think intuitively, you know, if you went to a doctor or a healthcare system, you know, that's meant to design to be a To help people with these problems, you might come in.
They'd spend a lot of time with you. They'd really try and get to know what was kind of behind what was going on in your life and put together a nice sustainable plan for you to thrive. Uh, anyway, that's what I was hoping I would see. Uh, but that was not what I saw at all. In fact, I saw something that was.
More like a conveyor belt of care, extremely transactional, you know, people going in for, you know, 30 minute initial evals, 15 minute med checks, uh, simply just getting prescribed medications for things like, mostly things like anxiety and depression, um, and. For a while, I didn't realize what I was seeing.
I'm like, what, like, is this, maybe this is just the way it's meant to be. And a lot of people tried to say, this is just, you know, mental illness. It's this biological thing. But the more I spent time around it, I realized it's, it's, it's kind of bullshit. Really? Uh, most of the anxiety and depression is completely, completely based on life stresses or prior trauma.
And we had just started, um, medicating people. And then I just kind of dug and dug further to figure out, you know, Why this is happening. And then I realized it's just a massive systemic issue kind of all over the world that that's just the way we're practicing mental health. And, uh, obviously a lot of people end up on these meds that don't help them long term, but then they're stuck.
And so I wanted to help them. And so that that's kind of like the, you know, what I think called 36, 000 foot overview of the whole situation.
Leslie: No, it's fantastic. Thank you so much for that. I mean, there's so much in there. I want to go back to but the real sort of loud alarm. It's kind of going off in my head right now.
It's just this idea that I do think the general public is often really misled by and it has to do with systemic issues in our profession. But just this idea that there's kind of run of the mill human suffering and then there's this other thing called mental illness. And, you know, what does mental illness mean, exactly?
Okay, well, you know, it's one thing to feel sad, but if you are depressed enough to meet however many, at least five of the criteria in the book, then you technically have this other thing, you know, called depression. And that depression is a mental illness that should ideally, many people believe, be treated with a pill.
And it gets at this, like, I just think, fundamental misunderstanding of the way that we look at human suffering and the way that our entire industry is set up right now. So, you know, I have a bunch of follow up questions based on what you just said, but I just can't help but want to start there.
Josef: Yeah.
Yeah. I mean, it's like, um, I feel like it's in the name, you know, five out of nine symptoms in the DSM. You have a major depressive disorder. Um, and most people hear the word disorder and they think, Oh, you know, there's something wrong with my brain. You know, there's something wrong with me. I'm disordered in some way.
Um, And then they get put in a special category where, you know, they should be treated with medications, at least in the US. It's a first line treatment for major depressive disorder. Um, it cuts short the whole thing. I mean, a lot of people, they, they get the title and then they stop digging or they think, okay, well, this is a medication problem.
You know, we've got the clinical trials to back up using them. They, they stopped digging. They don't. Really want to understand like, you know, why is this person having five out of nine symptoms? Like maybe we want to treat the root cause maybe we want to find out why they keep on Going in abusive relationships or they're kind of chronically unhappy in their careers Or you know how their neuroticism is impacting their, you know, their happiness and their relationships none of that is really looked at and Yeah, a lot of people just end up thinking they have a disorder
Leslie: What's coming to me is sort of the difference between brain and mind in the sense that I think one of the things that's really tricky about mental health care and the idea that we, you know, our physical health is tied to organs in the body and the brain is an organ in the body.
Therefore. you know, sort of ipso facto, everything that we're talking about, you can sort of see how a lot of misunderstanding occurs. But our minds are, they're more complex than that. They're more complex than just an organ in the body. And I know I'm more making a statement than I am asking a question.
But I just I wonder if you think about it that way, or what that provokes for you?
Josef: Huh. Yeah. I mean, it's wow. I mean, this is such such a deep question. I'm trying to think what does it provoke for me provokes kind of just confusion. Usually, uh, you know, when I think about it clinically, um, because I mean, there's. Two ways to get at something like depression. I feel like there's what do they say the top down approach and the bottom up approach.
I mean, the top down approach is you work on the mind because the mind is derived from the brain and you kind of challenge ideas. You help people change their traits. So it's like one way of getting at an issue. But the other way, um, more and more. So now is the bottom up approach, which is, you know, you, you give medications, you change brain physiology so that it, um, So that it just blunts or modifies, uh, the kind of the mind.
Um, I think the, um, I mean, the bottom up approach has so many problems pharmacologically long term, you know, because, uh, it's just less, it doesn't work long term. I mean, a lot of people, not everyone, but a lot of people end up developing tolerance to the medication. So they simply stop working or, you know, it's just, Sometimes it's not really, you know, very clean to, to get the changes you're looking for in the mind by changing the brain.
I mean, you might overshoot and make someone too blunt or, or sometimes you may, you know, when you're trying to energize someone, you might overshoot and make them manic. It's just, it's so much harder. I think it's a lot more precarious kind of tinkering with the brain to change and help people. People than it is to really change the way people think, you know, hit them at the level of the mind.
Um, that's more sustainable to me and it doesn't mess up all the neurochemistry underlying it.
Leslie: Yeah, so, you know, I'm, I'm kind of thinking about what you were saying about this conveyor belt thing that you. That you witnessed when you were first, you know, in your residency and in the early days of your career.
And I wonder if you want to tell people a little bit more about just like what you witnessed, what your thoughts are about that. What do we make about this whole conveyor belt that so many people unfortunately end up on?
Josef: Yeah, let me tell you how it made me feel to start because I'm just reflecting on this now.
It made me feel stupid. Um, because I was in a system and I was just like, this really doesn't feel intuitive to me. Like, why are we treating people in this way? And then I'm just like, we're just giving them these medications and diagnosing them based on that. on these checklists, all these professors and people I looked up to were doing and I said, they must know something that I don't.
Um, and so that was, that was the first reaction was just like, well, let me suspend my disbelief and go out and learn because obviously I don't know something. Um, but over time, you know, I kind of stuck with it and I was just like, actually what's going on is there's a lot of really perverse incentives here that have kind of captured the way medicine is practiced and drew, you know, We have, you know, systems that are more set up to the people that profit them than the people who who we want to help.
And that's a longer conversation about pharmaceutical industry, hospital chains and private equity. All of that is really the kind of the invisible hand, which has Led to what I think is an absolute dumpster fire in mental health these days and and how depression and anxiety is treated
Leslie: Yeah, and I think it's super important and I would love to explore that more if you want You know, I I won't bore anybody with the numbers, but I will just state for the purposes of the conversation that the two largest lobbying groups in the United States are the pharmaceutical industry at the top and then the insurance lobby, which is Number three.
And so, you know, do you want to give people a little bit of a, you know, 101 or even 501 level primer on your view of how all of this stuff, how do the moneyed interests impact the way people think about mental health?
Josef: Oh, yeah. Yeah. So let me, I'll give you a kind of a brief overview of what I think are the two major, the two major areas.
Let's start with the pharmaceutical industry, the people that make the psychiatric medications.
Surprise, surprise, you know, there's a commercial incentive in selling these, in selling these medications. You know, they have a duty to their shareholders to, Profit. And so I think a lot of people actually, I mean, some people may be cynical, but there's a lot of people out there who really believe that the pharmaceutical industry has this great public health mandate.
And they're trying to, you know, cure people. And don't get me wrong. That's what they do as well. And they help people. where things go off the tracks is instead of just stopping at helping the people who really need the medications, uh, the desire to increase shareholder profit drives them into a place where they try and make as many people as possible.
Take them. And you know, how, how does this happen? Um, well, it happens through the selective publication of research. Um, once a drug is on the market and there's a Drug label that the FDA has reviewed that just kind of sits there, you know that it goes out with the drugs many doctors might not see it and they just Kind of assume that that's the safety information.
Lots of doctors aren't looking at the labels. They may have learned about some of the risks, um, just from their colleagues over time. And, uh, the rest of what they usually learn about these medications comes through journals. Um, and it also comes through conferences. A lot of the articles and the conferences and the speakers, they're all, a significant amount of them, are facilitated by the pharmaceutical industry.
And they have an agenda to make doctors see the products in the best possible light. And so usually what doctors are hearing about is the benefits of the drug or some new population that they could use it in. If there's a risk of the drug, you know, maybe it's real and it could have a significant impact helping people.
If we. told doctors about it, they don't need to share that. Um, they, they would essentially just say, Oh, well, you know, it's in the drug label. Uh, you know, the FDA has it that we're not going to promote it. We're not going to put it in front of people. So the, you know, the desire to make doctors see the products in the best possible light ends up skewing the perspective that physicians have on these products.
You know, they overestimate the benefits, underestimate the risks, and that's one problem. And so that's, you know, that's That's how I think the pharmaceutical industry has streamlined, you know, mental health care into becoming like a conveyor belt just by making doctors overestimate the benefits and not understand the risks coming over to the other side.
Now, it's, um, You know, it could be the insurance industry, or it could be the private equity groups that own the clinics so that the way health care in the U. S. and I think a lot of places is reimbursed is really fee for service. So, uh, doctors aren't paid on an outcome basis. They're not paid for keeping people out of hospitals.
Psychiatric hospitals are not paid on metrics for depression. You know, people doing well over a certain period of time. They're just paid on how much they see them. Um, and there's some strange incentives here where you actually make more money if you, if you do fewer, briefer visits than if you do longer ones substantially, maybe 30 to 40 percent less, um, you'd, you'd make more just doing four 15 minute visits in an hour than say, um, you know, a 15 minute visit than a 45 minute visit that might be, As a doctor, you would make 40 40 percent less doing that.
Um, and so what that means is that the doctors are in a place where they get to choose whether they're going to meet there. It's called RV use in a lot of places. You know, there's these, um, certain incentives where the, you know, the, the more of these short visits that you do, the more of these units you accumulate, the more it impacts your salary and your bonus.
So the doctors will end up choosing 1. You know, do I want to see more people and make more money or see less people kind of be an outlier in my practice people, you know, management's unhappy with me and I make less. Um, so that's the, that's the other thing, you know, there's always this push to see more and more people, um, and.
Because of that, because you want to see someone in 15 minutes, it's not conducive at all to genuinely understanding the person and what's going on in their life. Um, and that's, it's just so bad for mental health because unlike other areas in medicine, like maybe you could pee in a cup and find a UTI and you really could handle that in 15 minutes.
Like, when we're talking about mental health, like the reasons why someone is depressed, it's I mean, you could take like 10 hours before you really like figure someone out, um, and figure out, you know, why it's like falling apart. And so, I mean, there's absolutely no way that's going to happen in a system that's incentivizing these 15 minute visits.
It's just, it's just, and this is not just family medicine. This is just in seeing psychiatrists as well. That's, that's the overview of, of, of how we got to where we are.
Leslie: Yeah. It's so interesting and, and distressing and upsetting, um, something that I feel aware of as I, cause there are a couple of dots that are getting connected for me and, you know, obviously you specialize in, specialize in help, in helping people to get off of.
all kinds of psychiatric medications. But I'm most interested in talking to you about antidepressants, but mostly because they're the ones that are the most commonly prescribed. And I'm thinking about this issue of doctors, what you're saying about doctors sort of focusing on, you know, the potential upsides and then minimizing the risks, the side effects.
And I'm thinking about, you know, something that I know you and I are both really frustrated by, which is just, General practitioners and primary care physicians writing a lot of scripts for antidepressants, I can only imagine that this is a factor for them, right? I mean, as far as I'm concerned, they're operating beyond their scope of practice, but I can only imagine, given what you're saying, that they are oversold on the benefits and undersold on the risks and the side effects.
Josef: Mm hmm. Totally. Um, I think this is like another one of these, you know, I know there's a story behind here. I, I'm not, I don't know it so well, but I think the reason why they're prescribed and family medicine doctors is was actually pretty deliberate. Um, I think it was done by marketing departments, hmm.
The antidepressant manufacturers where they realized that if they wanted to increase market share, they couldn't just have these drugs being used by a psychiatrist. And so they, I think there was this huge agenda, uh, to go out and speak to family medicine doctors and give them the PHQ 9s, which is that nine question questionnaire.
Like, does your patient have depression? You know, depression is, you know, and then you would say things like depression is undertreated, you know, it's a, it's an emergency and all of this. And it's not, I mean, that saying those things aren't aren't evil. But when you kind of plug it into a system where someone has 15 minutes and they've been, you know, You know, given all of these, uh, sample packs for the antidepressants, you know, it's, it's only going to go one way if they come in with a high score on that scale.
So I think a lot of these things were totally manufactured. Uh, you know, let's make the doctors feel like they're really safe, make them feel like antidepressants, you know, depression is underdiagnosed and undertreated. And oh, by the way, we've got this thing that works great. Um, even if it's super hard to come off of and, you know, the studies were only eight weeks long, you know, we'll, you know, give you these things and people will end up on them for decades, even though that's not really studied and, you know, who knows how many people that really helps longterm.
Leslie: Yeah. I think one thing that I just want to admit, um, is that I, I think something that I have really regretted in my career is I, I have never thought that antidepressant medication Was all that helpful in the sense that I don't think I don't think it's the right treatment for most people. I think those medications are vastly over prescribed, but I used to be under the false impression, perhaps that they were not particularly harmful.
And one of the things that I've become aware of more recently is the harm that sometimes comes from antidepressants. It's one of the things that I really wanted to talk to you about. So I wonder if you can, I'm sure there are going to be a lot of people listening to this, watching this that really have had no idea that antidepressants can cause so much harm.
Will you tell people a little bit about that?
Josef: Yeah, this is like a multi layered onion. I'm going to start somewhere that I think is going to be relatable for everyone and then we'll kind of roll into protracted withdrawal and PSSD later on, but the some ways they harm people is actually through the way that they're effective.
Um, and so I wouldn't even call it a side effect. Um, So these medications, when they do, you know, if we want to say work, you know, the therapeutic effect is typically one of emotional constriction. And so if you're someone who's a very anxious person, it's going to reign that in. If that anxiety was getting to a level where you were so overloaded with anxious thoughts that you collapse into depression, because you were so fatigued from the adrenaline surges you were having, you were going to feel better.
Because of it, that is going to be an improvement in your mood, um, much like a cast that you put on someone's arm after it's broken, uh, taking these, you know, you wouldn't leave that cast on forever because you would end up having atrophied muscles and things wouldn't work. Similarly, um, I think antidepressants could probably be viewed in that way where maybe some therapeutic blunting is helpful for a period of time.
But, uh, Only when it's in a comprehensive plan where we're looking at why did you get depressed in the first place? How are we going to help you out of this? So pretty quickly, you know, and I'm talking quickly, like, you know, three to six months, like you're off. You know, you've made changes in your life and you come off.
So what are the problems if you If you stay on something that constricts your mood long term, well, it could be numerous. Um, you've essentially dampened your ability to, to be attuned to stresses in your environment. Um, one way that that comes out is relational. Um, you may be less aware of things that are happening in your intimate relationship.
Um, you may be less aware of things happening around you. Um, maybe some of the reasons that you are anxious Or that you were anxious were pretty genuine, maybe there's some abusive people around you or there's some really bad situations in your life. If you just like turn that alarm off because you're on a medication long term, you've just lost a huge opportunity to really identify that it's a problem and actually fix it once and for all.
So you could spend decades kind of on a, medication, blunting you, putting up with situations that really ought to be addressed and feeling like you're okay.
Leslie: Kind of numbed out.
Josef: Yeah. Yeah. Kind of, kind of numbed out. Uh, and that, that's a risk that can happen to anyone. And so the biggest problem that I see is that people take them as if, oh, I'm disordered.
You know, this is like a major depressive disorder. They, they, they see it more as like insulin for diabetes, which is wrong. When they should see it more as, you know, it's a drug that's going to. Produce some emotional numbing and and because if you looked at it that way, I think you would better understand the potential impact of emotional numbing, you know, on your life.
Um, so that that's a risk that could happen to to anyone.
Leslie: Yeah, thank you for that. I'm also thinking about the restriction that comes from just even happier feelings to, you know, the whole range is constricted. Then you're also restricted from feeling, you know, elation.
Josef: Yep, that that's what a lot of people report.
Um, I have so many people that come to me and they just go, I just want to know who I am underneath this. Like, who am I anymore? Uh, I'm just so used to like not feeling like myself. Um, and unfortunately, a lot of people, they they lose confidence by being on the medications long term. They lose the ability to believe that they can cope with life and stresses and hardship with without a drug.
And so when I help. People come off the medications were usually, you know, rebuilding that confidence that they can, uh, you know, weather life storms.
Leslie: Yeah, one of the phrases that you used with me once in a previous conversation that really resonated is also the notion of opportunity cost, which is to say that if you go on an antidepressant, because you think that that's the answer, let's say you've been led to believe you have a chemical imbalance.
Yeah. You're also not doing the work that is required to actually get to the root cause of your suffering or to figure that out. And that part feels really true to me as well.
Josef: Oh, yeah. Yeah, because it's I know we wish it was a magic bullet or there was a quick fix, but I think intuitively for for everyone, we know, you know, there's there's no shortcut to.
to fixing kind of, you know, interpersonal problems, problems in your life, career dissatisfaction, you know, there's, there's no shortcut to fixing the things that are upsetting you. And if someone sells you something that makes you think that, Oh, you don't need to do any of that. It's usually a lie because the fastest and the easiest way to fix it is actually to get at the root cause with a professional.
And or even yourself if you're up to it, just to meditate on it and really figure out what's going on. And if you address the root cause, that's the quickest way to do it. Not by blunting the way you feel about your problems.
Leslie: We will get to things like protracted withdrawal and PSSD in a moment, but there's a question that I want to ask you right now.
I'm just sort of thinking about the people that might be listening to this. They're thinking like, no, but I think I, I do have a chemical imbalance because at one point in my life I felt depressed and you know there wasn't, there wasn't a reason why. I couldn't have thought of any other reason why. What might you say, and I'm going to give you my answer too, but what might you say to someone who's having that reaction listening to this?
Josef: Um, I would say it's, it's not something that you would land on quickly, uh, but if that was you, and you really can't find any contextual stresses in your life, and you've looked at diet, and you've looked at all of the other, all of the other variables that can really tank someone's mood, you know, there's medical problems.
If that was you, then, You, you may be the unicorn. Yeah. I mean, you may be this, this kind of mythical person that they keep on talking about who just has depression for no reason. And I mean, there's been reports of people like that, but it's far less common, you know, the most common person who I see falling into depression, depression or severe anxiety is.
It's like a neurotic person. It's someone who genetically at baseline is more sensitive. They're more sensitive to emotions. They're more anxious. That can be a strength for a lot of people. I'm not, you know, I don't want to say that's, that there's, there's this bad, you know, all bad things about that. But they tend to, Whether the hits from life a little bit harder, things get a bit more overwhelming for them.
Maybe they struggle a little bit more with confrontation. They end up kind of in difficult situations. And that's, so that's one person who I see develops a lot of depression. Um, just this, and they kind of, and, Sure. Okay. Maybe that neurotic personality we're going to say, or that more sensitive thing, that's biological.
A big part of that is, but if you can help that person, you know, address the stresses in their life, they're not going to be depressed, you know, they may be more sensitive to things, but if you still help them with their life stresses, they're much less likely to go on and get depressed. The other person, and I think this is probably the most common person who suffers from depression is, uh, they're just living in poverty.
You know, they're living in poverty and abusive situations and it's really environmental. And if you look at more societal things and how you could help them, like not, you know, You know, be a single parent with like four children working a minimum wage job, like that's a really hard problem to fix as well.
So there's kind of two, two people.
Leslie: Yeah, I will add one thing that I just think I've seen a lot of in my own career is that. One of the reasons why psychotherapy can be so helpful for people is because the brain is built to hide things from us. You know, I think there are a lot of people who go on antidepressants, never having gone to therapy, never having seen a therapist, and so they don't know that part of what's happening is that You know, there's a metaphor that's sometimes used that trying to explore your own mind without the help of another person is like sort of trying to see your shadow and it's right behind you, you know, that it's we do sometimes need the help of another person to point out the thing that is sometimes even glaring once you look at it through a slightly different lens, you know, and once you've you.
Isolate a problem then you can then go about fixing it but you know I think I know you and I were having a conversation once and it might have been when you were interviewing me on your podcast but it's just that idea of like denial ain't just a river in Egypt you know what I mean like it's it's it is part of how our minds work that it hides things from us.
Josef: Yeah, and I, I mean, it's so true and I think about it in my own life and I, as a psychodynamic psychotherapist, Leslie, I'm sure this is your bread and butter on, on how much our families kind of fuck us up because that's probably the main way that we are not aware of things. I mean, we grow up in families with certain value structures, with certain emotional ways of connecting with one another, which may be actually quite maladaptive.
Things that feel very normal to you are very maladaptive in the way that you move through the world, and you will never see that if that was your programming from a very young age, um, and you could spend your whole life figuring, figuring that out.
Leslie: Not only do I think that you are spot on, I will take it one step further and just point out to people that I think one of the reasons why.
Just this business of being human is so hard is because even under the best of circumstances, things are not perfect, you know, it's really hard to be a parent. There is no such thing as being the perfect parent. There's no such thing as being the perfect parent for the unique child that, you know, you have to raise.
And then you got to think about how many of them are there, you know, it's like there's children are competing for resources, you know, that sometimes are thin and their parents because life is hard. And I say that just to deep pathologize this as much as humanly possible. Absolutely. Yes. There are some people that struggle profoundly with feeling depressed or feeling anxious.
Because they have adapted to really dysfunctional environments and they don't even know how dysfunctional the environment was. But I think people can sometimes feel like something is a little off and they don't know why. And that's just because being a person is hard.
Josef: Sometimes, I mean, we're so different, different, uh, emotionally, sometimes it's hard for me to believe we're the same species, you know.
You know, I kinda, and I'm just talking about me and my wife, you know, some of the ways we look at things, uh, it's just, it's incredible.
Leslie: Exactly, and that just sort of really circles me back to this whole idea of the difference between, you know, normal mental suffering and this thing we call mental illness.
I think if people could look at the world the way I look at the world, they would see that. It's just it's all just different. Amplitudes of the same thing, you know, that we all are walking through the world with different mindsets, different belief systems, some beliefs support us, some beliefs are really dysfunctional and are not doing us any good, you know, and it's, it's amazing, just incredible things can happen when people go in and do the work and try to shift those things as opposed to just feeling like, Oh, this is how I am or, you know, I just have a chemical imbalance.
You know, it's just not the most useful way to think in my opinion.
Josef: Yeah. And I think interpersonally, I mean, the world is so connected these days and there's all these big groups. And I mean, the more awareness that you have of yourself and of how different people are, you know, just the more versatile you are at dealing with, you know, people.
All of the complexity of the different people around you because most people living in highly urban settings now are going to have to do that. You know, you have to kind of be aware that everyone is kind of different. And I mean, if you, if you struggle to do that, then I mean, no doubt things are harder for you.
Leslie: And I would say even outside of whether it's, you know, urban, rural or anything in between, partially because of the nature of the Internet, we're having to do that all the time. You know, we are being confronted with other people's points of view all day long.
Josef: It's just like a screaming match, stop being so sensitive, you know, stop being so rude.
You know, it's like, it's just two different sides.
Leslie: Oh, it's insane. Um, so to sort of get us back to this whole, a lot of the problems with antidepressants, because I think some of the follow up questions that I have are really important. So you mentioned protracted withdrawal and PSSD, we can go one by one here.
What are some of the things that you see in your practice with protracted withdrawal?
Josef: Yeah, so protracted withdrawal, let me just define it first so people know what, know what I'm talking about. So there's normal, there's a normal withdrawal syndrome when you come off antidepressants, and that might last, I don't know, a month, maybe two, where people stop the medication and they feel crummy for a while and then it goes away.
It's quite distressing, but it goes away. That's...a continuation of that is not what protracted withdrawal is. People hear the word withdrawal in there and they think, Oh, it's just a normal withdrawal syndrome. You know, they start thinking, Oh, if you just got back on the medication, it would go away.
Protracted withdrawal is a brain injury. It's essentially brain damage. We're talking about neuronal damage that happens to a small group of people when they, uh, enter a state of severe antidepressant withdrawal. So if all of a sudden you were taking Effexor and you stopped it and you went into severe withdrawal, It's quite likely that 99, well, let's say 95 percent of people, they feel miserable, but they're completely recovered two months later.
Five percent of those people, uh, they don't recover. They, um, for reasons we don't understand, um, that state of, uh, Acute withdrawal has been toxic to their brain, and they develop a whole range of neurological problems, numbness, tingling, gastrointestinal problems, autonomic problems, their heart races crazy, you know, they, uh, you know, even when they're just sitting down, they sweat, you know, their ears ring, they have light sensitivity, they have severe anxiety and depression, and this um, And this brain injury essentially can, can take years to improve.
Most people improve in about 18 months or so, but there's a lot of people who are still having serious problems 5, 6, 7, 8, 9 years later, um, And so part of the reasons why protracted withdrawal is so, so scary is that no one knows who's going to get it when they come off the medication and, and there's some, you know, there's a lot I could talk about.
I mean, I could talk about how to prevent it. I can talk about it's acknowledgement in the medical community. I'll go wherever you want me to go. Yeah.
Leslie: Well, some of the immediate follow up questions that are coming up for me are, first of all, when somebody sort of enters into a syndrome like this, does it help at all to go back on the medication or to re up the dose?
Or is that at all a method for undoing the harm that's been done by coming off of it?
Josef: So once, once the damage has been done, you know, uh, you know, after they've entered the severe withdrawal state and that's hurt them, uh, so to speak, uh, going back on the medication won't help because it's not a withdrawal problem.
It's a neuronal injury problem at that time. In fact, a lot of people, when they go back on the drug, they have side effects to it and it makes them even worse. The only point of intervention is really to make sure that the person never has. severe withdrawal in the first place. And so that's, that's the main thing that you do, you know, if you have to stop this medication, you do it slowly over several months, sometimes several years in a way where people don't go into severe withdrawal states.
And that, and that's how you prevent it. But once it's happened to you, your, I mean, your life may be on hold for years while you recover from it.
Leslie: My goodness. So I just want to really make one thing super clear for anyone who's watching or listening to this. So, it sounds like a big part of what you're talking about is the importance of tapering off a medication slowly.
You know, we always say, I always say, if you ever, if you're on an antidepressant medication and you want to stop it, don't. So I take it that tapering slowly and maybe even very slowly is probably one of the best ways to potentially avoid having this kind of extreme withdrawal reaction.
Josef: That's it. Spot on.
The number one way to avoid this is to taper at a pace that is safe for your body. Um, and so that might be six months for some people. It might be two years for someone else. You just. Taper, you know, usually 5 to 10 percent a month. You slow it down if you have symptoms and then you have to be especially cautious right at the end on the lowest milligrams of the dose, you know, you don't want to drop those suddenly because for because the way these drugs interact with the receptors in our brain, it's not linear and what happens is that the lower doses is when you drop them, there's It changes the receptor binding a lot more than when you cut at the higher doses.
So when you get really low, you have to taper even slower usually. So don't be surprised if you have severe symptoms when you're right at the end of the taper. It just means you have to go slower and not rush it. That's also the time where people usually develop protracted withdrawal because right at the end, they're the most likely to have severe withdrawal.
So that's the point of it that you want to treat very cautiously.
Leslie: What an incredible PSA. I mean, this just feels so important. I think, especially for anyone who might be watching this episode and second guessing the medication they've been taking all this time, you know, it's, I want to make sure that we're giving people really responsible information.
So thank you for that. It's so important.
Josef: It's, it's a crazy thing and I want to say this. I mean, it may sound alarmist because a lot of people listening to this have been like, Hey, my doctor just like cut me off in three months or he just stopped one and started me on another or my mom just stopped.
That's true. You know, there are a lot of people that go through this. In fact, the vast, vast majority who go through this without problems, but there's no way of predicting who is going to be sensitive to it. So the only way to make sure that you're safe is actually, it's to taper slowly without severe withdrawal, and that's why you kind of have to do these tedious slow tapers.
I mean, that's my strong belief.
Leslie: Yeah, that's so helpful. So, um, I personally would like to move along and talk about PSSD, but is there anything you want to add to that before we shift gears a tiny bit?
Josef: No, just that the tide is changing. I mean, the, the doctors that you're with, they, they will begin to hear about it.
I think in 2019, it was finally acknowledged by the Royal College of Psychiatrists in the UK. They updated their guidelines. They've given out slow tapering plans to their physicians. And so there's finally there's more mainstream acknowledgement of this problem. And so, yeah. A lot of your doctors may not have heard about it, but that's going to change soon.
Leslie: That's really good to hear. Really, really good to hear. Um, so, you know, one of the things that initially inspired me reaching out to you for this interview is I know there's a growing body of people, uh, that I am, uh, connected to on, on Twitter primarily. Uh, and I'll see you next week. who identifies having post SSRI sexual dysfunction, which I know is a very small subset of people who take antidepressant medication.
But nonetheless, part of what we're here to talk about is the fact that these medications are so overprescribed that we're now talking about a small number of a large group of people, a small percentage of a large number of people. Will you explain to everybody what PSSD is and what. What people are struggling with in that area.
Josef: Sure. Yeah. So, PSSD, post SSRI sexual dysfunction. It is a uncommon adverse reaction that someone has to antidepressants. Um, can be several of them, but most of them appear to be the serotonergic ones. So, a lot of the tricyclics, the SSRIs, things like Prozac and Lexapro, SNRIs like Cymbalta and venlafaxine, some metazapine as well.
Um. And what's happening in, in these individuals is it's varied how it presents, but the most common story is this, they'll take an antidepressant medication, they'll have some sexual dysfunction, which is fairly normal, or maybe even just a very small amount. When they stop the medication, either the sexual dysfunction persists, Or for reasons that we're not aware of, it actually gets worse.
Um, and this can go on for years, uh and sometimes decades for some people. Um, and I mean, I don't uh, really need to say but it's obviously a huge problem for, for people, um, and
you know, so sexual dysfunction. Maybe it's good to kind of flesh that out. What, what do I mean when I say sexual dysfunction? Well, a lot of people, um, we'll talk about men first. They'll have a hard time sustaining an erection. Um, and, and that can be one of the major symptoms for men and women. They can have very, um, muted orgasms.
The quality of the orgasm changes, um,
Leslie: Difficulty orgasming at all. I think in many instances.
Josef: Yep. Yeah. Complete difficulty. And the one thing that makes it quite, Okay. unique and hard to kind of misdiagnose as something else, like, I don't know, you could say performance anxiety, or maybe some vascular problems leading to mainly erectile problems, is that they can develop genital anesthesia.
And so this is a sensory change. in the genital region. Some people report that they lose all, um, of that sexual type of feeling. And all sensation.
Leslie: I've heard, I've, I've heard the phrase like numbing of the genitals a lot. And it's interesting because it happens to women just as much as men. So it's not like, it's just an erectile dysfunction issue.
It's like, Men and women and everybody in between is experiencing like numbing of the genitals, which sounds pretty profound to me.
Josef: A lot of people will say, uh, you know, my, my privates, they, they feel like I'm touching the back of my, my arm. They, they've lost all erogenous sensation down there. Um, and Along with this, you know, it's not always just isolated to the genital region.
In fact, many of the people who develop this, you know, upon withdrawal have a range of cognitive problems as well. They'll report brain fog, difficulty concentrating, severe fatigue as well. Um, and And for a lot of people that can be really debilitating. I know a lot of them talk about intense dissociation, you know, they, they no longer feel connected to their life.
It's like they're watching their whole life play out through a screen. Um, and they feel very Blunted and disconnected from everyone and it's usually the cognitive problems that they're having along with the sexual dysfunction, which are the most disabling and the ones that lead to the suicidal behavior and things, which are unfortunately very common in this population.
Leslie: Thank you so much for all of that. You know, it's, it's all so distressing. And I just think about, I know that there are a lot of people who follow me on Twitter and interact with me on Twitter that are victims of this. I won't, I won't use the word survivor because I think they feel very much so victimized by it and they continue to feel victimized by it.
And the sense that I get more than anything from connecting with this community is that there's a feeling of almost desperation for people in the medical community, people like me and you to, to take this issue seriously, to give a voice to it and to help to amplify the fact that this is a real experience that a lot of people are having.
It's a, it's a, it's horrific.
Josef: It is. I mean, it's, I, and, and I know your audience may not be familiar with my social media, but I'll talk about it. A big thing of what I do on my YouTube channel is I interview people with adverse drug reactions. So I've heard, I've heard probably 20 stories from people who had PSSD, and you say it's horrific because it is a horror show, and I'll tell you an anecdote from Rosie, who's someone that I spoke to, she took the medication, um, never warned about PSSD, she's a young lady who had anxiety, no informed consent at all, just normal, she saw, I don't know if her family was taking it, or her friends were, or maybe it just It was normalized because it's so frequently talked about on TV and on social media, but she, she took it without ever being informed about this for anxiety that was really not that bad.
Uh, she had almost an immediate and severe adverse reaction to it. She came off and had the cog, you know, intense dissociation and sexual dysfunction moving forward. She talked to her doctors about it. And she was not believed. In fact, they thought she had become psychotic. She was sectioned in a psychiatric hospital.
And essentially, um, Railroaded onto taking anti psychotic medication. Oh, Jesus Christ. Um, her family didn't believe her at first. None of the doctors believed her. Her life actually became a real horror show.
Leslie: Yeah,
Josef: And the story doesn't end there because well, I mean Rosie eventually gets out of the psychiatric hospital because she tells them that she's going to take the medication and she escapes her family comes around and they eventually support her.
But there was another guy I spoke to in India. Who was involuntarily hospitalized, um, and force medicated for over three months because they did not, because he was so distressed by the PSSD, they thought he was delusional, um, his family didn't believe him. It completely ruptured the family. They were like, just go and see the experts, see the psychiatrist, they know what to do.
They didn't. They had hurt him. They couldn't recognize it. So it is, it is horrific. I mean, it, your life literally turns into a horror movie. No doctors believe you. Sometimes your family doesn't believe you and everyone tries to gaslight you. It is, it is the biggest story in psychiatry, the biggest untold story in psychiatry at the moment.
It's, it's, it's that terrible.
Leslie: Yeah. This strikes me as what you're giving is particularly extreme examples of something that Sadly, I think is relatively routine in psychiatry, which is just to say that someone can start taking a psychiatric medication. They get a side effect from that medication. Then they're given another medication to treat that side effect.
You know, someone is given an antidepressant that probably shouldn't be. It induces mania. Then all of a sudden, someone thinks they're bipolar. And then all of a sudden, they're put on a mood stabilizer. And the examples that you're giving are. Horrible. But I think that just in case anyone is listening to this in a state of disbelief where they just think, you know, this can't be real.
There are versions of this that happen all the time. It's actually not that uncommon.
Josef: And I mean, we haven't even touched on the antidepressants and the suicidal behavior. I mean, that's a whole nother can of can of worms. I mean, some of the stories that have happened when people have taken these medications and had acute.
episodes of mania and disinhibition and the things that they've done to themselves or others or their children. I mean, it's just, um, I mean, it's, it's, it's so sad and, and, and horrific how quickly things can change.
Leslie: My, my understanding is that if you look at the data, please tell me if you know anything about this, that in the United States, where we obviously have a really big problem with school shootings, that if you look at the data for kids that, um, you know, carry out these school shootings, a majority of them have been prescribed an antidepressant medication.
Josef: Have you ever heard that? I have heard it. And, um, what I will say is unless you know the specifics, it's kind of hard to know how much they played a role. You know, what we do, what we do know about the medications is that they can cause states of disconnection and disinhibition, which for sure they could facilitate someone doing this.
And in fact, I talked to David Healy. He's another. prominent psychiatrist who looks at adverse reactions, um, on my channel. And we talked about, um, the Aurora school shooting with James Holmes. And there's actually a whole movie about this now about, and now that's one case where the antidepressant really does appear to have been, you know, involved.
Yeah. Cause he doubled, you know, he went up on his dose of Zoloft and then shortly thereafter, you know, carried out Shooting, I think, you know, tens of people died and I think 50 people were injured there. Um, and he walks into the courtroom with dyed orange hair, wide eyed, you know, pupils dilated. I mean, he looks like he's in a, some kind of amphetamine like intoxication, you know, this is someone who's never had a history of bipolar disorder and the behavioral change happened shortly after going up on the dose.
Leslie: Right.
Josef: Uh, that looks like that was. Uh, antidepressant induced and I'm sure if you drilled into the stories of these other mass shooters, some of them, you may find a similar story where states of disinhibition were recently preceded by starting them on a medication or some kind of dose change or abrupt withdrawal.
Leslie: I know that what we're talking about is. really dark stuff. So I wonder if we can end on a little bit of a brighter note here. Um, we're talking about some stuff that is there. These are obviously rare reactions to a lot of medications that people take routinely all the time. Can you tell us anything that might make some people feel better about this conversation they're listening to right now?
Where is there a silver lining in any of this?
Josef: Sure. So there's a few silver linings. The first silver lining that I'm the happiest about is that PSSD is finally being acknowledged, um, even though it's been kind of in the medical literature since the early 2000s. The EMA has finally updated their labeling.
This is the second largest drug regulator in the world. And then now. you know, it's mandated in the labels for the SSRI medication class, those antidepressants that that that warning is acknowledged, meaning that all of the clinicians in the EU area now, um, have it in the labels. They're aware of it and they're going to start giving informed consent to people.
So, um, I think this is going to tilt it in a way where Really the antidepressants are only going to be used by people who are knowledgeable about this and where they really believe that the risks outweigh, that the benefits outweigh the risks. So that's a great sign. Um, Health Canada. has updated their labels.
We're hoping for something similar in the, in the US. I think Hong Kong have updated the labels. So we're finally getting a wave of drug regulators waking up to that. Um, when it comes to, um, protracted withdrawal, um, yeah, protracted withdrawal acknowledged, um, by the Royal College of Psychiatrists, huge landmark and also for the protracted withdrawal with the benzodiazepines, um, which is the other big issue, uh, that's acknowledged in the drug labels.
So, so more and more of the major health authorities are waking up to these problems and educating the physicians about them. Back to the topic of protracted withdrawal, uh, the prognosis is positive, even though it's awful and, you know, it sounds like you could have it for years. Uh, the people that I support through this, The vast majority of them return to full health or near full health.
They go on with their lives. Um, and they live. Yeah, happy and fulfilling lives after they recover. Just they just need the support. So a lot of there's a lot to be hopeful for out there with, you know, you know, these, these, these terrible things they haven't. Happened in vain, you know, they really are causing changes out there that are going to lead to safer patient care.
Leslie: I think that it's such a good point and I'm so glad that you're saying it and it's amazing to think that when it comes to stuff like this, what we really need is a paradigm shift and a sea change and it is. Wonderful to hear that that might be on the horizon.
Josef: Yeah, I'm hoping I'm hoping for more but you were heading in the right direction.
Leslie: Yeah, at least we're heading in the right direction. Right. Well, thank you so much for having this conversation with me. Is there anything that we haven't talked about that you want to add or anything you want people to know?
Josef: If you're tapering medications, do it slowly. Um, if you're interested in learning how to do that, um, we create a lot of free resources over on my YouTube channel. It's, uh, Dr. Josef, and that's Josef, spelled J O S E F, the German way. And it's just filled with free resources on how to do safe tapers. Um, so if you're thinking about it, check us out over there.
And, um, and you could use it to work with your doctor anywhere in the world. And I firmly believe that if. If you're listening to this and you want to come off medications, uh, anyone can do it regardless of the age, so long as you have the right plan and the right support, and I think there's an awful lot to be hopeful about if that's something you've been thinking about and you want to do.
Leslie: Thank you so much. I also just want to give your social media a plug because I know that you're, you're at Taper Clinic in most places and people can find you at taperclinic.com, but. your social media, the material that you put out is both educational and surprisingly entertaining. You've managed to make some pretty dark stuff interesting to pay attention to and sometimes even fun to watch.
So thanks for doing what you do.
Josef: Thank you. Thanks.
Leslie: You've been watching or listening to The Nature of Nurture with me. Dr. Leslie Carr, and I want to thank you for joining us. Dr. Josef is at Taper Clinic across all social media platforms, and you can learn more at taperclinic.com. Find me personally on Instagram.
I'm @drlesliecarr. Many thanks to Dr. Witt-Doerring for having this conversation with me, and to all the people who worked behind the scenes to make it happen. Full credits can be found in the show notes. If you found this conversation valuable, please let me know by leaving a review or rating, or by sharing the episode with at least one person who you think might enjoy it too.
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