Antidepressant Drug Side Effects

by Jay S. Cohen, M.D
www.MedicationSense.com

In A New York Times Expose, A Doctor Describes Her Own Reaction To An Antidepressant Drug. But She Doesn't Explain Why Antidepressant Side Effects Occur and How to Prevent Them. -- This Article Does.

In the Times' Sunday health section, psychiatrist Nanette Gartrell reveals her personal experience -- and lack of awareness -- about antidepressant side effects ("A Doctor's Toxic Shock").1 Grieving over a friend dying of liver cancer, Dr. Gartrell began taking buproprion, better known as Wellbutrin, but her reaction could just as easily have occurred with Prozac, Paxil, Zoloft, Celexa, Lexapro, Luvox, Effexor, Sarafem or other antidepressants, or Zyban, the smoking-cessation drug that's identical to Wellbutrin.

"Within 10 days, I developed insomnia, agitation and tremors," Dr. Gartrell writes. "I lost the ability to distinguish between sadness and the drug's side effects.... panic attacks started... I needed every ounce of energy to concentrate at work.... I forced myself to eat but still lost 10 pounds. Sometimes I felt paranoid, and I wondered if I was delusional. When I wasn't working, I was curled in a fetal position, contemplating whether I should hospitalize myself."

Antidepressants help millions of people, but antidepressant side effects can be wicked. Even worse, many doctors cannot identify even common antidepressant side effects and frequently give patients the wrong advice. Dr. Gartrell did what she told patients to do: stick it out until the drug's benefits kick in. That's the mainstream medical party line, but many side effects are so unpleasant or vicious, such advice is downright dumb.

Worse, in a few patients, panic, agitation, sleep deprivation, and impaired judgment may reduce impulse control, and antidepressants have been linked to people acting out, sometimes violently. Thus, the headlines about homicides and suicides by people who never were violent before starting on antidepressants. Yet, although there's considerable literature on this problem 2-16, few doctors know about it because their information sources are heavily influenced by the drug industry, whose research somehow keeps missing the problem.

The Devil Is in the Dosage

Dr. Gartrell's side effects began shortly after starting buproprion. This is a common story. Why? I explained this in a previous newsletter:

"These reactions are occurring because the standard starting doses of many antidepressants are excessively strong for many people. One clue is that most of these reactions occur shortly after people have been started on antidepressants or after the dosage has been bumped up. These are called `first-dose' reactions by mainstream medicine, and they almost always indicate a mismatch between the patient and the dosage."17

My book, Over Dose: The Case Against The Drug Companies, which received a glowing review by JAMA (Journal of the American Medical Association), explains that most side effects are dose-related and that the standard starting doses of many top-selling drugs are too strong for millions of patients.18 No doubt, Dr. Gartrell started with the standard dose of buproprion. It was too strong for her. Many standard drug doses, based on studies in which most subjects are male, are too strong for many women.

Studies prove this. The standard starting dose of Prozac is 20 mg/day, yet even before Prozac was marketed, a large study showed that 54% of patients did fine with just 5 mg.19 But drug companies like to keep their dosage guidelines simple because that's what doctors prefer. So Prozac was marketed at a one-size-fits-all initial dose of 20 mg/day -- 400% more medication than many patients needed -- and the package insert made no mention of the safer, proven-effective 5-mg dose.

Many experts besides me recognized the problem. A 1993 study concluded "that starting fluoxetine [Prozac] at doses lower than 20 mg is a useful strategy because of the substantial fraction of patients who cannot tolerate a 20-mg dose but appear to benefit from lower doses 20." An even earlier report warned: "Clinically, we have observed fluoxetine to be effective over a wide range with many patients requiring very low dosages... 21."

With buproprion, the standard initial dose is 150 or 200 mg/day, which is often quickly increased to 300 mg/day. But 50 mg twice-daily is often enough, and doctors report that some patients tolerate only 50 mg/day.22-24 Similar problems plague other antidepressants, yet few doctors challenge drug company guidelines and instead follow them without question. This explains why doctors prescribe the same strong drug doses to young and old, big and small, healthy and frail. Or prescribe the same doses to people taking no other medications and people taking a dozen. Such methods defy medical science and common sense, but if that's what the drug company guidelines say, that's what most doctors do. And if drug companies claim that side effects are infrequent and mild, doctors believe this rather than believing their own patients.

This is unfortunate, because so many side effects can be prevented by simply starting lower. If a lower dose isn't effective, it can be easily increased. I call this "precision prescribing," and my new nonprofit organization, the Center for the Prevention of Medication Side Effects, is dedicated to promoting this better, safer, patient-friendly paradigm and to providing information about lower, proven-effective drug doses to doctors and patients.

An Indictment Of Mainstream Medical Education

Dr. Gartrell says that she is now much more sensitive to patients' complaints about side effects, and she is quicker to adjust their medications to halt their reactions. But why did it take so long for her to learn this lesson? Why wasn't she trained to do this from the start?

Dr. Gartrell's new attitude speaks well of her. But her previous approach, which her colleagues and most doctors share, speaks poorly of medical education, which provides no time for in-depth training in pharmacology and, in most cases, not a single lecture on identifying and handling side effects.25 So it's not surprising that when patients complain of legitimate side effects, their doctors respond with ineffective interventions or downright denial. That’s why the New York Times deserves credit for publishing Dr. Gartrell's confessional, because it not only confirms that patients' complaints about side effects are legitimate, but it also reveals why their doctors refuse to believe them or take appropriate action. No wonder so many patients are dissatisfied, quit treatment, and seek alternatives.

Yet, sometimes medications are necessary. What can you do? You must become your own researcher, using books and the Internet, learning enough to choose selectively from the information you see. Access my data on lower, safer medication doses via my published articles and books, and the MedicationSense.com website. Take your information, like Dr. Gartrell's and this article, to your doctors. Spread the word and help us change the system.

References
1. Gartrell, N. A Doctor's Toxic Shock. New York Times, Jan. 5, 2003:nytimes.com.
2. FDA statement regarding the antidepressant Paxil for pediatric population. U.S. Food and Drug Administration, June 19, 2003:www.fda.gov -- accessed 9/18/O3.
3. Harris, G. Debate Resumes on the Safety of Depression's Wonder Drugs. New York Times, Aug. 7, 2003:nytimes.com.
4. Waechter, F. Paroxetine must not be given to patients under 18. BMJ, June 14, 2003;326:1282.
5. Medawar, C, Herxheimer, A, Bell, A, et al. Paroxetine, Panorama, and user reporting of ADRs: consumer intelligence matters in clinical practice and post-marketing drug surveillance. International Journal of Risk & Safety in Medicine 2002;15:161-169.
6. Donovan, S, Clayton, A, Beeharry, M, et al. Deliberate self-harm and antidepressant drugs. Investigation of a possible link. British Journal of Psychiatry, 2000;177:551-6.
6A. Rogers, L, Waterhouse, R. Prozac Makers Told to Warn of Side-Effects. The Sunday Times [Britain], July 8, 2001:www.sunday-times.co.uk/news.
7. Glenmullen, J. Prozac Backlash: Overcoming the Dangers of Prozac, Zoloft, Paxil, and Other Antidepressants with Safe, Effective Alternatives. Simon and Schuster, March 2000.
8. Healy, D. The Antidepressant Era. Harvard University Press, Sept. 1997.
9. Hickling, L. Questions Persist concerning Prozac's Role in Suicide Risk. Www.drkoop.com Health News, May 11, 2000: www.drkoop.com/dyncon/article.asp?at=N&id=11009.
10. Teicher, MH, Glod, C, Cole, JO. Emergence of intense suicidal preoccupation during fluoxetine treatment. American Journal of Psychiatry, 1990;147(2):207.
11. Fichter, CG, Jobe, TH, Braun, BG. Does fluoxetine have a therapeutic window? Lancet 1991;338.
12. Anderson GM; Segman RH; King RA. Serotonin and suicidality: the impact of fluoxetine administration. II: Acute neurobiological effects. Israel Journal of Psychiatry and Related Sciences, 1995, 32(1):44-50.
13. Lancon, C, Bernard, D, Bougerol, T. [Fluoxetine, akathisia and suicide]. Encephale, 1997 May-Jun, 23(3):218-23. Abstract.
14. Liu, CY, Yang, YY, et al. Fluoxetine-related suicidality and muscle aches in a patient with poststroke depression [letter]. Journal of Clinical Psychopharmacology, 1996 Dec, 16(6):466-7.
15. Jackson, A. Drug Turned Loving Man into a Killer, Says Judge. Sidney Morning Herald, Fri., May 25, 2001:www.smh.com.au/
16. Donovan, S, Clayton, A, et al. Deliberate self-harm and antidepressant drugs. Investigation of a possible link. British Journal of Psychiatry, 2000;177:551-6.
17. Cohen, JS. Suicides and Homicides in Patients Taking Paxil, Prozac, and Zoloft: Why They Keep Happening -- And Why They Will Continue. Underlying Causes That Continue to Be Ignored by Mainstream Medicine and the Media. The MedicationSense E-Newsletter Oct.-Dec. 2003:www.MedicationSense.com.
18. Cohen, JS. Over Dose: The Case Against The Drug Companies. Prescription Drugs, Side Effects, and Your Health. Tarcher/Putnam, New York: October 2001.
19. Wernicke, JF, Dunlop, SR, Dornseif, BE, et al. Low-dose fluoxetine therapy for depression. Psychopharmacology Bulletin 1988;24(1):183-188.
20. Louie, AK, Lewis, TB, Lannon, MD. Use of low-dose fluoxetine in major depression and panic disorder. Journal of Clinical Psychiatry 1993;54(1):435-438.
21. Schatzberg AF, Dessain E, et al. Recent studies on selective serotonergic antidepressants: trazodone, fluoxetine, and fluvoxamine. Journal of Clinical Psychopharmacology 1987;7(6):44S-49S.
22. Elliott, RL, Shillcutt, SD. Using Newer Antidepressants In The Medically Ill: An Update. Primary Psychiatry 1996;3:42-56.
23. Kirksey, DF, HartoTruax, N. Private practice evaluation of the safety and efficacy of bupropion in depressed outpatients. Journal of Clinical Psychiatry 1983;44(5 Pt 2):1437.
24. Stern, WC, Harto-Truax, N, Bauer, N. Efficacy of bupropion in tricyclics-resistant or intolerant patients. Journal of Clinical Psychiatry 1983;45(5, Section 2):148-152.
25. Very Few Students in American Medical Schools Receive Training about Adverse Drug Events. U.S. Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Sept. 4,
2001:www.ahcpr.gov/news/press/pr2001/studntpr.htm, last checked 4/9/02.

Copyright 2003, Jay S. Cohen, M.D. All rights reserved.

Readers have my permission to copy and disseminate all or part of these articles if it is clearly identified as the work of: Jay S. Cohen, M.D., The Free Underground MedicationSense E-Newsletter, www.MedicationSense.com. The purpose of this E-Letter is solely informational and educational. The information herein should not be considered to be a substitute for the direct medical advice of your doctor, nor is it meant to encourage the diagnosis or treatment of any illness, disease, or other medical problem by laypersons. If you are under a physician's care for any condition, he or she can advise you whether the information in this E-Letter is suitable for you. Readers should not make any changes in drugs, doses, or any other aspects of their medical treatment unless specifically directed to do so by their own doctors.