Drug Side Effects
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
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.
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."
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.
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.
Devil Is in the Dosage
Gartrell's side effects began shortly after starting buproprion.
This is a common story. Why? I explained this in a previous newsletter:
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
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.
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
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."
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.
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.
Indictment Of Mainstream Medical Education
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?
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. Thatís 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.
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.
1. Gartrell, N. A Doctor's Toxic Shock. New York Times, Jan. 5,
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.
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,
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,
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,
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.
18. Cohen, JS. Over Dose: The Case Against The Drug Companies. Prescription
Drugs, Side Effects, and Your Health. Tarcher/Putnam, New York:
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
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
Jay S. Cohen, M.D.
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