Dr. Mark Horowitz is an academic psychiatrist and an Honorary Clinical Researcher at UCL. In this Next Level Human Podcast episode, Dr. Jade and Dr. Mark discuss depression medications, their effect on the body, and the best way to come off these medications. Dr. Mark explains that these clinical drugs directly influence the brain, and it can take months or even years for the body to learn not to rely on them.
In addition, Dr. Mark explains the differences between addiction and physical dependence and how antidepressant drugs affect not only serotonin - a specific chemical in the body known as the “happy hormone” - but several other neurotransmitters.
Having been diagnosed with depression at a very young age, Dr. Mark has dedicated his career to studying this topic, knowing more about withdrawal symptoms, and helping patients with the same condition.
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Next Level Human
Episode 211- How to Manage Depression Medications
Host: Dr. Jade Teta
Guest: Dr. Mark Horowitz
Podcast Intro: [00:14] welcome to the Next Level Human Podcast. As a human, you have a job to do. In fact, you have four jobs; to earn and manage money, to attain and maintain health and fitness, to build and sustain personal relationships, to find meaning and make a difference. None of these jobs are taught in school and that is what this podcast is designed to do. To educate us all on living our most fulfilled lives through the mastery of these four jobs. I'm your host, Dr. Jade Teta and I believe we are here living this life for three reasons and three reasons only; to learn, to teach and to love. In this podcast, I will be learning, teaching, and loving right along with you. I'm grateful to have your company; here is to our next level.
Okay, everybody, welcome to today's podcast. I have a very exciting podcast at least this one was a really exciting one. For me. This is Dr. Mark Horowitz. Now, Dr. Horowitz is a neuroscientist and a clinical research fellow in psychiatry at the National Health Service in England. And he is a world leading researcher in psychiatric medication D prescribing. What that means is he takes people off their mood medications, and you're going to learn in this podcast, why that is so important. And some of the downsides of mood medications and how difficult they are to come off. This is one of the reasons I really wanted to talk with Dr. Mark Horowitz in this podcast because this is something that is so prevalent in our society, many of our kids even had been prescribed these drugs and then cannot get off of them. And you're going to learn exactly how to do that. In this podcast, as well as some issues around prescribing mood medications for depression, in particular, in the first place. Now, Mark co wrote the Royal College of Psychiatrists guidelines on antidepressant discontinuation. And it's based on the principle of gradual hyperbolic tapering. And what this essentially means is there is a very specific way to come off mood medications, it takes time. And it needs to be done in a particular way his firsthand experience of the difficulty of coming off antidepressants because he himself has been a depression sufferer and was on these medications, and had a very difficult time taking himself off, as you will learn. And he realized that there is really no support for this and that most doctors don't understand or it's not even on their radar in terms of the downsides and dangers of some of these mood medications, you're gonna learn that he is a co founder of outro health outro.com, which allows people to have professional support to get them off of these mood medications. This is a very important episode one I was very happy to be able to do. And I think you're gonna find it is extremely valuable, not just for people who are suffering with depression, and on mood medications. But we go into an awful lot about what changes our moods. What is this all about? What are the mechanisms how science has essentially gone very wrong here and I'll give you a little bit of a clue here that there is no real scientific evidence that serotonin is the issue in depression, which is shocking giving, that the drugs that we use our serotonin SSRIs serotonin selective reuptake inhibitors or selective serotonin reuptake inhibitors, these SSRI drugs that are very prevalent in the treatment of depression, SSRIs and SNRIs. And you're going to learn an awful lot about these and we're also getting to a discussion about purpose and meaning at the end and you're gonna hear Dr. Horror which is his own next level human journey in this podcast. So obviously you can tell I'm very excited about this very passionate about this. We talk a little bit in this episode about the research I'll be doing in my PhD work that delves into this idea of taking on our suffering or mental emotional suffering by doing good for other humans. And so I really, really enjoyed doc Horowitz you'll be able to get all the information on where you can find him at the end of the episode. And without further ado, let's get started with this episode. Welcome to the show everybody, I have a very exciting guest today, somebody who I think you're gonna get a lot of information to someone that I was very keen to have on the show. This is Dr. Mark Horowitz; you heard an awful lot about his expertise in the intro to the show. One of the major reasons that I was wanting to talk to Dr. Horowitz are we are in a very unique time right now in the world, we are having a really tough time with depression. I myself have spent many, many years dealing with people who are on prescription medications for their mood disorders, and have seen the downside of this. Now we have a true expert in this space, someone who has devoted his career to solving this issue. And I think it's incredibly important to have this discussion. So Dr. Maher Horowitz, thank you so much for being on the show. And why don't we start with just a little bit of your background, your story in terms of how you got into this work. It's incredibly important. And I'm so grateful you're doing it.
Dr. Mark Horowitz 6:12
Thank you very much, Jay for having me on the show to talk about this topic. So I'll talk to you about my professional, my personal background and how it led me to focus on the area of how to stop antidepressants safely. So I'm originally from Australia, Israel from my accent. I studied medicine in Australia. I've done my psychiatry training in between Australia and London. I did a PhD in how antidepressants work and the neurobiology of depression at the Institute of psychiatry, psychology and neuroscience at King's College London in London, in which I particularly looked at how to enter to prisons affect stress hormones and inflammation and what is the biology of depression, I now run a clinic in London in the National Health Service to public health system that primarily helps people to stop psychiatric drugs, particularly antidepressants. And all of my research is now on how to stop these drugs. How I got to that which is quite a right hand change in my career is on the other side of the desk. I'm also patient and I was diagnosed with depression when I was 21. I was a third year medical student then a very unhappy young man. If you've if you've seen Woody Allen films, you know, the sort of character I am, I'm a I'm a neurotic Jewish warrior. That's who I am not worrying with an A. And I was diagnosed with depression then and I was given antidepressants and I took antidepressants for the next 20 years. Now, when I was finishing my PhD, which was in the way I did presents work in London, I came across a paper that talked about withdrawal symptoms from antidepressants, the trouble that people have when they stop. And I found that very surprising, because I had never been told in medical school or my psychiatry training or my doctoral studies, about withdrawals from antidepressants. And, you know, my understanding was drugs that cause withdrawal symptoms are drugs that you become accustomed to, you become tolerant to them. And they're not generally that good for you. Because drugs like Valium, or drugs like OxyContin cause withdrawal symptoms. And that made me think perhaps I should try to stop the drug. When I tried to stop my antidepressant, which was Lexapro or as Taliban. I'd been at that point for 15 years, when I couldn't have led to stopping it. I did both the nerdy thing and the millennial thing, the nerdy thing was to read all the articles written about stopping antidepressants. Some of them were written by professors and MIND Institute, which I should say, had passed Harvard while I was there as the top rated Institute Psychiatric Research in the world. In other words, the professors at my institute were world leaders. They all said, you can come off an antidepressant over about two to four weeks without much trouble. discontinuation symptoms are mild and brief. Not much of a problem. The millennial part was I went on to Google to check what do other people say. And I found a very different story there, that people found it very hard to stop their drugs. They had awful withdrawal symptoms. And some people took months or years. I decided to hedge my bets and go down the middle. So I stopped my antidepressant over four months when I was in my early 30s. And it led to the most horrendous experience of my life. I had trouble sleeping. I would wake up in the mornings. Like I was being chased by a wild animal in full Don't panic, I would have that panic for the rest of the day for for several hours. I had never had a panic attack before then. But what I had then was panic that lasted for most of the day. I feel dizzy. Things around me feel dreamlike. I took up running as not the most athletic person around 10 kilometers a day, I read until my feet bled because it gave me some relief. After weeks and weeks of that I thought about killing myself. And I, I didn't have any doubt it was nothing like what had put me on drugs in the first place. Like I said, I'm a neurotic, I'm pessimistic. I'm a ruminant regulatory person. You know, not the not the not the most cheerful, easygoing fellow around. But what I experienced when I came off, it was nothing like that. It was it was panic attacks, the first time in my life, it was trouble sleeping. And I read all these accounts online, people had very similar experiences, they had withdrawal effects from the drugs. Eventually, I actually moved back to my parents house in Australia, that was how total I was by that process, I went back on the drug, even to a higher dose, and the symptoms went away. At that point, I realized that I was on the drug because I couldn't stop it. I had been trapped on the drink. This was extremely surprising to me, because I had been taught throughout my entire career. These drugs were benign, they were effective, they were fairly easy to stop. So to find that it was the most horrendous experience of my life to come off the drugs, I was now stuck on them really shifted my understanding of what I've been taught about these drugs. And that led to a, I guess, a journey of reappraising what I've been taught in my studies, because my, my real life experience had been so different from what I've been taught. And that led in brief, I wrote an article that was published in The Lancet psychiatry, a good a good journal in Europe, on how to stop antidepressants. And that led to a shift in the guidance now in England, for how to stop antidepressants. A shift that hasn't been mirrored in other countries, certainly not in America, where they have really not paid very much attention at all to the progress that's being made. And then on the on the personal side, I have slowly come off my antidepressant. In fact, I ended up on several more drugs, for various reasons, I think, actually, a prescription cascade, where one drug led to a side effect leading to disruption of another drug actually ended up on five psychiatric drugs. I spent the last few years coming off those drugs slowly. And that experience has been profound, it's profound, and changed the course of my life, I had a number of health problems, whilst I was on the drugs, primarily fatigue, trouble concentrating and had trouble with memory, all of which have greatly improved in coming off for my one about 1% of the drugs I was on studying. So that's that is what has completely changed the direction of my career, which is now focused on how to stop these drugs safely. The the balance of benefits and harms for these drugs, when, when they should be used and when they shouldn't be used. And that's what led me to start my clinic in London public health system, and to write a number of papers and conducted a number of studies on how to safely stop these drugs.
Yeah, you know, you're an incredibly unique clinician, from the perspective of, you know, you think most clinicians, they simply see patients, they don't necessarily have the condition that they're treating, you had the condition that you're treating not only that, you're not just a clinician, you're also a researcher. This makes you incredibly unique. We oftentimes talk about experts as being either role models, researchers or results getters. That's sort of I don't know if you know, Brendon Burchard is, but I really liked that model. You know, we tend to have those three types of experts in new normal, you're getting one of those types of experts. With you, you're getting essentially all three, which, to me says something very unique about where you're coming from. And I do want to just say one thing for the listeners here, if you'll allow me, Mark is just one of the things if you're listening to Dr. Horwitz speak here, one of the things we talk a lot about with next level human is that sometimes our suffering is the source to meaning sometimes our pain is a path to purpose. Sometimes the way we get hurt is a way to help. And one of the things that I like to talk about with next level human and sort of this work is this idea. Hear that, we can make a huge difference by taking the lessons from our suffering as individuals, and then creating something to better the world with it. And from my perspective, yours is a perfect hero's journey, in a sense in your ability to take what must have been, and perhaps still is, at times, one of the most difficult things someone can go through and use it, to not just grow yourself, but better others and evolve the world. And so I just think it's I just wanted to point that out. Because it's a beautiful story, even though we're talking about, you know, mood medications and coming off of them. It's a beautiful story, your transition and your journey into this. Now, where I want to go next with this is I know that a lot of my listeners are clinicians, and people who are working in this space. And I would be remiss if I didn't ask the expert, you know, tell us what you found out, like, what is actually going on with these drugs? What are the mechanisms behind this? Why do they tend to become addictive and so difficult to come off? And then once we sort of understand that, maybe there's some hints there that can lead us into helping you describe for us, what is the best way to come off with these things?
Dr. Mark Horowitz 16:22
Okay, thanks, Joe. Thanks for your very, very kind words. I mean, I'll just say about me being a doctor and a patient and researcher, one thing about that is, I would never have understood what I understood, or what I understand now, had I not gone through the experience of coming off the drugs. You know, it's very easy when you read textbooks, and it says it's mild and brief symptoms, you know, the core discontinuation symptoms, or euphemism from drug companies, I would have memorized that I'm very good at exams, I would repeat that to patients. If I did that, before, I've been through this experience, I would never have appreciated how severe and how terrible it could be had I not gone through it. So I see a lot of my colleagues who don't believe in this process don't think this can happen, because they've been taught it by textbooks. And they tend not to believe patients telling them these stories, which is where I get some of the most upset emails from from people around the world telling me their doctor will not believe them. So I appreciate that point of view, because we're all sort of taught to follow authorities. There is now increasing research coming out to support the fact that a lot of people have more trouble than then the textbooks used to say. And the textbooks were were often influenced by drug company studies, which I have returned to. But but certainly I was given an insight, as you say, through suffering, which I wouldn't have chosen. But But you're right, the silver lining to that is the ability to use that to help others. So let me just tell you what the drugs do and why they've caused these problems. The first thing I do, which is going to sound pedantic, but but it's a really important idea to get across is the difference between addiction and physical dependence. Because people say loads to hard stop these drugs must be addictive, because of it. And prisons are not addictive. So what what is going on here? Now, the words addiction and physical dependence are often talked about interchangeably. And the reason for that is in the DSM, they are used interchangeably. But there's a historical reason for that, that's caused a lot of confusion. So in pharmacology, physical dependence is the predictable physiological consequence of using a drug chronically that affects the brain in particular, although other other conflict other organs as well. So for example, if you use caffeine every day, your brain will adapt to it, it'll become caffeine will have less of an effect on you. And when you stop it, you'll get withdrawal symptoms. Most people are not snorting caffeine, they're not breaking into the neighbor's house to get caffeine, that but they are physically dependent on caffeine. The same is true for corticosteroids. You become physically dependent on them, when you stop them, you can get a withdrawal syndrome. antidepressants have this have have a similar effect of us that it presents long term, your brain will adapt to the presence of the drug. We can see on brain scans, that your serotonin receptors will be downregulated there'll be less often in response to the increase in serotonin that these drugs will produce in the short term. And so because your brain has adapted to them, you become physically dependent. Addiction involves extra things like compulsion craving, and obsession with the drug. Some drugs can cause both so benzodiazepines cause physical dependence and can cause addiction. Antidepressants tend not to be enough fun to cause addiction. So what they do causes physical dependence. The reason why those ideas have become conflated is in the DSM three people thought the word addiction was stigmatizing addicts and they prefer to use the word dependence. So they used it To be politically correct, the trouble was they've mixed up two different terms, which is caused a lot of confusion. So just so I just That's it sounds like pedantry. But actually, people get very confused. They say, well, and prisons aren't addictive, so they're easy to stop. Yeah, very important point. And still not easy to study. So you get the idea, you're taking this drug, it causes abnormally high levels of serotonin, we now know there is not low serotonin in depression. So that's another probably another point to get across. You know, for years, we've been told by drug company marketing, that depression is caused by low serotonin, colloquially known as the chemical imbalance. You know, now, there's widespread consensus among psychiatrists, that's not the cause of depression. There's no evidence of lowered serotonin levels in depressed people. So when we introduce a drug that increases serotonin is having an abnormal effect on the brain, it's causing an increase in serotonin. And we have the process of homeostasis, where we'd like to keep in the middle, it's too hot outside, our bodies will cool down, it's too cold, they'll warm up. If we have too much serotonin in our brains, our brain will adapt to go back to average, in the middle, that's the process of homeostasis. And that's what leads there to being less serotonin receptors. Now, when you stop the drug, that that stimulus has gone away, because your brain is used to there being less serotonin. So it's used to there being more serotonin and you've taken away the drug, your brain will experience that as there being a lack of serotonin in the same way, as in your allowed concert, and your and your ears adapt to there being too much noise, the walk out into the quiet street, everything sounds quiet and muffled. It takes a while for your brain to get used to the fact you're now in a in a quieter sitting setting. The same happens when you stop at the prisons, it takes your brain a while to get used to the fact that there's not that level of serotonin around. And what we know from brain scans is it can take the brain months or even years to get used to the fact that drugs are not there. And so that's another misconception. People think, okay, withdrawal symptoms from antidepressants, it must last for a few days or a couple of weeks, because that's how long it takes for the drug to leave your body. But the the reason for withdrawal symptoms is because your brain has become accustomed to high levels of the drug. And it's the time taken for your brain to become really accustomed to the drug not being there. That explains how long withdrawal symptoms last for. And that's what they can last months or years, rather than the days or weeks that it takes for the drugs to leave the body. Now, serotonin, and the other neurotransmitters affected by antidepressants affect every organ system in the body. They don't just affect the brain, they affect the endocrinology system, they affect the bones, they affect the gut, there are serotonin receptors everywhere. And that is why the symptoms of withdrawal affects so many different systems and cause such a wide array of symptoms that can be quite surprising to people that are not used to this area. So there are really two broad types of withdrawal symptoms people get, they are emotional symptoms and physical symptoms is the way that people have divided them up. When I say emotional symptoms, I don't mean they're in people's head is a from physiological changes from being on the drug. But they're expressed psychologically, because the brain is obviously affected by these drugs. Those symptoms can include low mood, anxiety, panic attacks, crying spells, in extreme cases, psychotic symptoms, or that's unusual. And we know that those symptoms are symptoms of withdrawal, and not just a return of the underlying condition for which these drugs were prescribed, because they occur even in people without an underlying mental health conditions. So for example, there are studies looking at people who were put on antidepressants for pain, or the menopause. And even if those people were they stopped their drugs, they can get low mood anxiety, panic attacks, practicals, and they never had anxiety or depression to start with. And that's how we know that these symptoms are in fact withdrawal symptoms. You can see like the point here, you can see how easy it would be for someone, a patient or a doctor to mistake those symptoms for a return of an underlying condition. So the really common story that I see in here is someone walks into the doctor's office, it's out of stock mine antidepressants, and I feel terrible that a lot of doctors will stop you right there and say, look, it's obvious what's happened. You know, you've become depressed or anxious again, you need to be back on the drunk. And maybe this is a sign you need it long term, maybe even lifelong. But if you think that those are withdrawal symptoms, as we now understand occurs to about half of people who stop their drugs, but that is a very perverse response. Because if someone, for example, said they've stopped cigarettes, and they feel very irritable and anxious, the doctor is not going to say to them, well, that that shows you must need cigarettes, you must keep spiking them. So it's very important to differentiate between withdrawal effects, and a return of someone's condition is known as a relapse. I'll explain a bit more about that later. But I'll just point that out. Now, that that mistake, that misdiagnosis is extremely common, and can lead people to mistakenly think they must need the drug, perhaps long term, rather than the response if it if it is withdrawal, which is you need to come off the drug more slowly, carefully, which I've learned myself. The second lot of symptoms people get when they stop antidepressants are physical symptoms. And the common ones there are dizziness, one of the most common
Dr. Mark Horowitz 26:11
brain zaps one of the most kind of characteristic, which are these little sensation that your brain has been switched off for a second or a little zapped, gone through it, sometimes in arms and legs, but mostly in the head, sometimes moving your eyes. It's almost pathognomonic of any universal withdrawal syndrome. It's so characteristic. We don't know what causes it. People think it's got to do obviously with the nervous system. There's a similar symptom in multiple sclerosis, called lumity sign where people get a shooting zap down there that's thought to be thought to be thought to relate to an effect on the myelin sheath around nerves. But brain zaps are very typical withdrawal. Other things like trouble concentrating insomnia, people could experience depersonalization and derealization and sense that things are dreamlike or not quite real. People get headaches, they can feel nauseous because any business affect the gasps. You go to almost every organ system and find some symptoms, people can get muscle tremors, and muscle spasms and muscle pain because serotonin is involved in affecting some of the transmitters involved in your muscular junction. So there's actually 80 symptoms of withdrawal. If a doctor is not well informed, they can make all sorts of misdiagnosis, they can diagnose people with chronic fatigue syndrome. If people's fatigue is very prominent, they can diagnose them with neurological disorders if people have jerking limbs, or complaining of a headache. And as I've mentioned, a relapse of a of an underlying condition. Mental health condition is also very common. And so what we've learned about this in the last few years is about half of patients will have withdrawal symptoms based off antidepressants. So it's very common. We are less certain about how many people will have severe reactions. surveys suggest it's up to a quarter of people. So half of people that get symptoms will have them in severe. There is less studies about how long they last for but a very large randomized control trial published in the New England Journal of Medicine last year, found that on average, for people who had been on the drugs for more than two years, they experienced nine months of withdrawal symptoms. Wow. In other words, we're talking about a very large group of people because in England, in America is 43 million people on antidepressants, if a quarter of them are at risk of severe withdrawal symptoms that lasts for months, that's 10 million people. So there's a very large group of people that are at risk of these issues coming off antidepressants.
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Dr. Mark Horowitz 33:00
I've never heard anyone put it that way before but you're exactly right. This is serotonin resistance that's being formed. So you've put your finger on it, which is exactly what happens. When you're when you're exposed to too much of something your brain becomes less sensitive to it. And that's that can be described as resistance. Your you're right, it is very likely that there is more than just stereotyping going on. The reason I focus on serotonin is one, it's well known with these antidepressants, and two, it's been studied. So there is brain imaging, that shows that serotonin to serotonin, for certain one A receptors are affected by an antidepressant. There isn't the same research that I'm aware of the noradrenaline but I would absolutely put my money where you have, which is these drugs don't just affect serotonin, they're going to affect a variety of neurotransmitters, and in the same response is going to happen if those neurotransmitters are increase, the brain is going to respond by becoming resistant to those transmitters. And if you have an SNRI, that's increasing both serotonin and noradrenaline, then my money would be that there would also be noradrenaline resistance. And people have suggested that that is the reason why it can often be harder to stop SSRIs, because of the additional effects from noradrenaline. The drugs don't affect dopamine as much directly but all these things interconnect. So it's very hard to affect one without affecting the other. I don't know the details of what would happen to dopamine, but if it is, if it's increased the resistance if it's decreased, and there'll be a greater permissiveness of dopamine signaling. So you're right. There are all sorts of downstream effects. And there's likely to be a wide variety of changes in the brain as a result of these drugs that modify brain chemicals. Now, what can you do alongside coming off to make things easier? There has been only some research in this area. The number one reason which I'll talk about in a second is is the is the way to come up with these drugs. And really, in simple terms, it's coming off at slowly at a rate that you can tolerate. And what is probably happening there is your brain is really adapting to being the bigness of the drugs. If you do it slowly enough, it's not this, it's not. I'll give you an example, stopping them abruptly is the worst possible thing to do, I should say, as a public health decision, the middle of this, anybody thinking about stopping your antidepressants, should not do it abruptly, as in not going in the bin, do it slowly, with oversight from a physician, the equip started off throwing them in the bin and stopping abruptly is the same as jumping off top of a 10th floor building, your brain is used to a certain level of the drug going to zero is like jumping down. Coming off story by story, floor by floor makes it easier. And even better. If you do it step by step by step, you give your brain time to get to adjust to lower levels. And in that way you can turn what happens if you jump off the top of a building end up in ICU if you're lucky to the worst thing that happens is you knock your knees a little bit become done step by step. So studies show that the longer you take to come off it, the easier it is. That's now some observational studies showing people who have trouble coming up quickly and avoid trouble coming off slowly. My personal anecdote is that's very much the case. I couldn't come off in four months, it's been fine on I've come off over a few years. Everyone always wants to know How can they make things quicker and to make the process easier. There's no specific research finding anything helps. But I would say from my clinical experience, that people who do healthy things generally have an easier time. So I think the things that are helpful are probably helpful for everybody. You know, I think it's an exercise, if you're well enough to do it, depending on how from withdrawal, eating a healthy diet, state and keeping your mind on other things. I think distraction is an important thing. People who are otherwise engaged, don't dwell on their symptoms so much that can get you through it. Are there specific? I think I think I think everything that helps you to relax. So I think whether that is mindfulness, the breathing, or anything else, that that can help you get into a relaxed state is useful. There's a little bit of evidence for mindfulness treatment in getting people through it. Although I don't think it's a cure all. It's no substitute for coming in slowly, in terms of supplements. So the there's no research saying any supplements particularly helpful. People try all sorts of things because they always want to find something that'll make things easier. People in withdrawal can, for reasons we don't quite understand, become more sensitive to supplements they would normally be. So I think it's something about the brain experiencing pitch changes makes it more fragile and sensitive. So for example, people who are social drinkers of alcohol can find that the glass of alcohol or beer, a glass of wine can cause them great difficulties that wouldn't have they wouldn't have done it before. They're in withdrawal. So people often become more sensitive to supplements in that process. And for that reason, people often need to avoid it. That includes nicotine and caffeine sometimes, supplements tend to be a bit hit and miss. Some people say that fish oil is helpful for brain zaps, or different aspects. Other people find that they react badly to official so it's very hard to draw out some kind of generic advice, the precursors to different neurotransmitters, things like five HTP, I would generally recommend to people to avoid the following reasons your brain is trying to get used to there being less serotonin delivered by these drugs. If you substitute with something else that is artificially increasing those transmitters, then you will be you will go from being physically dependent on the antidepressant to being physically dependent on the substitute. So it might make withdrawal symptoms better. I don't know, I've never tried it. I've never seen it in patients certainly tested. But if it did work, you would be substituting one chemical for something doing something quite similar. And that's a general warning. Sometimes people come to me and say I found something that will help me get through withdrawal. It makes my withdrawal symptoms better. And often they they've produced a benzodiazepine, or another psychiatric drug, sometimes alcohol or sometimes opioids. And of course those drugs can squash withdrawal symptoms, but you're gonna become physically dependent on them and have trouble coming off. So I'm not sure there's any brilliant shortcuts to just the slow process of your brain becoming accustomed to there being less of the drug. But like any repair process, being generally healthy, doing things that support your health probably make the process easier. So I would certainly encourage people to pursue all those different pillars of Holistic Health.
And if you don't mind, I'll share a couple of things here that will be interesting for you and I to discuss being a being a naturopathic physician coming at this more from the natural side, one of the things I think is important for the listener to understand is, I'm not a researcher, yet, I'm currently doing my PhD work and in transpersonal psychology, but I do have experience with people coming off mood medications. One of the things that Dr. Horowitz pointed out is about 50%. And this is, you know, probably true from I would say, my clinical experience is, you know, maybe, I don't know, maybe 6040 60% of people trying to come up these things do horribly. I agree with you 100%, I have never wanted to take someone off their mood medications. It is usually done with the person they're going to do with anyway. And I'm trying to encourage them not to simply because I've seen it be a disaster for people. And I think this is important for me to say, along with Dr. Horowitz. Because I am a natural medicine practitioner, I do tend to want to use more natural things, although I'm not opposed to drugs, although my I'd never had a prescriptive rights for mood medications. My prescriptive rights are mainly for antibiotics, hormones, things of that nature. But I can tell the listener this, certainly I have done a slow removal of medication with an MD an MD looking after that using things like tyrosine, five HTP. However, we have to be and Dr. Horowitz is pointing this out. And I think it's important that you listeners listen to this as well, those people may have done just fine coming off those medications in general, because there is a particular group of people who do much better. And because we don't have the evidence base there right now, we can't say for sure that these things are doing anything, really, and we need the evidence base. And this is incredibly important, especially when we're talking about natural medicine. I also know for a lot of you listeners, it is frustrating. But you're listening here to a conventionally trained medical doctor who also has had this as a condition himself and you're also listening to a naturopathic physician who does come at it from a slightly different point of view than most traditionally trained doctors. And we're both telling you of sort of the same thing here the evidence base needs to be there before we can reliably begin to say, let's do it this way. And one of the things that Dr. Horowitz is pointing out to us is that right now in his clinical experience, in his reading of the research and in his work, the only thing he is finding that seems to be most beneficial is a very slow, tapered stepwise process down now in the future perhaps we will find that there are some reliable evidence based things like exercise supplements and things like that that we can do. But right now it sounds like what you're telling us data or which is that this is where we are unfortunately, there's not a whole lot more that can be said there. Now one of the things I do want to just pick your brain about because like having you here is really just I think useful for us is that why the obsession with serotonin, where did this where did this happen? Right? You know, you're essentially telling us Hey, Jade, listen, you know, serotonin we don't need we can't even say that people are having low serotonin yet. The pharmaceutical industry has focused on this, is there any indication as to why did we go down this path? And if it's not serotonin, then do we have any indication of what it might be?
Dr. Mark Horowitz 43:44
where it's come from? Alternatively, I'll tell you the might at the moment, by Professor John Moncrief is writing a book about the modern history of serotonin so people might like to get that in when it's out late in the year. Serotonin first became of interest to academic psychiatrists in the 1960s. The early drugs that had been derived from antibiotics that were thought to be added the presence of drugs that were first of all treating tuberculosis, which seemed to make people's spirits better, which is where aneurysms came from, were found to increase levels of serotonin and noradrenaline. And based on that academic psychiatrists thought, well, if those increasing serotonin, noradrenaline, improves mood, then maybe low mood is caused by a lack of serotonin and lack of nitrogen. In actual fact, that line of reasoning is so common and so faulty. It's got a Latin phrase, it's called XQ. van Peebles fallacy. It means arguing for the opposite of what treats something and for example, you could use that line of reasoning to say, well, if given aspirin or Advil treats a headache, then headaches are caused by a lack of excrement or lack of Advil. Whatever the local drug is, it's used as a painkiller in America. But in any case, it was a genuine academic hypothesis in the 1960s put forward by American psychiatrists, there was a lot of different hypotheses, someone I think counted, there was 43 different hypotheses for the chemical cause of depression. But the reason why all of your listeners will have heard of serotonin, and not some of those other hypotheses is because in the 1990s, and 2000s, the drug companies came up with a new class of antidepressants called the selective serotonin reuptake inhibitors. The first one was Prozac, it was launched in America in 1987 1988. And to promote that, drug companies pushed the serotonin hypothesis. So in your country, you're one of only two countries in the entire world, where direct to consumer advertising by drug companies is legal. It's illegal everywhere else in the world. And so in the 1990s, and 2000s, you have walking across your screens, the sad little blobs is all of commercials, where the voiceover said, this little serotonin blob, or this little blob, like serotonin in its brain, if you give it sold off, it'll increase serotonin. And now the blog is playing Team sports and having satisfied relationships. In other words, this message was communicated by the marketing departments of drug companies, to the public, and also to doctors. So we've looked at textbooks and academic papers in the 1990s and 2000s. And serotonin exploded in interest, in part because drug companies had directed so much attention to it and so much Medical Edge education towards it. So now, the upshot of that is in surveys done in the 2000s, and 10s. If you ask the public what causes depression, 85 to 90% of them will say that depression is caused by a chemical imbalance and chemical imbalance is the colloquial everyday description of that low serotonin hypothesis. So the marketing of serotonin has been incredibly effective. You can go on tick tock today, if you can work out how to download it. And in you'll see people talking about their low serotonin days, and they're angry because of their dopamine. You know, in one sense, there's a sociologist who has described the fact that we have become our neurochemical selves. That way we perceive ourselves has been completely filtered through a chemical lens. And why did the drug companies do this, it's fairly obvious that if you think that your depression is caused by low serotonin, then you're going to be very happy to take a drug that increases serotonin, in the same way, as someone being told they've got low thyroid hormone is probably going to be fairly happy to be given thyroid replacement. And so there's experiments that have been done. If you tell someone who's depressed, that the depressed because of a chemical imbalance, they're more likely to want to take medication, they're more likely to be hopeless, they're more likely to feel they can't do something themselves to help themselves. If you tell people they're depressed because of things happening in their lives, they're less likely to want to take medication, and they're going to feel more efficient, more empowered to take action themselves. Because obviously, we have effects. We have the ability to affect what's happening in our lives, but not in not in the chemistry in our brains. So that's where serotonin came from. And that's why it's so it's so well known. It's been, it's been understood in academic circles, that depression is not caused by low serotonin since really the early 2000s. We published a paper last year in molecular psychiatry, where we summarized all the research and found there was no evidence of low serotonin and depression. A lot of academic psychiatrists greeted that paper with a yawn. They thought this has already been done. But it was very big news to the public, because the public has been so convinced that depression is caused by low serotonin has actually been one of the most shared scientific papers in history. So asked her what does cause depression? And there are all sorts of hypotheses again, about people say it's different chemicals. It's glutamate. People say it might be the growth factors in the brain, neurogenesis, inflammation. But I always say, What would people's grandmothers say? What would my grandmother say? My grandma would have said, depression occurs because people have miserable lives. Or the more the more PC ways their emotional needs are not being met. The research six decades of research has said that my grandmother was absolutely correct, because if you look at the number of stressful life events that someone's experienced in 12 months, stressful life event the loss of a job breakdown relationship, death of a loved one diagnosis of physical illness, you can predict If it's fairly good accuracy, the likelihood they'll be depressed in the next two months. So if you're exposed to all sorts of stressful life events, your chance of being depressed is very high. If you have a relatively carefree life, someone out there, your chances is very low. Yes, there's aspects of personality, people who are more neurotic, which basically means sensitivity to stress, and more likely to become depressed and people who are more, less neurotic, the less sensitive to stress. We say that difference between Woody Allen and Obama, something like that. So there is a bit of genetics in that. So I'm not I'm not dismissing that, of course, it's some genetics in our personalities, as well as our upbringing. So there's clearly some biology in there. But the relationship between stressful life events, and depression is one of the strongest I've ever seen in any of any research, it's just a straight line that goes, it goes up.
Dr. Mark Horowitz 50:54
couple things to say about that. Number 180 6% of people by the age of 40, will meet criteria for clinical depression or anxiety. So this idea of what causes depression, as if it's some sort of strange condition that affects only some people is a ridiculous idea. You know, there was a great study done by brilliant researchers in New Zealand, they took 1000 people that were born in a certain hospital in a certain year, not selected. So it's completely random sample, fold them up every few years, gave them diagnostic interviews, like a doctor would do in a hospital. And by the age of 40 86% of them met the criteria for depression, anxiety, or mental health disorder. So the 14% are other weird ones. They're the exception. They're either lying, or they're sociopaths, or they're politicians, or they're both, they're the strange ones. So unless you have a life that involves no stress at all, then chances are at some point, you're going to feel depressed, or you're going to feel anxious when you feel things are insecure. So it's a very common part of being a human being. The next question people ask is, okay, so stress is what causes it? What is actually happening in the brain? Is it an effect on neurogenesis? Is it inflammation? Is it noradrenaline? I would say, is that really the best question to ask? To me, it's like saying, if someone comes up to you, and they say, Look, I'm really upset friend of yours, my mother's just died, I feel really depressed and low. And you say that, look, I don't want to deal with the surface stuff, let's talk about your mother, let's get you in a scanner and work out if your amygdala is over firing or not, let's get to the real depth of this. You know, that's, that would be a sociopathic response. Everyone understands what the person needs is emotional support, talking through it, making sense of that above. So if people's depression has been caused by financial stress relationship problems, then the solution needs to be focusing on the external world and not in trying to fiddle the brain, you know, would be would be my my best guess. You know, it's, it's unfortunate that sociopathic example is actually the way that the funding is currently directed into mental health. Every time a celebrity comes out and talks about the mental health is a terrible suicide. The call is always for more research into genetics, into drug research. But if the drivers are inequality and financial problems are related to issues, that understanding the brain is not the solution. To me, it's a bit like trying to make trying to understand Shakespeare by studying ink. The ink is very important. You cannot have emotions without the brain. I'm not. I'm not a duelist I understand. But, uh, trying to make sense of what happens in people's lives. But suddenly, Brian, to me is making a category error. Like, if you like, if you had a problem with your Microsoft Word, and you called the software engineer, and he opened up the back of your computer and started soldiering the circuits, you'd think this software engineer doesn't quite get what's going on? Because in one sense, of course, Microsoft Word does occur in circuits. But we know that's the wrong level at which to understand things. So I think the neuro chemicals action of our thinking about mental health problems has misdirected a lot of attention to what really does make a difference, which is people's lives, emotional support, I think all sorts of things that enhance health, you know, being physically fit and eating healthily that all affects us because there is biology involved. So I'm not dismissing that. But I think it's very important to appreciate what happens to us in our lives, our emotional needs being met or not being met, as being under threat being insecure. Those are the things that explains mammalian emotions. It's not just humans, it's true for dogs and mammals as well. And so I think we really should keep a mind to the bigger picture. And that we're never ever going to find it. I think it's a delusional idea. we're ever going to find a single chemical that if we increase it or decrease it and solve human existential problems, I think that's, you know, mistake.
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Please check out element, use the code next level drink element.com That's d r i n k l m n t.com Drink element.com And let's get back to the show. So so well said and actually now we're getting into the area that I'm most interested in researching my hypothesis is that this is partly a result of the lack of purpose and meaning in people's lives from my perspective, and I know we're running up on time but I would love to get your your thought on this as well. Um, from my perspective, I go, you know, purpose and meaning is something that people misunderstand, we are culturally influenced and playing a culture level game rather than the authentic game of why we humans are on the planet. In the first place. In a sense, you us, we heard an incredible story about you using your suffering as a source to meaning and your pain as a path to purpose. And in that, my hypothesis would be that rather than trying to read people, or you know, say we all have neuro chemical imbalances, the idea is to help people understand that pain, suffering is inevitable as a human, and that our job is to integrate it in a way that takes into account our authentic nature. And the reason that we're on sort of the planet in the first place. And I want to do research, sort of around that, and certainly in my clinical practice, and one of the reasons I am, you know, basically stopped doing what I was doing. And that's why it's so nice for me to talk to you is similar path to you, at least clinically, I started to see that these whether it was drugs, or natural supplements, none of these seem to be touching the underlying issue. And of course, we die and we suffer regardless. And so from my perspective, I want to start focusing on the idea of purpose and meaning as a shield to stress purpose and meaning as a way to make sense of the suffering in the world, and purpose and meaning as a means to begin to help us do what we're here to do. So my question about that is, how do you see this, and I'll frame it this way, because there's two aspects of this, you, you and I both know that, you know, there's a huge amount of research in this idea of safe spaces, emotional compassion, empathy, humans need to be heard, they need to be able to feel they need to be able to be safe in their suffering. And at the same time, we must make sense of this and build a degree of resilience. And a lot of people don't understand how to integrate these two things. So there's two questions here, I guess, what do you think about this idea of purpose and meaning, beings? And then the second part is how to if that is the case? How do we reconcile this idea of the need for emotional safety, security, acceptance and belonging with this idea that we must as humans, this is my opinion. So I want to see what yours is, we must at some level, build the resilience necessary to weather our suffering so that we can learn the lessons so that we can teach and love from those lessons,
Dr. Mark Horowitz 1:02:39
I'm very pleased to hear you take the conversation in this direction. I'm looking forward to reading your PhD now. Yes, I mean, I couldn't agree with you more about purpose and meaning. I mean, you know, to me, if we, you agree with a very long line of philosophers and psychologists, you know, existential psychologies, is this sort of area, you know, Nietzsche said it more than a century ago, you know, man, if any well I can put up with anyhow. You know, of course, what you're talking about makes sense. I think, you know, I hoping that society will emerge from the fog, the neurochemical fog, it's been in, we're thinking about chemical imbalances and drugs, to cure human distress, you know, that's, to me is the wrong field of endeavor, what you're talking about is absolutely right. You know, people need a higher purpose, they need a sense of community, and that will get them through lots of tough times. And without it, you know, it's very hard to find, you know, it's a bit like a shark, you know, all these all these very common analogies, cliches, you know, you need to keep moving forward, you need to have something that's that's driving you, otherwise, everything becomes unpleasant. I certainly, you know, that's my own life points where I felt much more purpose driven, I can put up with the same levels of stress that would drew me in and other times, you've also talked about the balance between safe spaces and also resilience. And, look, it's not my area of expertise. But I know that, you know, in early childhood, having a very safe space creates resilience later on, you know, you don't want to be under threat your entire life, because that produces very nervous, insecure people. If you're gonna if you're growing up in a place where you don't have that kind of attachment, that kind of inner security being bred. If you do have that, it certainly can make you more resilient. So I think that places of peace and security can create resilience for areas of conflict. And of course, we all exist within those two areas. It's very hard to be in conflict all the time to feel you're always in opposition to other people. So everyone needs some kind of a safe space. And I think that's the basis of what can help people be more resilient. And how do you balance those both? I guess you've got to have a an inner sense of calm and security that you're that you're an essentially okay person, which we really derive from interjecting people telling us that You know, I'm not the ideal person who's our primary caregivers giving us that sense of we're an okay person. But sometimes people are not lucky enough to have that kind of circumstance. People can develop it, I think over life by positive experiences. There's a great professor of psychology called John Reed in England, who summarizes all mental health problems and treatment in the following way. He says, all mental health problems come from being treated badly by others. And all recovery comes from being treated well by them, which I think covers probably quite a lot of, of what we what we go through.
And one thing I want to add, and you know, and then we'll begin to wrap up here. But one thing I want to add, this is one of my hypothesis, and one of the things that I want to study is I agree 100%. You know, we know that resilience comes from, at least when we look at adverse childhood events, we know that children who are well cared for safe loved, have the ability to express themselves end up being more resilient. What I'm interested in is adults who perhaps didn't have that, or who've dealt with many traumas, then how do we deliver that, and one of the hypothesis that I have is to turn the focus toward the person now becoming the caretakers of others, there's two ways to deal with pain, right? One way to deal with pain is to pass it on. We know the saying hurt people hurt people. My hypothesis is that hurt people also can help people. And by helping people, they help themselves. And so one of the ideas that I have is that if we take someone who has been traumatized throughout their whole life and never had safe spaces, if they turn their purpose in meaning into creating safe spaces for others, if they make that their mission, and that would be difficult to do in this population. But if we could train them to do that, and they went out in the world and said, I may not have been safe, I may not have been cared for. But I will create a safe, caring place in the world with my actions. Does that then allow them to feel that and see themselves that way? My hypothesis is yes. But it's something that I'm interested in, in trying to discover.
Dr. Mark Horowitz 1:07:05
I think that's I think you have a policy is a good one. I don't think someone once said to me, there's an idea that there's some people that attend polls, everything else sort of relies on them. But there's another thing, I think in TPS where all the sticks are off balance, they're all weak, but they form a circle. And that supports the teepee. And I think that's a pretty good, we're all imperfect, we're all vulnerable in some way. And I think we get a lot from supporting others. I think your idea is very sensible. It gives us a sense of agency and autonomy, you know, and you don't have to be perfect to do it. So I think that makes a lot of sense. And that's what that's what the places are a lot of communities are imperfect people supporting. I've got one key technical message to deliver, I might talk about it for a couple of minutes. And it's just that on the idea of slow tapering. So I've got my piece across. It'll only be a couple of minutes. Tell me Can I share a slide or is that is that difficult in this
setup, you should be able to share a slide that's okay
Dr. Mark Horowitz 1:08:02
I'll do it. I'll do it. I can I can click it.
It's coming up on my end. That's fantastic. Good. Okay.
Dr. Mark Horowitz 1:08:07
Okay. So I want to say one thing. Look, I've said onto the How to come off antidepressants safely. I've talked about coming up with slowly the difference between jumping off the top of a building coming down step by step. There's one other idea that's been the focus of my work that has to explain, which is, this is a graph that shows the relationship between the dose of a drug in this case of telephone, a very common antidepressant and effect on the brain. That's the y axis here. And the key issue is this is not a straight line doubling dose doesn't double the effects on the brain. It's a hyperbola, it goes up very steeply at small doses, and it flattens out at higher doses. That lets us understand what happens when people stop these drugs. It's very common for doctors to say well have your drug go from 20 to 10. Harvard again, and then stop it. And it seems intuitively appealing, because it makes sense, it's very easy to do with existing tablets. The problem with that is the reduction from 20 to 10 causes a bit of a reduction in effect on the brain not too much 10 to five a bit more. But that final reduction from five to zero is like jumping off the cliff, you can't quite see it causes a much bigger reduction in effects on the brain. And that's what people report this first reductions are not too bad, the last one is unbearable. So what I've developed over the last few years is coming off in a way that reduces the effect on the brain by even amounts and not by dose. And that requires what are called hyperbolic tapering, going down by smaller and smaller effects. So the final dose before zero is a very small dose. Now the smallest tablet in America for this drug is 10 milligrams, it's gonna go down to very small doses to make this tolerable. The key to doing that is using either liquid versions of the drug or compound tablets, you get very small doses and that you is what we do at which is a digital clinic that I've set up with some colleagues that's running currently in Canada, and will open in America later this year, we help people to come off antidepressants safely using the latest science. It's funny that in England, the technique I've just shown you is now the national guidelines. But in Canada and America, there hasn't been a change in guidelines for years. And the guidelines still recommend that old fashioned way, I showed you in the first picture where people stop in this linear way, reducing down to five milligrams and then stopping. And what studies have shown is that if people come off these drugs more slowly, sometimes it can take months, sometimes more than a year, they can reduce the intensity of withdrawal symptoms, and are able to come off the drugs with less disruption to their lives. As I said before, we also add outro, we do all the things that I've said, all those things around tapering, united, it's not the solution coming off slower is the main thing. But having a therapist around doing healthy things, having the pillars of Holistic Health put in can make the process easier. And we also follow people very closely through the process with nurse practitioners checking in so that rather than being left out on your own, as doctors sometimes can leave people, here's a couple of doses on a piece of paper, with people throughout the entire process. It's very similar to what I do in my clinic in London. So it's much more hands on, it's hard for busy doctors to accommodate that kind of thing in their practice. And we're hoping to educate other doctors to do the same thing, and help and hoping to help people come off their medication, especially people who thought they couldn't, because of the way that come with in the past.
Yeah, there's simply not a company like this in the world that I am aware of. And it's shocking, when you think about it, how many people are suffering as a result of being on these things so long and not being able to come off of them. So to me, it's absolutely critical that people understand what you're talking about here. It's outro.com, for those of you who are wanting to and trust me, you know, somebody or you yourself, who are dealing with these issues, it's incredibly important. And I think what you've done here, Dr. Horowitz is create something that simply does not exist out of your own suffering. And we're also grateful for this work. outro.com Do you have any final sort of thoughts, you want to leave us with anything that you feel like we missed or you didn't get a chance to adequately talk about?
Dr. Mark Horowitz 1:12:41
I'll do that one last thing, alphabet, it's the main reason people want to come off their medications. And the number one reason is because they feel that their drugs are numbing their emotions. So if you ask people in surveys, why they would come off antidepressants. That's the number one reason I just want to highlight that, because there's a lot of debate, how do antidepressants work? We didn't quite talk about it here. If it's not correcting a serotonin problem, how are they working? In 70% of people on antidepressants, when you ask them in surveys, they'll tell you they feel their emotions. And that means that the positive and the negative emotions are reducing the intensity. I can see why in one sense, that means the drugs did work, because if they were in strife, panic, anxiety, terrible despair, having your emotions turned down from a nine to a three is probably a relief. There are different effects in the long term, having numbed emotions may affect your relationships, intimacy, quality of life, people say I lose their guts, that sense of that gut sense. And that can become unpleasant because it with the drugs are not so clever as to target negative emotions, negative, they affect both negative and positive emotions. And so that's the number one reason people come to my clinic and some odd reason people keep wanting to stop their drugs. And I think that also can kind of make sense of how these drugs actually do produce the effects that they're producing. And I think that actually, people should be more aware. That's what these drugs are probably doing. If the doctor said to you, this drug may numb your emotions, people may still choose to take it, but they might take it for a shorter period of time. Because if they're told this drug will fix an underlying chemical problem, they're more likely to take it lifelong or for too long. And we know that most people don't need to take these strokes for more than a few months. That's what the guidelines say. And there's a whole group of people, especially in America, who are now on these drugs for years or decades, that is well beyond what the evidence says. So I just like to let the audience know that
so important. I mean, I swear I could talk to you and go on and on and on with this discussion. I think it's so critical and so important, but I really appreciate your time. Thank you so much for educating all of us. Thank you for what you have created you We talk about next level human learn, teach love, love being synonymous with create something for the world that evolves it and grows it. You certainly done that with altro.com. I so appreciate you Dr. Horowitz. Thanks so much for hanging out on the show. And where can people just find you real quick? Are you on social media, Facebook, any of those places where if someone wants to reach out to you?
Dr. Mark Horowitz 1:15:24
Sure, the usual plugs, I'm on Twitter at Mark Horowitz. I've got a website, www.markhorowitz.org. You can find more of my work and more of my lectures there.
And don't forget about altro.com everybody and thanks for staying hanging out on the show and we will see you at the next one. You've been listening to the next level human podcast with Dr. Jade Teta. If you enjoyed this episode, please make sure you subscribe and consider leaving a review you make the biggest difference where you pass on your lessons and inspire others. That's why reviews like this are so powerful. Your words may be the only ones that resonate for someone else. Please remember the information in this podcast is for educational purposes only. Always consult your personal Physician or Therapist before making any lifestyle changes. And finally, thank you for where you are in the world. And the difference you make