Posted on Thursday 20 August 2015
As I’ve mentioned before, back in the early days of SSRIs, I was lucky to have a good friend whose wife, a sophisticated Social Worker, had taken Paxil shortly after it came on the market. When she stopped, she got ill and was perceptive enough to recognize that it wasn’t anything like her “depression coming back.” It was something else. It was a withdrawal syndrome. She described it clearly back then, including “brain zaps,” just like we’ve come to know it now that it’s more recognized and well characterized. So I knew about withdrawal early, and began slow tapering off of SSRIs a long time ago with all of them [never prescribing Paxil]. When I mentioned it to colleagues, they didn’t know what I was taking about.
Today, I ran across a post from Bob Fiddaman, a long-time reference source on all things Paxil [Seroxat], linking two previous posts of his I’d missed. He’s been on the trail of some Clinical Trials of Paxil done in Yugoslavia [back when there was a Yugoslavia to do trials in].
The Seroxat/Paxil Yugoslavia Trial Part I July 8, 2015
The Seroxat/Paxil Yugoslavia Trial Part II July 9, 2015
At this time, SKB were seeking approval of Paxil and the Yugoslavia trial was to show the FDA (the US drug regulator) how effective Paxil was in treating depression – they would also try to show the FDA how it was important to keep taking Paxil and not to stop… because if you did stop then you would go into relapse, in other words, SKB were trying to prove that stopping Paxil meant the patient’s original illness would return.
With the results they wanted, SKB then provided the FDA with apparent evidence that showed patients staying on Paxil continued to enjoy a normal, “depression free” life, but that those abandoning the drug would suffer relapse back into a depressive state. One thing that was irksome to SKB was that they had to convince the FDA that the relapses shown in the study were not simply patients suffering withdrawal.
MHRA Missing Key Seroxat/Paxil Withdrawal Information August 18, 2015
The thing that struck me in this story is that they even did the relapse trial in the first place. They must’ve known about the discontinuation syndrome early on and actually did this Clinical Trial to spin it away.
That brings up something that has nagged at me for years. I still see depression in two major categories, just as I did before I even came into psychiatry. Depression [with a capital “D”] meaning Melancholia, the Depressive Episodes of Manic Depressive Illness, Post-Partum Depression, etc. And depression [with a little “d”] as in everything else [formerly known as Neurotic Depression]. Whichever the case, depression is a time-limited condition – and medication for depression is a time limited medication. The guideline I recall from the days of the Tricyclics and MAO Inhibitors was that patients who had responded to these medicatiuons should continue them for 6 months before stopping to prevent a relapse [I have no clue how that guideline got into my mind so long ago].
I followed that practice even after the SSRIs came along. Years later, when I retired and started seeing patients in a clinic where patients had been medicated by someone else, it was apparent that the rest of the world saw things differently. Patients had been on an antidepressant for years and obviously thought it was keeping their depression away. And getting them to give it up required knowing them for a while, and withdrawing slowly as a trial. Otherwise, it was like taking away a talisman, or a comforting blanket. I’ve wondered how that idea of antidepressant as preventative-forever ever came about. Avoiding withdrawal may well be the answer…