Marion Brown is a retired psychotherapist, who in recent years accidentally found herself a campaigning for patient safety. Her late husband was a GP in Scotland. Marion shares here a personal record – which she hopes will be of interest to GPs.

Imet my late GP husband (Charles Brown 1953-2011) in the early 1970s when we were both students at St Andrews university. I had grown up in South Africa, my mother a 1951 St Andrews BSc Biology graduate. Mine was an active privileged rural and farming childhood. I remember our mother reading Silent Spring by Rachel Carson in the early 1960s and this having an influence on her thinking – certainly around environmental poisons and toxins. We visited the doctor when ill or injured or needing specific medical intervention.

My husband had grown up in Scotland within a well-respected medical family.  His father, grandfather and uncles were all practising doctors – and his brother still is.  Medicine was always very much part of family life – and indeed still is, now within a 4th generation.

My 1970s BSc had included Physiology, alongside medical students.  After graduation I worked for 3 years as a cancer research technician in Manchester, whilst my husband completed the clinical part of his medical degree there. I subsequently lived much of my adult life as wife of a Scottish village GP.  This included – especially in the 1980s and 1990s – the local GPs and spouses being taken out for meals by Pharma reps and having all sorts of branded items around the place. I was certainly aware of incentives for GPs to diagnose depression and prescribe antidepressants during the mid-1990s RCGP/RCPsychiatrists Defeat Depression Campaign,1 when there was much press and public education about ‘defeating depression’.

….the mid-1990s RCGP/RCPsychiatrists Defeat Depression Campaign, when there was much press and public education about ‘defeating depression’.

In the 2000s, with the establishment of NICE, the NHS introduced GP prescribing incentives including the Quality Outcomes Framework which included guidance and incentives for GPs to continue to diagnose – and treat – depression and anxiety. By then the use of the Pfizer-funded PHQ-screens,2 especially PHQ-9 were encouraged.3,4 McPherson and Armstrong comment that “The PHQ9 was entirely self-report, requiring no clinician involvement. The purpose was to create a measure that would detect depression in primary care, where the majority of mental illness had now come to be managed.”4

From around the early 2000s there was a growing trend to encourage GPs to recognise difficult-to-manage so-called heartsink patients, who kept visiting the doctor for all manner of physical complaints – but who, despite various tests etc., apparently had nothing physically wrong with them although tended to have a history of depression/anxiety.  I later learned that the PHQ-15, together with PHQ-9 for depression & GAD-7 for anxiety, had been developed specifically to help GPs to recognise patients with medically unexplained symptoms5 in order for them to be ‘managed’.

My husband elected in 2007 to do his annual required Continuing Medical Education over a one-week pharmaceutical-sponsored course in St Andrews and we stayed in the town.  I had by then embarked on the Human Givens Psychotherapy Diploma and was invited to sit in on the day that depression was the main topic.

I qualified as a Human Givens practitioner in 2011 and our training stressed that any issues around prescribed medicines that any client might be taking were entirely between a client and their prescriber. My psychotherapist role was to enable clients to figure out what unmet human needs might be causing them to experience symptoms of overwhelming stress and emotional distress, typically symptoms such as insomnia, anxiety, panic attacks, depression etc.. and to support them to discover what human resources they might be able to draw upon and/or learn, in order for them to return to ‘normal life’ – generally within a few sessions of Human Givens therapy www.hgi.org.uk.

Common ‘unexplained somatic symptoms’ overlapped strongly with the serotinergic effects … of SSRI/SNRI antidepressants.

It was late in 2016 that I first became aware that Medically Unexplained Symptoms (MUS) was being acquired in people’s medical records – and that MUS was a recognised DSM-IV diagnosis (now Somatic Symptom Disorder DSM-5).  By then the work of Fava et al6 on the ‘effects’ of antidepressants – and of antidepressant discontinuation/withdrawal – was raising questions.  It was striking that that the common ‘unexplained somatic symptoms’ overlapped strongly with the serotinergic effects – on all main body systems – of SSRI/SNRI antidepressants.  It has now become apparent that the many/multiple system somatic symptoms often experienced by patients are also known ‘effects’ of antidepressants taken as prescribed per guidelines, and that these symptoms are mostly being misdiagnosed as relapse, MUS, functional disorders, bodily distress and so on.

Now MUS is becoming increasingly referred to as Functional Neurological Disorder (FND), and it appears that many people suffering serious antidepressant (and indeed other prescribed drug) side effects and withdrawal effects are acquiring these ‘functional disorder’ labels ‘of unknown aetiology’ – with the result that patients are further misdiagnosed and disbelieved.  We wrote about this in our Patient Voice article for BJGP Life The Patient Voice: Antidepressant withdrawal, MUS and FND and an expanded version published by the Journal of Critical Psychology, Counselling and Psychotherapy JCPCP.7

Many people suffering serious antidepressant side effects and withdrawal effects are acquiring these ‘functional disorder’ labels.

One has to wonder whether the 1990s Defeat Depression Campaign1 (DDC) has inadvertently resulted in a long trail of chronic illnesses due to underestimation of the risks of SSRIs/SNRIs.  During the DDC GPs were encouraged to suggest or imply that the patients were suffering a chemical imbalance, in the brain, of low serotonin, thus reducing stigma, and to reassure their patients that the newer antidepressants were ‘safe and effective’, and ‘not addictive’.  Patients were told to not stop taking them as they would suffer ‘relapse’ of their condition.  Patients were also told that they may experience some mild side effects on starting, and might even feel worse in the first two weeks or so, but that after that the anti-depressant effects should ‘kick in’.  It might be that a switch to another antidepressant could be an option if the first one didn’t suit.  They should then take them for at least 6 months and then continue for at least 4-9 months after remission of depression to prevent relapse/recurrence.  By which time there would be some level of physiological dependence.  These messages are widely prevalent to this day and we now have many cases of treatment resistant depression where people have been tried on many different antidepressants – and are more depressed than ever.8

Stevie Lewis’s 2020 article for BJGP summarises her own personal patient experience, which began during the DDC. She introduces the Guidance for psychological therapists: information for GPs advising patients on antidepressant withdrawal.

In recent years growing evidence of actual patient experience has been added to the formally published research, for example this special collection by Therapeutic Advances in Psychopharmacology from Sage Journals. Some GPs have been raising concerns too, including Des Spence , Richard Byng and Sian Gordon .

Psychotherapy practice has become seriously complicated by what has happened as a consequence of the DDC. Seeing people who are not on antidepressants, and/or other psychiatric medications, is increasingly rare, and many people have now been taking them over decades. These drugs were specifically designed to be consumed orally, to pass through the digestive and circulatory systems, to penetrate the blood-brain-barrier and act on the subtle functioning of the brainstem, the very seat of the human autonomic nervous system, thus affecting homeostasis and  higher conscious thought. This is of course the brain area concerned with the most basic and essential autonomic fight/flight/freeze systems – which, by definition, impact on all the essential bodily systems and functions. When we ‘tinker with’ such essential brain functions – most especially those controlling vitally important sleep – we can impair the capacity for recovery and can cause harm. We are seeing increasing cases of development of akathisia – unbearable sub-cortical nervous system dysregulation, most commonly initiated when starting, changing, or stopping medications including antidepressants. Once developed, akathisia is very hard to resolve and is so excruciating that it leads inevitably to incidences of self-harm and suicide. See information from the Akathisia Alliance for Education and Research.

We are seeing increasing cases of development of akathisia – unbearable sub-cortical nervous system dysregulation.

The recent 2021 Cochrane Review of the evidence for antidepressant discontinuation and continuation concludes “All included trials were at high risk of bias. The main limitation of the review is bias due to confounding withdrawal symptoms with symptoms of relapse of depression. Withdrawal symptoms (such as low mood, dizziness) may have an effect on almost every outcome including adverse events, quality of life, social functioning, and severity of illness.”9

Patients have been disbelieved and ‘put down’.  This has had a detrimental effect on doctor-patient relationships and patients and doctors (who are also patients) have suffered and continue to suffer.  Even now, no-one seems to be ‘listening to patients’.  I have recently expressed alarm concerning the 2021 NICE guidance for Chronic Pain – and its recommendation of antidepressants.

My late husband’s case example is one of countless others.  In his case, in 1985 at age 31, he suffered complete Addisonian crisis following a particularly stressful work and life period, whist a junior GP partner in a busy small-town practice.  On his third emergency hospital admission within a week a Synacthen test confirmed the diagnosis of Addison’s Disease. He began to recover once started on lifesaving, lifelong medical treatment for this condition. Within a few weeks he had recovered well enough to take up a new position as GP in a small rural practice. He worked full-time as a GP for a further 25 years.  In the early 1990’s he was started on Seroxat for depression, commonly experienced alongside Addison’s Disease. He remained on 20mg Seroxat until after his retirement in 2010, when he was recommended by a psychiatrist to switch to Venlafaxine. This only lasted two months as the side effects were intolerable, and he went back onto Seroxat 20mg which seemed to suit him better. Just a few months later he developed almost complete insomnia, terrors, awful gut issues, severe arthralgia, chronic pain, loss of temperature regulation, paranoia, nightmares, agitation, cognitive issues and altogether felt terribly ill. No-one could seem to fathom what had gone wrong, despite various tests and investigations, adjustments to usual medications and a trial of Melatonin. His notes record an exchange between his GP and endocrinologist where they agree that he is probably ‘somatising’ and ‘just needed stronger antidepressants’. Of course, the Addison’s disease was a significant complication. He was increasingly deeply suicidal and utterly desperate, and acted upon this.

Having now learned of so many unsuspecting souls who have experienced the horrors of medication-induced akathisia, my husband’s ultimately fatal experience following 20 years on Seroxat probably was a form of catastrophic autonomic dysregulation and overwhelmingly intolerable akathisia.  He thought he had completely lost his mind.

My hope is that this article will encourage … caution about use of these commonly used so called safe and effective anti-depressant drugs.

My hope is that this article will encourage reappraisal and respectful caution about use of these commonly used so called safe and effective anti-depressant drugs, especially when considering starting people on them. Patients, and their prescribers, need to respect the risks and limitations of these medications so that genuine ‘informed consent’ can be reached before prescribing, or starting to take, any drug. Patients need reassurance that good sense and effective practical and psychological measures can often be taken at the outset to resolve the common symptoms of human stress, emotional turmoil and distress, sometimes without any need for prescribed mental health drugs (including the now emerging trend to develop and market synthetic medical psychedelics), or needing to resort to electrical or other invasive treatments.

Our brains are subtle, complex and precious.  We need, most of all, to give ourselves and others the very best chance of gently supported recovery from periods of physical illness/injury – and/or overwhelming overload or distress.

References 

  1. Priest R. 1996  Lay people’s attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launch | The BMJ
  2. PHQ screeners   phqscreeners
  3. Kendrick A. 2015 Long‐term antidepressant treatment: time for a review? – Kendrick – 2015 – Prescriber – Wiley Online Library
  4. McPherson S. 2021 Psychometric origins of depression – Susan McPherson, David Armstrong, 2021 (sagepub.com)
  5. Burton C. 2013. ABC of Medically Unexplained Symptoms. BMJ books
  6. Fava G. 2015 Withdrawal Symptoms after Selective Serotonin Reuptake Inhibitor Discontinuation: A Systematic Review – FullText – Psychotherapy and Psychosomatics 2015, Vol. 84, No. 2 – Karger Publishers
  7. Brown, M. Lewis, S. (2021). The Patient Voice: Antidepressant Withdrawal, MedicallyUnexplained Symptoms, and Functional Neurological Disorders. Journal of Critical Psychology, Counselling, and Psychotherapy, 20 (4), 14-20    (1) (PDF) JCPCP v20 i04 Brown&Lewis (researchgate.net)  Contents – JCPCP, Vol. 20, No. 4, Winter 2020 (egalitarianpublishing.com)
  8. McLachlan G. 2018 Treatment resistant depression: what are the options? | The BMJ
  9. Van Leeuwen E. 2021 Approaches for discontinuation versus continuation of long‐term antidepressant use for depressive and anxiety disorders in adults – Van Leeuwen, E – 2021 | Cochrane Library

 

Featured photo by Vijendra Singh on Unsplash