Horowitzisms
Handy analogies for talking about prescribed harm, from Dr Mark Horowitz
Explaining psychiatric drug harm to people who have never experienced it can be a tricky business. Lots of people are reluctant to acknowledge the harm that can be caused by widely prescribed psychiatric drugs, and it’s sometimes difficult to challenge people’s assumptions without being accused of being a conspiracy theorist. It gets even harder when we try to unpick the dodgy evidence underpinning the use of psychiatric drugs, and find ourselves having to explain complicated technical terms, like ‘hyperbolic tapering’, ‘receptor occupancy’ and ‘homeostasis’.
Fortunately, Dr Mark Horowtiz has made something of a speciality of devising common sense analogies that can make it easier to talk about prescribed psychiatric drug harm. You’ll find these ‘Horwitzisms’ outlined below.
Explaining the role of homeostasis and physical dependence in psychiatric drug withdrawal
Horwitzism: Our bodies are always trying to maintain a state of balance, or ‘homeostasis’. If we get too cold, our body tries to warm us up by shivering. If we get too hot, it tries to cool us down by sweating. Psychiatric drugs disrupt natural homeostasis by increasing or decreasing the production of brain chemicals called neurotransmitters. This creates a new state of homeostasis that is dependent on the presence of the drug. We have now become physically dependent. When we abruptly discontinue a psychiatric medication that we have become physically dependent on, the new, medication induced state of homeostasis is again disrupted and we may experience withdrawal symptoms while the brain tries to readapt to the absence of the medication.
Why physical dependence is not the same as addiction
Horowitzism: Giving up caffeine can cause withdrawal symptoms, but we understand that people who drink coffee aren’t ‘addicted’ to caffeine. In the same way, people can be physically dependent on psychiatric drugs without being ‘addicted’ to them.
Most psychiatric drugs aren’t ‘addictive’, but they do cause physical dependence. Addiction is characterised by a combination of physical and psychological dependence, that drives addicts to behave in compulsive and irrational ways in order to sustain their addiction. By contrast, physical dependence just means that the body has become dependent on a particular substance in order to avoid experiencing withdrawal symptoms.
People who drink coffee on a regular basis become physically dependent on caffeine and will experience some withdrawal symptoms if they try to stop. But people giving up coffee don’t resort to stealing in order to feed their caffeine habit. Nobody has lost their job, alienated their friends and family or become homeless because they just had to have a cappuccino.
Likewise, people who rapidly stop taking psychiatric medications may experience withdrawal effects as a result of physical dependence, but this doesn’t mean they are ‘addicted’ to psychiatric drugs. Physical dependence and addiction are two different things.
Why using psychiatric drugs can be like getting stuck in quicksand
Horowitzism: The longer a person is stuck in quicksand, the further they sink and the harder it is to get out. Likewise, long term use of psychiatric drugs causes more and more physical dependence, making it harder and harder to stop without triggering debilitating withdrawal symptoms.
Why psychiatric drugs aren’t good for long term use
Horowitzism: When you’ve broken your arm, putting it in a cast helps it to heal. But if you leave the cast on long term, your muscles will be weakened and your arm will be damaged. Similarly, using psychiatric drugs long term can cause more problems than it solves, so it makes sense to use them for the shortest time possible.
Why rapidly discontinuing psychiatric drugs causes withdrawal symptoms
Horowitzism: Climbing a mountain can cause altitude sickness. If we climb too quickly, our bodies don’t have time to adapt to the lower oxygen levels at greater heights. Rapidly discontinuing psychiatric drugs is the same. If we go too fast, our brains and bodies don’t have time to adapt and this is what causes withdrawal symptoms. Slow, hyperbolic tapering gives our bodies and brains the time to catch up.
Why it’s important for doctors to understand safe deprescribing
Horowitzism: Prescribing psychiatric drugs without a plan for safe deprescribing is a bit like selling a car with no brakes. At the moment, doctors are well informed about how to get people started on psychiatric drugs but often have no idea how to safely deprescribe when they want to stop. Even though they don’t know where the brake pedal is, they’re still advising people to get in the car and start driving.
How hyperbolic tapering minimises withdrawal symptoms
Horowitzism: Rapidly discontinuing a psychiatric drug is a bit like jumping off the top of a ten story building, rather than walking down the stairs.
Rapid tapering doesn’t give our brains the time they need to adapt to the absence of psychiatric drugs. In order to taper safely we need to minimise disruptions to our brain chemistry by making small, hyperbolic dose reductions. If we are trying to get down from the top of a ten story building, we know it makes sense to go down the stairs one by one rather than just jumping straight off the roof. Hyperbolic tapering follows the same principle. Gradual reductions minimise the disruptions of brain chemistry that cause withdrawal symptoms.
Why short term studies can’t tell us anything about psychiatric drug withdrawal
Horowitzism: Relying on short term studies to measure psychiatric drug withdrawal is like safety testing a car by crashing it into a wall at just 5 miles per hour.
We’ve all heard the claim that psychiatric drug withdrawal is “mild and self-limiting”. For people who have experienced debilitating and protracted withdrawal symptoms when stopping their drugs, it can be incredibly frustrating to see this phrase being bandied around.
Supporters of psychiatric drugs like to point to meta analyses such as this one, by Michail Kalfas et al, to claim that the “mild and self-limiting” narrative is backed up by evidence. What they conveniently fail to mention is that papers like Kalfas are largely irrelevant to the real world context in which psychiatric drugs are actually prescribed.
Kalfas and colleagues concluded that antidepressant withdrawal is “mild and self-limiting” based on the results of 11 randomised control trials (RCTs). Just over half of these RCTs measured withdrawal symptoms after a mere 8 weeks of antidepressant use. Only one lasted longer than 12 weeks, and this single 26 week trial examined withdrawal effects from agomelatine, a psychiatric medication which doesn’t cause withdrawal.
The trouble is that most people take psychiatric drugs for far longer than 12 or even 26 weeks. Millions of people have been taking them for years or decades, and we know that the risk of experiencing withdrawal is higher the longer you’ve been on the drug. In other words, the findings of the Kalfas paper are irrelevant to the vast majority of patients.
If people generally drive at 60 miles per hour, then a crash test conducted at just 5 can’t tell us anything about car safety. A 5 mile per hour test is irrelevant to the way people drive in the real world. Likewise, claiming that withdrawal is “mild and self-limiting” based on short term studies that are irrelevant to the way these drugs are used in practice doesn’t tell us anything about the incidence or severity of psychiatric drug withdrawal.
How relapse prevention studies conflate ‘relapse’ and ‘withdrawal’
Horwitzism: Misclassifying withdrawal symptoms as ‘relapse’ in order to argue that people need lifelong psychiatric drug treatment is a bit like saying that smokers who get anxious and irritable when they quit just need to keep smoking forever.
Many patients are told by their doctors that they must take psychiatric medications long term in order to prevent a ‘relapse’ of their underlying mental health condition. The evidence supporting this view comes from so called “relapse prevention studies”. Unfortunately, these studies are completely useless. This is because most of them make no effort to distinguish between ‘relapse’ and withdrawal.
Relapse prevention studies are conducted by dividing patients taking psychiatric drugs into two groups. One group continues their medication as usual. The second group has their medication abruptly replaced with a placebo. Any deterioration in the placebo group is then treated as evidence of ‘relapse’ and used to justify what is often lifelong psychiatric drug treatment. Check out this helpful video from Dr Josef Witt Doerring, in which he breaks down the problems with relapse prevention studies.
Abruptly discontinuing a psychiatric drug is very likely to cause withdrawal symptoms, particularly if it has been taken for many years. Some withdrawal effects, such as brain zaps, digestive problems and blurred vision, aren’t typically regarded as symptoms of any underlying mental health diagnosis. However, withdrawal symptoms like anxiety, depression and panic can closely mimic those of a mental health condition. Nonetheless, researchers conducting relapse prevention studies usually fail to distinguish between symptoms caused by withdrawal and those attributable to ‘relapse’. In relation to antidepressants, Dr Horowitz summarises the evidence as follows:
In these discontinuation studies people have their antidepressants stopped abruptly, or rapidly, making withdrawal symptoms very likely, and little effort is made to measure withdrawal symptoms or distinguish them from relapse. We conclude that there is currently no robust evidence for the relapse prevention properties of antidepressants, and current guidance might need to be re-evaluated.
When people quit smoking, they often experience symptoms like irritability and anxiety as a result of nicotine withdrawal. But doctors never advise people to keep smoking on the basis that cigarettes are preventing a ‘relapse’ of anxiety or irritability. We understand that these are withdrawal symptoms caused by physical dependence on nicotine, not a reemergence of an underlying anxiety disorder that was being helpfully corrected by smoking.
In the same way, when people abruptly stop taking psychiatric medications they are likely to experience withdrawal symptoms. But this is evidence of physical dependence on the drug, not proof that psychiatric medications are correcting or controlling an underlying mental health condition. In both cases, the solution is to minimise withdrawal symptoms by reducing the dependence forming substance in a gradual and tolerable way, not to conclude that it is essential and must be taken on a permanent basis.
Given that we have known for decades that abrupt cessation of psychiatric drugs can cause withdrawal symptoms, it's frankly astonishing that researchers conducting relapse prevention studies have failed to take withdrawal into consideration. As a result, most of the literature on this subject just isn’t worth the paper it’s written on.
Brake pedal