Only in Psychiatry

These posts examine modern psychiatry from a critical point of view. Unfortunately, mainstream psychiatrists usually react badly to any sort of critical analysis of their activities, labelling critics as “anti-psychiatry,” whatever that is. Regardless, criticism is an integral part of any scientific field and psychiatry is no different. As it emerges, there is a lot to be critical about.

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About 30 years ago, when I first mentioned to psychiatrists that psychiatric drugs seemed to cause strong withdrawal effects, and therefore qualified as addictive, some people laughed because they thought it was just my twisted sense of humour; most ranged from dismissive to contemptuous, while a few were frankly hostile. Times change. Last week, in an educational seminar, Prof. David Taylor and Dr Mark Horowitz, co-authors of the recent Maudsley Deprescribing Guidelines [1] discussed safe approaches to helping people get off these drugs. It’s not before time. Ever-increasing numbers of people are taking more and more psychotropic drugs, especially antidepressants, for longer and longer.

While these drugs have been authorised for use on the basis of short-term studies, mostly 8-12 weeks, people end up taking them for years, if not decades. In the US, 25million people have been taking them for more than two years; in the UK, it’s 4million and in Australia, about 2million [2]. That’s a lot of people taking a lot of drugs, especially when most don’t need them and we don’t actually know what these things do. Unfortunately, once people have been taking them six months, it becomes increasingly difficult to stop them. After two years, practically everybody who could stop them has done so and, for the rest, it’s all but guaranteed they will have a bad time (for some chilling vignettes from a number of patients, see this video, starting at 4.00; Dr Horowitz speaking).

It’s important to remember that for over half a century, psychiatry refused to consider the possibility of withdrawal effects from antidepressants, or from any of their drugs. People who complained of feeling bad on stopping the drugs were told “That’s your mental illness coming back, quick, start the tablets again.” Naturally enough, on resuming the drugs, the symptoms went away, which convinced everybody that they were needed in the very long term to “control the illness of depression,” like insulin controls diabetes. I’ve seen people who had taken them for over 25 years as they didn’t dare try to stop them again. However, in recent years, psychiatrists have been forced to consider the possibility of withdrawal, which they can’t bring themselves to say so it’s given the twee label “antidepressant discontinuation syndrome” (aka withdrawal).

Three questions arise: how to tell the difference between withdrawal effects and “depression coming back”; how to withdraw people who no longer need them; and how to reduce the numbers of people who start them. Generally, it’s not difficult to distinguish between withdrawal and recurrent depression. Withdrawal causes a wide range of generally peculiar but intense neurological and psychological symptoms that don’t match anything else. People complain of headaches, insomnia, poor concentration and patchy memory, nausea, loss of appetite, sometimes diarrhoea, muscle and joint aches and pains, etc, but the worst and most serious are intense agitation including panic attacks, muscle twitches and spasms, “brain zaps”, akathisia and, most seriously, suicidal and/or homicidal ideas. Occasionally, people can go into mixed states of sleep deprivation and agitation which reach psychotic intensity. The insomnia starts immediately, the rest come on more slowly, over days or even weeks and then fade very slowly, if the person can stand them. Most people can’t, they commonly say withdrawal is far worse than the original problem.

All of this has to be taken very seriously and not dismissed as “neurotic” or deceitful. The important thing is that these are not the symptoms of depression itself, they’re something different, which is why continuity of care is important. When patients are seen by different people each visit, they won’t recognise how different the new symptoms are. The quality is different, and that can’t be conveyed in skimpy case notes signed by a different person each month.

Next, how should people be withdrawn? Slowly, or what is now known as tapering. Because of the unusual way drugs work on neuroreceptors, they can be withdrawn fairly quickly at first, but then much slower as the dose gets down. This is a problem because for practically all psychiatric drugs, the lowest dose available is higher than the largest permissible drop when tapering them. For example, somebody taking 40mg of a tablet can drop by 4mg at first. When they get down to 2mg, a 10% drop is 0.2mg, or 200mcg, the smallest tablet is 10mg, so they’re in trouble. If the drug is available as a liquid, that’s a lot easier to manage but otherwise, people have to pay to have the drugs compounded by a pharmacist, which isn’t cheap. Some years ago, I looked into starting a company that would provide much smaller doses of drugs so people could withdraw safely. Most psychiatric drugs can be produced in India for practically nothing. That idea went nowhere. I was told that each preparation of each drug by each manufacturer had to go through an identical certification process. Each application needed a wheelbarrow full of reports and studies and trials and so on, and cost $150,000. So much for my brilliant idea. Tapering kits are available for some drugs in some countries in Europe but not in any Anglophone countries I know of, certainly not in Australia.

Finally, if these drugs are so troublesome, surely the best idea is to reduce the numbers of people who are started on them each year? Impossible, says mainstream psychiatry, the rates of diagnosis of mental disorders go up and up, never down. It used to be said that bipolar disorder affected about 0.5% of the population; now, it’s about 5%. ADHD started life at about 1% of children; now we’re up to 15% in some places and rising by the minute. Same with ASD, with OCD, and, of course, with the previously very rare urge to change sex. However, just as it’s possible to practice general psychiatry without using ECT, it’s also possible to practice without constantly reaching for the prescription pad. I managed. I had a busy general adult practice in working class areas, seeing up to 200 new cases a year, but started antidepressants for no more than 2-3 people a year. It’s actually easy although I don’t recall anybody ever asked for my “secret ingredient” so I’ll say it anyway: First, take a proper history and second, warn people of the side effects of antidepressants.

Starting with the side effects, they include drowsiness and clumsiness (important for people driving or operating machinery), emotional numbing, lack of energy and apathy, etc, plus the big ones: weight gain (often massive); loss of sexual interest, sensation and performance; akathisia; intense agitation that looks like a hypomanic attack; and suicidal and/or homicidal ideas. When people are told these, almost all of them refuse the drugs. The only way they can be prescribed at today’s astounding rates is by suppressing this information. Does this happen? It most certainly does. Despite any misleading statements from the RANZCP or their equivalients (e.g. RCPsych in the UK), people are NOT told of these side effects and their consent is not in any sense of the word “informed.” They are deliberately misled, by people who are experts in misleading just because they believe their own propaganda. Which comes straight from the drug companies anyway.

As for taking a proper history, most psychiatrists these days don’t know how to. They are looking for stand-out symptoms, the specific markers of each diagnostic category, and when they find them, they look no further. The reason is their concept of “mental disorder as brain disorder” says that’s all they need to do, there’s no point looking further as the symptoms say it all. In fact, in public psychiatry, the job of taking the history is delegated down the line as though it’s not important. It’s a bit like cardiac surgery. The operation starts without the chief surgeon; only when the heart is exposed and everything is beating along nicely do they call the surgeon to come and do the crucial bit. Once that’s done, the surgeon hangs around for a while to see the junior is closing properly, then goes out to the next case. Psychiatrists leave the history to somebody armed with a questionnaire; they glance at it, ask a few questions, write a script or, more likely, don’t even write it, that’s left to the junior, and off they go. I mean, psychiatry’s so easy, isn’t it, there’s nothing to it. Recognise a few symptoms, tick the boxes, write the script and move on to the next one. So easy, and so boring.

A proper history reveals that at least half the people presenting with depressive symptoms have a long-standing, unrecognised and severe anxiety state. It’s long-standing because anxiety starts early in life; it’s unrecognised because none of the clever psychiatrists ask about it because they think anxiety is trivial; and it’s severe, partly because anxiety reinforces itself and partly because everybody keeps saying “Get a grip, pull yourself together, stop this nonsense.” Would that it were so easy [3] but this point is important. One of the speakers at the seminar (Prof. Taylor) said that the old notion of two types of depression, one a biological disease of the brain and the other a reaction to life events, seems to be true. He suggested 80% of cases of depression follow a real event, either recent or remote, and this has to be dealt with. In my view, it’s 100%, but if you don’t ask precisely the right questions, you’ll never know what’s going on. You can’t expect patients to tell you, many of them see anxiety as a moral failing so they don’t want to admit it. The rest just don’t understand its significance but that’s not surprising as nor do the psychiatrists.

If you take a history and find that the primary problem is an anxiety state of one sort or another, and give the patient the full list of side effects of antidepressants, they refuse them. That’s the secret ingredient. However, they still need treatment. Taking a careful history is very important. Time and time again, people have said to me: “I’ve been seeing psychiatrists for 10 years and nobody ever asked any of those questions, but now it’s so clear.” Explaining the nature of anxiety as a self-reinforcing biological system is important; a program of psychological management helps; and the oft-derided but specific, cheap and old-fashioned drugs known as beta blockers help. So why is psychiatry so determined to persist with toxic and highly addictive drugs like antidepressants? Because that’s what their theory says. You could ask “Why did physicians persist with blood-letting when so many of the patients died?” Because that’s what their theory said.

OK, so given these facts, that antidepressants are both toxic and unnecessary, why doesn’t psychiatry change its approach? The answer is that nobody wants to change. People who have devoted their careers to researching, advocating, teaching, and prescribing (and profiting from) antidepressants are not going to drop them just because somebody shows a better approach. I mentioned this a few weeks ago of how, when insulin coma treatment was shown to be useless, mainstream psychiatry closed ranks and drove the apostate out. That is a classic feature of a pseudoscience. We see the same thing happening with antidepressants. Given several years of troubling results (e.g. John Read, professor of psychology at East London University, here and [4]), psychiatry’s response has been to attack the critics as “antipsychiatry,” an undefined ad hominem insult. That’s failed, as Horowitz and Taylor show, so the next level is to follow the “tobacco playbook,” i.e. to try to cast sufficient doubt on scientific basis of the criticism for people to ignore it. Two studies should be mentioned, both in highly influential journals.

The first, from Lancet Psychiatry last year [5], was a meta-analysis from Germany of 79 studies, published over many years and covering 21,000 patients. Henssler et al noted that “Medical professionals continue to hold polarised positions on the incidence and severity of antidepressant discontinuation symptoms …” [p527]. That’s not quite true as the great majority of psychiatrists are convinced antidepressants are entirely benevolent. They concluded that withdrawal symptoms affect about 15% of patients and are rarely troublesome. Two criticisms need to be mentioned. Firstly, a lot of the studies they used were just no good: “We found existing studies to be heterogeneous in both outcomes and methodologies.” That’s code for “They were ancient, highly subjective and disorganised and shouldn’t have been compared.” Second, they stated: “We did not find a difference between studies that applied tapering of the drug and studies with abrupt cessation of the drug.” The reason is that their idea of “tapering” is a week. Coming off venlafaxine can take up to 18 months. The fact that they think one week equals tapering is firm evidence that they don’t actually know what they’re talking about.

The second paper comes from a large group from Imperial College London, published in JAMA Psychiatry a few months ago [6]. They didn’t think much of the German effort: “The incidence and nature of discontinuation symptoms following antidepressant cessation remain unclear.” They found 49 studies covering nearly 18,000 patients, i.e. they excluded many of the papers Henssler et al had included. They opened by mentioning that the experts in the UK and US are agreed: withdrawal effects from antidepressants are mild and transient:

The American Psychiatric Association guidelines state that antidepressant discontinuation symptoms usually resolve within 1 to 2 weeks without treatment (p897).

After a heroic statistical analysis, they found that a week after stopping the drugs, symptoms were fairly mild and not much worse than if people had either stopped a placebo or continued the antidepressant. The most frequent symptom was dizziness but on their measure, withdrawal symptoms failed to reach clinical significance. People who became depressed later were “more likely to represent depression relapse.”

Mark Horowitz, co-author of the Deprescribing Guidelines, criticised this paper in a letter to the Journal [2], pointing out it was misleading as it used a small number of papers, and most patients had taken the drugs only 8-12 weeks. The longer people take the drugs, the worse the withdrawal effects. They also biased their results by including agomelatin, which has no withdrawal effects at all. There were a number of other ploys used to produce an artificially low result. The list of conficts of interest for the ICL paper was enormous although I can’t find how it was funded. As most of them are university employees, they could probably bang it through on their departmental accounts.

What’s the point? The point is that 70 years after these drugs were introduced, and after hundreds of millions of people have taken them (and huge numbers of people have used them to kill themselves), there remains an almost impenetrable ignorance over their long-term effects. This doesn’t happen in other fields of science, only in psychiatry. The two papers quoted above would appear to have impeccable credentials yet they are both seriously misleading. They each used a mish-mash of short-term studies to conclude that antidepressant withdrawal is not worth worrying about; patients should stop complaining and be grateful for the marvels of modern science. Was that an accident? I don’t believe it was. The authors of both papers are highly sophisticated in analysing drug trials. They should know that full-blown drug dependence takes time to develop. You learn that in medical school and see it every day in practice. They are, however, totally committed to the idea that all mental disorder is biological and drug treatment is mandatory so they are not the people who will find that antidepressants are dangerous.

The remarkable thing is that they trumpet how all mental disorder is brain disorder, yet they don’t seem to realise that rectifying a brain disorder will require powerful drugs that act directly on the brain itself. Of course antidepressants produce brain changes, that’s what they’re meant to do. If the drug is stopped, those brain changes will reverse themselves, which is experienced as drug withdrawal. As the vignettes in the video above show, drug withdrawal is painful and prolonged. Those authors know that fact but they don’t want to admit it and, mirabile dictu, that’s what their reviews found. Seek, and ye shall find.

I don’t see these papers as genuine. It is easy to manipulate data to get the result you want and, consciously or unconsciously, I believe that’s what they’ve done. What is needed is a proper, long-term study of the effects of these drugs, focussed on adverse effects and withdrawal. If $1.00 is collected per year for each of the perhaps 100million people taking them, that would quickly fund a very substantial multi-centre trial and not affect the drug companies’ bottom line, which is all they’re concerned about. Seventy years after the drugs were launched and people are still arguing over whether they’re addictive or not. That’s not how science should be done. Only in psychiatry.

References:

1. Taylor D, Horowitz M (2024). The Maudsley Deprescribing Guidelines: Antidepressants, Benzodiazepines, Gabapentinoids and Z-drugs.London: Wiley-Blackwell.

2. Horowitz M (2025). Letter re Kalfas paper. JAMA Psychiatry August 16^th 2025. At: https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2836262 (Scroll down).

3. McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. Amazon.

4. Davies J, Read J, Hengartner MP, et al. Clinical guidelines on antidepressant withdrawal urgently need updating. BMJ 2019; 365: l2238.

5. Henssler J et al (2024). Incidence of antidepressant discontinuation symptoms: a systematic review and meta-analysis. Lancet Psychiatry, 11: 526–35. Published Online June 5, 2024 https://doi.org/10.1016/S2215-0366(24)00133-0.

6. Kalfas M et al (2025) Incidence and Nature of Antidepressant Discontinuation Symptoms. A Systematic Review and Meta-Analysis. JAMA Psychiatry. 82(9):896-904. doi:10.1001/jamapsychiatry.2025.1362

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My critical works are best approached in this order:

The case against mainstream psychiatry:

McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon (this also covers a range of modern philosophers, showing that their work cannot be extended to account for mental disorder).

Development and justification of the biocognitive model:

McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge. At Amazon.

Clinical application of the biocognitive model:

McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

Testing the biocognitive model in an unrelated field:

McLaren N (2023): Narcisso-Fascism: The psychopathology of right wing extremism. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

The whole of this work is copyright but may be copied or retransmitted provided the author is acknowledged.